Surgical complications and graft survival in kidney transplant recipients according to CT-scans evaluation.

INTRODUCTION: Obesity is a risk factor for significant surgical complications following kidney transplantation. We examined morphometric parameters other than the body mass index (BMI) that could predict surgical complications and determine their impact on graft survival. MATERIALS: Kidney transplantations performed at our center between 2012 and 2019 were retrospectively evaluated. Data for visceral adipose tissue (VAT), subcutaneous adipose tissue, psoas surface, abdominal perimeter (AP), and vessel-to-skin distance (VSK) were collected from pre-transplant computed tomography (CT) scans. The primary outcome was the occurrence of surgical complications within 1 year of transplantation; the secondary outcome was graft survival. RESULTS: We included 321 (88%) of 364 kidney transplant recipients, of which 154 (46.5%) patients experienced some form of surgical complication in the 1st year of follow-up. Univariate analysis revealed that higher VAT (P=0.004), VSK (P=0.007), and AP (P=0.01) values were potential risk factors for early postoperative morbidity. However, none of these factors were significant in the multivariate analysis. Concerning the secondary outcome, while the univariate analysis identified higher VAT (P=0.001) value as a risk factor, in the multivariate analysis only delayed graft function demonstrated a significant impact on graft survival (P=0.002). CONCLUSIONS: Although morphological parameters showed greater accuracy in predicting surgical complications in univariate analysis, these results were not significant in multivariate analysis. Moreover, these factors were not significantly associated with graft survival. Therefore, routine application of analyses based on these parameters, regardless of BMI, may not be useful.

Evaluation of local control after percutaneous microwave ablation versus partial nephrectomy: A propensity score matched study.

INTRODUCTION: The incidence of small renal tumors (≤4cm) is on the rise. The gold standard treatment is partial nephrectomy (PN) but focal therapy can be a good alternative. We evaluated oncological control after treatment of T1a renal tumors by microwave ablation (MWA) compared to PN. METHODS: This is a retrospective, single-center study of all patients treated for TNM stage T1a renal tumors by either PN or MWA between 2010 and 2020. A propensity score was calculated and patients were matched 2:1 to compare recurrence-free survival, metastasis-free survival and overall survival between groups. We also compared postoperative complications using the Clavien-Dindo classification. RESULTS: After matching and propensity score, the two groups (41 MWA and 82 PN) were comparable. The median follow-up was 23 months (interquartiles, 9-48 months). Recurrence-free survival was higher in the PN group compared to MWA, with a recurrence rate of 17.1% in the MWA group vs 4.9% in the PN group (P=0.003). MWA treatment was a risk factor for tumor recurrence (P=0.002), but there was no significant difference in terms of metastasis-free survival (P=0.549) or overall survival (P=0.539). MWA was associated with fewer postoperative complications (P=0.0005). CONCLUSION: This study shows that MWA was associated with higher risk of recurrence but similar metastasis-free survival and overall survival compared to PN. Recurrence was treated with new MWA or active surveillance. MWA may be an interesting alternative to PN for small renal tumors. LEVEL OF EVIDENCE: Grade C.

Learning curve in flexible ureteroscopy for renal stones: A propensity score-matched study.

OBJECTIVE: To assess the learning curve and evaluate the impact of surgical experience related to the outcomes of flexible ureteroscopy (fURS) for upper urinary tract stones. METHOD: We evaluated retrospectively lithiasis fURS performed in our institution between January 2004 and December 2020. Patients were divided into two groups by the number of procedures performed by surgeon. Group 1 (G1) included the first 50 procedures, and group 2 (G2) the next cases. These groups were matched on baseline characteristics by a propensity score. Stones free rate (SFR) and complication rate (CR) were compared. Learning curves were realized using logistic curve with 95% confidence interval. RESULTS: After criteria exclusion and propensity score matching, 1548 procedures were analyzed (1:1, G1 and G2, n=774 procedures). A total of 29 surgeons were evaluated. The overall SFR was 68.4% without statistical difference between the two groups (G1=67.9% vs. G2=68.8%, P=0.72). The surgeon's experience was not associated with SFR (OR=1.15, 95% CI: 0.90-1.47), except in subgroup stones>2cm (OR=2.89, 95% CI: 1.29-6.46). The overall CR was 12.5%, mainly Clavien-Dindo grade I-II complications (96.2%). Surgical experience was not associated with CR (OR=1.06, 95% CI: 0.77-1.45). The overall logistic curves for probability of stone clearance and complication tended to be a flat slope. CONCLUSION: Impact of surgical experience on fURS for UUTS was not associated with SFR and CR. However, for stones larger than 2cm, surgeon's experience tended to be associated with SFR, but without impact on overall complications.

