Trends in the use of partial nephrectomy for cT1 renal tumors: Analysis of a 10-yr European multicenter dataset.

AIM: Although extensively addressed in US registries, the utilization rate of Partial Nephrectomy has been poorly addressed in European settings. Our aim is to evaluate the impact of hospital volume on the use of PN for cT1 renal tumors. METHODS: 2526 patients with cT1N0M0 renal tumors treated with either PN or radical nephrectomy at 10 European centres in the last decade were included in the analysis. Joinpoint regression analysis was used to identify significant changes over time in linear slope of the trend for each center. The correlation between yearly caseload and the slopes was assessed with the non-parametric Spearman test. Coincident pairwise tests and regression analyses were used to generate and compare the trends of high-volume (HV), mid-volume (MV) and low-volume (LV) groups. RESULTS: Yearly caseload was significantly associated with increased use of PN (R = 0.69, p = 0.028). The utilization rate of PN was stable at LV centres (p = 0.67, p = 0.7, p = 0.76, for cT1, cT1a, and cT1b tumors, respectively), while increased significantly at MV (p = 0.002, 0.0005 and 0.007, respectively) and HV centers (all p < 0.0001). Regression analysis confirmed the trends for HV and MV as significantly different from those observed in LV centres (all p ≤ 0.002) and highlighted significant differences also between MV and HV centres (all p ≤ 0.03). CONCLUSIONS: We confirmed the association between caseload and the use of PN for cT1 tumors. Our findings suggest that a minimum caseload might turn the tide also in LV centres while a selective referral to HV centers for cT1b tumors should be considered.

[Clinicopathological study and immunohistochemical expression of CA9 in cystic multilocular renal cell carcinomas]. / Étude anatomoclinique et de l'expression immuno-histochimique de CA9 dans les carcinomes kystiques multiloculaires du rein.

OBJECTIVE: Multilocular cystic renal cell carcinoma has been considered as a distinct subtype of clear cell renal cell carcinoma according to 2004 WHO classification. CA9 has proven to be a diagnostic and prognostic marker for clear cell renal cell carcinoma, but the study has been limited to solid tumors. The aim of this article was to analyse the clinical features of multilocular cystic renal cell carcinoma with focus on CA9 expression. PATIENTS AND METHODS: Nine multilocular cystic renal cell carcinomas were found. Their age was from 33 to 74 years old with a median of 54 years. There were five men and four women. The computerized tomography was analyzed. There were three total nephrectomies and six partial nephrectomies. The follow-up ranged from five to 102 months with a median 56 months. Immunohistochemical staining was performed on surgical samples to detect CA9 expression. RESULTS: There were seven pT1a, one pT1b and one pT2; four grade 1 and five grade 2. The Bosniak classification was: one B2F, six B3 and two B4. In CT examination, all tumors showed a hypodense mass. Seven out of nine showed multiple intern septa, more or less thick and vascularized with an enhancement after injection of contrast. No metastasis or relapse was found during follow-up. Eight out of nine multilocular cystic renal cell carcinomas expressed strongly CA9. CONCLUSION: Multilocular cystic renal cell carcinoma was a low malignant tumor with a good prognosis. The diagnostic criteria based on the WHO classification 2004 should be adopted in routine. CA9 could be a new diagnostic marker for this tumor.

[Nephron-sparing surgery is superior to radical nephrectomy in preserving renal function outcome in tumors larger than 4 cm]. / Intérêt de la néphrectomie partielle pour la préservation de la fonction rénale des patients ayant une tumeur rénale de plus de 4 cm.

OBJECTIVE: The objective of the present study was to analyse whether nephron-sparing surgery (NSS) was superior to radical nephrectomy (RN) in preserving renal function outcome in tumors larger than 4cm. METHODS: The data from 888 patients who had been operated upon at eight french university hospitals were retrospectively analyzed. Glomerular filtration rate (GFR) pre- and post-surgery was calculated with the abbreviated Modification of Diet in Renal Disease (MDRD) equation. For a fair comparison between the two techniques, all imperative indications for NSS and all GFR<30 mL/min/1.73 m(2) were excluded from analysis. A shift to a less favorable DFG group following surgery was considered clinically significant. RESULTS: Seven hundred and thirty patients were suitable for comparison. Median age at diagnosis was 60 years (19-88). Tumors measuring more than 4cm represented 359 (49.2%) cases. NSS and RN were performed in 384 (52.6%) and 346 (47.4%) patients, respectively. In univariate analysis, patients undergoing NSS had a smaller risk than RN of developing significant GFR change following surgery. This was true for tumors≤4cm (P=0.0001) and for tumors>4cm (P=0.018). In multivariate analysis, the following criteria were independent predictive factors for developing significant postoperative GFR loss: the use of RN (P=0.001), decreased preoperative DFG (P=0.006), increased age at diagnosis (P=0.001) and increased ASA score (P=0.004). CONCLUSION: The renal function benefit offered by elective NSS over RN persists even when expanding NSS indications beyond the traditional 4 cm cut-off.

[Characterization and outcome of renal cancers ≤ 4cm treated by surgery]. / Caractéristiques cliniques, histologiques et évolutives des cancers du rein de taille inférieure ou égale à 4cm traités chirurgicalement.

PURPOSE: In a retrospective study, we described the characteristics and the outcome of renal cancers less than or equal to 4cm treated by surgical excision. MATERIAL: Two hundred and eighty four cancers less than or equal to 4cm on preoperative CT scan (T1a) were extracted from our database. We studied, the presence of symptoms, the ECOG and ASA scores, the size, the histological type and the Fuhrman grade. The follow up was clinical, biological and radiological. RESULTS: The mean age was 60.8 years. 21% of patients were symptomatic. The renal capsule was intact in 182 cases (64.08%), the urinary tract in 267 cases (94.01%). Seven patients (2.46%) were metastatic with tumors greater than or equal to pT3a. The most common histological types were the conventional renal cell carcinoma (78.52%) and the papillary renal cell carcinoma (16.55%). 76.06%. of the tumors were low grade. With a median of 66.9 months, 33 patients died (11.61%) . For N0M0 patients, with a median of 59.3 months, three specific deaths (1.19%) and 17 deaths from other causes (6.77%) were observed. The average survival of N0M0 group was 227.2 months. CONCLUSION: The renal cell