[Pelvic floor rehabilitation before prostatectomy: An update]. / Rééducation sphinctérienne et périnéale avant prostatectomie : Mise au point.

PURPOSE: Preoperative pelvic floor physiotherapy is commonly prescribed to limit postoperative stress urinary incontinence after radical prostatectomy. It can be done in different ways. The objective of this work is to achieve a description of the objectives and existing techniques. MATERIAL AND METHOD: A narrative review is carried out based on a non-systematic review of the literature and on the authors' experience. RESULTS AND CONCLUSION: Although discussed in the literature, preoperative pelvic floor therapy is essential for patient support and follow-up. It should not be limited to strengthening the pelvic floor. It includes a significant time of information, which should not be neglected and should be carried out in association with a holistic care to best prepare the patient before his intervention.

Impact of blood transfusion on survival after nephrectomy for localized or locally advanced renal cancer.

OBJECTIVE: Several studies have reported blood transfusion were associated with a decrease of survival after oncological surgery. For kidney cancer, the effect of blood transfusion is still debated. The objective of this study was to determine the effect of blood transfusion after oncological nephrectomy on overall, specific and recurrence-free survival in a retrospective cohort of localized or locally advanced kidney cancer. MATERIAL AND METHODS: We performed a monocentric retrospective analysis of all patients managed by surgery for localized or locally advanced renal cancer between January 2000 and December 2016. We compared overall and specific survival and recurrence-free survival between two groups: patients transfused and not transfused. Demographic, surgical and tumor characteristics were compared. Survival analyses were performed using univariate Cox regression and multivariate Cox proportional regression test. RESULTS: We included 382 patients in this study: 320 (83.8%) were not transfused and 62 (16.2%) were transfused. Transfused patients were significantly older (P=0.001) and had a lower pre-operative hemoglobin level (P=0.008). Operative and oncological characteristics were also different between both groups. In univariate analysis, we showed that blood transfusion was associated with lower overall survival (P<0.001), specific survival (P<0.001), and recurrence-free survival (P<0.001). In multivariate analysis, we found that blood transfusion was not associated with overall survival, or specific survival, but it was associated with lower recurrence-free survival (HR: 1.967, CI95% [1.024-3.780], P=0.042). CONCLUSIONS: Perioperative blood transfusion is an independent risk factor that increases tumor recurrence among patients treated with nephrectomy for renal cancer.

[Sacral neuromodulation as treatment of non-neurological vesical emptying disorders]. / Neuromodulation sacree dans le traitement des troubles non neurologiques de la vidange vesicale.

GOAL: The goal was to evaluate the results of sacral neuromodulation (SNM) in non-neurological vesical emptying disorders. PATIENTS AND METHODS: From February 2010 to October 2017, 28 patients presenting voiding symptoms or a non-obstructive chronic urine retention without neurological cause have been operated for an SNM (test phase). The test was positive in case of decreased number of proper intermittent self-catheterization (SC) or post-voiding residual urine (PVR) of at least 50 %. A 100 % positive result meant the return to a spontaneous voiding without SC with a non-significative PVR (<100ml). RESULTS: The median follow-up was of 53.2±21.2 months. Twenty-four (85.7%) tests were positive, from which twenty-two (78.6%) were 100% positive. 16 (84.2%) out of 19 patients with SC had spontaneous voiding without PVR. The number of daily SC decreased from 4.6±1.5 to 0.4±1.2 in post-operative (P<0.001). The PVR was of 287.1±170.4ml vs. 30.4±48.6ml in post-operative (P<0.001). Fourteen patients (58.3%) underwent at least one chirurgical revision or a removal of material ; mainly for loss of efficiency, end of battery, electrode migration and pain on material. At the end of the follow-up, 70.8% of the responding patients had their device still efficient. CONCLUSION: Results showed that SNM appears to be an efficient treatment of non-neurological emptying vesical troubles. Nevertheless, the re-operation rate was still significant. LEVEL OF EVIDENCE: 3.

[Localized Prostate cancer in candidates for renal transplantation and recipients of a kidney transplant: The French Guidelines from CTAFU]. / Recommandations françaises du Comité de transplantation de l'Association française d'urologie (CTAFU) : cancer de la prostate localisé chez le patient transplanté rénal ou en attente de transplantation.

OBJECTIVE: To define guidelines for the management of localized prostate cancer (PCa) in kidney transplant (KTx) candidates and recipients. METHOD: A systematic review (Medline) of the literature was conducted by the CTAFU to report prostate cancer epidemiology, screening, diagnosis and management in KTx candidates and recipients with the corresponding level of evidence. RESULTS: KTx recipients are at similar risk for PCa as general population. Thus, PCa screening in this setting is defined according to global French guidelines from CCAFU. Systematic screening is proposed in candidates for renal transplant over 50 y-o. PCa diagnosis is based on prostate biopsies performed after multiparametric MRI and preventive antibiotics. CCAFU guidelines remain applicable for PCa treatment in KTx recipients with some specificities, especially regarding lymph nodes management. Treatment options in candidates for KTx need to integrate waiting time and access to transplantation. Current data allows the CTAFU to propose mandatory waiting times after PCa treatment in KTx candidates with a weak level of evidence. CONCLUSION: These French recommendations should contribute to improve PCa management in KTx recipients and candidates, integrating oncological objectives with access to transplantation.

[Postoperative complications and long-term outcomes of transplantation with expended criteria donors transplants]. / Complications chirurgicales et résultats à long terme des transplantations rénales avec transplants à critères élargis.

OBJECTIVE: The objective of this study was to analyze early, late complications and outcomes following expended criteria donors (ECD) kidney transplantation compared to standard donors. MATERIALS AND METHODS: We performed a retrospective study including 470 patients who received a kidney transplant between 2005 and 2016. Expended criteria donors were defined following the United Network of Organ Sharing criteria. In each group, length of stay, delayed graft function, surgical site infection, acute rejection, surgical complications by type and according to Clavien and Dindo classification were analyzed in univariate and multivariate analysis. The impact of ECD transplant on transplant and patient survival was assessed using a Cox proportional regression model. RESULTS: One hundred and ninety seven (41.9%) patients received ECD kidney. The mean follow-up was 61,4 months (22.4-93.89). Patients with ECD transplant presented more delayed graft function (HR=2.1 (1.1-3.68), P=0.008) but the rate of complications including surgical complications was not different. Patients and transplant survival were decreased in ECD transplant group (P=0.005 et 0.001 respectively). In multivariate analysis ECD kidney was an independent factor only associated with decreased transplant survival (HR=1.81 (1.1-2.98), P=0.029) but not with patient survival. CONCLUSION: ECD kidney transplantation was not associated with increased postoperative complications but a higher rate of delayed graft function. Nevertheless, it was associated with a decreased transplant survival. The use of pulsatile perfusion machine for explanted criteria transplant should be evaluated to improve these results.

[Prostate MRI and screening: Practice survey with general practitioner of the "Bourgogne-Franche Comté" region]. / IRM de prostate et dépistage : enquête de la pratique auprès des médecins généralistes de Bourgogne-Franche-Comté.

PURPOSE: The goal of our study was to describe general practitioner's (GP) practice regarding prostate cancer screening, the prescribing of prostate MRI and to investigate the factors associated with the prescribing of prostate MRI (pMRI). METHODS: A survey was addressed to 1127 GP of the "Bourgogne-Franche Comté" region before the new CCAFU's guidelines publication. RESULTS: 93 practitioners responded, giving a response rate of 8.3%. Eighty GP (86%) responded performing prostate cancer screening. The main means used were the assaying of PSA alone (23 practitioners, 28.8%) or the combination of PSA dosage and digital rectal examination (36 practitioners: 45%). It should be noted that 31 practitioners (39%) did not perform digital rectal examination as part of prostate cancer screening. Thirty two physicians prescribed pMRIs (34.5%.) before any urological consultation. The main indications were several abnormal PSA assays (27 GP, 84.4%) and/or suspicious rectal examination (15 GP, 46.9%). The main reason of this prescription was the gain of time for patient or urologist. Screening was carried out independently of the demographic characteristics of the physicians interviewed. Similarly, the prescription of prostate MRI was not related to the achievement of prostate cancer screening or the screening methods used. CONCLUSION: It seems that the prescription of pMRI has already become part of the prescribing habits of a number of general practitioners. LEVEL OF EVIDENCE: 4.

[Radiotherapy of oligometastases: Sequences and interactions with systemic therapies, example of kidney cancer]. / Radiothérapie des oligométastases : interactions/séquences avec thérapies systémiques, exemple du cancer du rein.

This article is a review of the literature that aims to clarify the place of systemic and locoregional treatments, with a focus on radiotherapy and surgery in the management of patients with oligometastatic kidney cancer. We have selected articles of interest published in Medline indexed journals. We have also analysed the related guidelines: National Comprehensive Cancer Network (NCCN) 2019, European Association of Urology (EAU) 2019, European Society of Medical Oncology (ESMO) 2019, Association française d'urologie (Afu) 2018 as well as some abstracts of international congresses. The main treatments evaluated were surgery and radiotherapy. We defined the different scenarios conventionally encountered in clinical practice. The evolution of systemic therapies (increased overall survival and response rate) is likely to increase the number of patients potentially accessible to locoregional treatments. The complete analysis of the literature underlines the place of locoregional treatments whatever the scenarios mentioned. Data on stereotactic radiotherapy found a local control rate consistently above 70% in all studies with a maintained response and positive impact on overall survival and progression-free survival. The improvement of overall survival by sequential use of the various therapeutic classes confirms the need for optimization of locoregional treatments in the model of oligometastatic kidney cancer. The dogma of radioresistance must definitely be set aside with current irradiation techniques.

[Concordances and predictors of biopsies in renal tumors]. / Concordances et facteurs prédictifs des biopsies dans les tumeurs rénales.

AIM: Evaluate the concordance between the renal lesions biopsy's histology and the final histology of the surgical specimen according to histological subtype, and search for predictive factors of non-concordance. MATERIAL: We performed a monocentric retrospective study that included 156 patients suffering from a renal tumor that benefited a lesion biopsy before surgical treatment. Sensibility and specificity of the renal lesion's biopsy for histological diagnostic of the different renal tumors where calculated. RESULTS: One hundred and fifty-eight renal tumor biopsies were realized between 2001 and 2016. One hundred and forty-three renal cell carcinoma were found on the surgical piece, 135 were diagnosed on prior biopsy. Global concordance rate was 88%. For the establishment of the nuclear Fuhrmann grade, the concordance rate (low vs. high grade) was 72.9%. The cohort was divided into 2 groups according to the existence (group 1, n=139) or the absence (group 2, n=19) of concordance. Group 1 and 2 differed by the predominance of men in group 1 (66% vs. 37%, P=0.013), distance between the sinus and the tumor above 4mm (65% vs. 42%, P=0.05). CONCLUSION: In renal tumor care, renal biopsy is a reliable testing. However, some factors most likely linked to the tumor anatomy (intra-sinusal tumor) and their histological composition were involved in the lack of non-contribution to the diagnosis. LEVEL OF EVIDENCE: 4.

[Renal transplantation on vascular prosthesis]. / Transplantation rénale sur prothèse vasculaire.

INTRODUCTION: In front of a very calcified aortoiliac axis, renal transplantation with implantation of the artery on vascular prosthesis can be proposed. This rare intervention is considered difficult and morbid. The main objective of this work was to evaluate the overall and specific survival of the transplant in this situation. The secondary objective was the study of the complications and the evolution of the transplant's renal function. MATERIAL AND METHODS: From a multicenter retrospective data collection of the DIVAT cohort (6 centers) added with data from 4 other transplant centers, we studied transplants with prosthetic arterial anastomosis. RESULTS: Thirty four patients was included. The median duration of follow-up was 2.5 years. 4 patients died in the month following transplantation, 16 were hemodialysis and 9 were transfused. The median survival of the transplant was 212 days. Functional arrests of the transplant were mostly associated with nephrological degradation and return to dialysis (about 80%) while 10% were related to a death of the recipient directly attributable to renal transplantation. The surgical complications of the transplantation were marked by one arterial stenosis, one fistula and 4 urinary stenoses. CONCLUSION: Thus, renal transplantation with arterial anastomosis on vascular prosthesis, on selected patients, offers an alternative to dialysis. A national compendium of transplanted patients on vascular prosthesis would allow a long-term follow-up of transplant's survival and define selection criteria prior to this kind of surgery. LEVEL OF EVIDENCE: 3.

[Oligometastatic prostate cancer management]. / Prise en charge du cancer de la prostate oligo-métastatique.

OBJECTIVE: To review biology and management of oligometastatic prostate cancer. MATERIAL AND METHODS: Relevant publications were identified through Medline (www. ncbi.nlm.nih.gov), Embase (www.embase.com) and the US National Library of Medicine (www.clinicaltrials.org) databases using the following keywords, alone or in association, «prostate cancer; metastasis; oligo-metastasis¼. Articles were selected according to methods, language of publication and relevance. After careful selection 99 publications were eligible for our review. RESULTS: Oligometastatic prostate cancer is a new entity including prostate cancer with a limited number of metastasis. This particular state becomes more frequent with the imaging progresses especially with the common use of new PET imaging with Choline or PSMA. There is no consensus about a strict definition of oligometastatic prostate cancer, number and sites of metastasis vary widely in the literature. Moreover, oligometastatic state can be observed de novo at the time of prostate cancer diagnosis as well as in case of recurrence after a primary treatment. There is actually an important lack of evidence-based medicine and no guidelines regarding treatment can be found. In de novo oligo-metatastatic prostate cancer, treatment of the primary tumor in association with androgen deprivation therapy seems to increase survival in selected patients but this needs to be confirmed by ongoing prospective clinical trials. In recurrent prostate cancer, metastasis directed therapy with or without androgen deprivation therapy is now routinely performed but its impact needs also to be analyzed. CONCLUSION: In absence of consensus or guidelines, management of prostate cancer should be an individualized, patient-based management taking into account primary tumor stage and grade, number and types of metastasis and patient characteristics.

[Vascular targeted photodynamic therapy in low-risk prostate cancer. A literature review]. / Photothérapie dynamique dans le cancer de la prostate à faible risque. Revue de la littérature.

INTRODUCTION: Currently, about 50% of newly prostate cancers are localized and low-risk according to D'Amico risk classification. Focal therapies whose objective is to treat only the index lesion appear as a new alternative being evaluated in the management of these cancers. Besides the interest in the control of the disease, focal therapies present a very low risk of morbidity. Vascular targeted photodynamic therapy (VTP) is one of these new emerging therapies. METHOD: An exhaustive review concerning VTP in prostate cancer was carried out. A search by the following keywords "low-risk prostate cancer", "focal treatment", "vascular targeted photodynamic therapy" "TOOKAD" was carried out in Pubmed and Embase. RESULTS: In phase II studies, VTP showed a rate of 80% negative biopsies at 6 months, with good clinical tolerance. The European phase III, randomized prospective study, comparing VTP to active surveillance showed a lower proportion of progression, as well as a more significant duration before progression for VTP. The adverse events are mostly moderate and transient. The quality of life of patients is preserved, with a moderate impact on erectile and urinary functions. CONCLUSION: VTP appear to be a promising new approach in localized low-risk prostate cancer.

[Surgical complications of renal transplantation]. / Complications chirurgicales de la transplantation rénale.

OBJECTIVE: To report the nature, incidence, diagnosis and treatment options of surgical complications after renal transplantation. MATERIAL AND METHODS: Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov/) and Embase (http://www.embase.com/) database from 1960 to 2016 using the following keywords "fistula; lymphocele; stricture; thrombosis", in association with "renal transplantation" in Title/Abstract field. Articles were selected according to methods, language of publication and relevance. A total of 7618 articles were identified including specifically 981 for vascular complications, 1016 for urologic complications and 239 for lymphocele; after careful selection 190 publications were eligible for our review. RESULTS: Surgical complications occur in 1 to 30% of renal transplantations while being incompletely reported without consensual management. Angioplasty techniques led to a significant improvement of short- and long-term vascular complications outcome. Risk factors for transplant thrombosis are a right allotransplant, multiple renal arteries or vasculopathy in the donor, diabetes, arterial disease or thrombophilia in the recipient and hemodynamic changes during procedure. Urinary complications and lymphocele significantly impair overall outcome and recipients quality of life with no demonstrated impact on allotransplant survival. Immediate or salvage pelvi-ureterostomy is a main treatment option for ureteral strictures and fistula. CONCLUSION: Prevention of surgical complications following renal transplantation relies on careful allotransplant preparation and strict respect of surgical best practices. Increasing comorbidities in recipients as well as marginal donors are significant limits for the improvement of post-transplant surgical outcome.

[Challenges in renal transplantation]. / La transplantation rénale et ses défis.

OBJECTIVES: To describe kidney transplantation surgical techniques and to propose strategies in high-risk recipients. MATERIAL AND METHODS: Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov/) and Embase (http://www.embase.com/) database using the following keywords, alone or in association, "renal transplantation; peripheral arterial disease; obesity; third and fourth transplantation; robotic-assisted kidney transplant; anticoagulant therapy; dual kidney transplant". Articles were selected according to methods, language of publication and relevance. The reference lists were used to identify additional historical studies of interest. Both prospective and retrospective series, in French and English, as well as review articles and case-reports were selected. A total of 1949 articles were analyzed for arterial disease and anticoagulant therapy, 1083 for obesity, 663 for dual kidney transplants, 458 for third and subsequent procedures and 84 for robotic-assisted kidney transplantation. After careful selection, 304 publications were eligible for our review. RESULTS: Surgical assessment of future recipients is a pivotal step to anticipate technical difficulties, to interrupt clopidogrel or direct oral anticoagulants and to propose a revascularization procedure when necessary. Lack of data regarding obese recipients does not allow us to conclude about best surgical care or optimal timing but suggest that an early global management of obesity in chronic kidney disease patients is mandatory to improve access to a successful transplantation. In neurologic bladder and congenital anomalies, urodynamics and bladder function must be assessed prior to the onset of oliguria to intend an early treatment. Urinary diversion may be performed prior to or after transplantation with similar survival outcome and comparable rates of infections. Because of a rigorous selection of donors, the French dual kidney transplant program provides satisfactory outcomes, but fails in convincing surgical teams nationwide. Third and subsequent transplant procedures remain a surgical and immunological challenge, with an increased morbidity and a moderate decline in transplant survival only when donors are extended criteria' with extensive duration of waiting time between procedures. Robotic-assisted kidney transplantation is a recent technique requiring methodical evaluation. CONCLUSION: Kidney transplantation in challenging recipients implies a global understanding of patients' prognosis and benefits versus dialysis, in the context of the attribution of a valuable resource awaited by other patients on waiting list.

[Simultaneous pancreas and kidney transplantation]. / Transplantation simultanée de rein et de pancréas.

OBJECTIVES: To perform a State of The Art about the different aspects of pancreas transplantation such as indications, technical features, immunosuppressive strategies and outcomes of simultaneous pancreas-kidney transplantation. MATERIAL AND METHODS: An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords (MESH) : « pancreas transplantation; kidney transplantation; simultaneous pancreas-kidney transplantation; immunosuppression ¼. Publications obtained were selected based on methodology, language, date of publication (last 20 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 2736 articles. After reading titles and abstracts, 23 were included in the text, based on their relevance. RESULTS: These last few years, considerable progresses were done in optimizing indication for pancreas transplantation, as well as surgical improvement and a better used of immunosuppression. In the first part of this article, demographics, indication and pre-transplant evaluation will be described. The different techniques of procurement, preparation and transplantation will then be discussed. Finally, the results and outcomes of pancreas transplantation will be reported. CONCLUSIONS: Despite its morbidity, pancreas transplantation is the optimal treatment of end stage renal disease in diabetic patients under 55. Long-term results and quality of life improvement after pancreas transplantation are excellent. LEVEL OF EVIDENCE: NA.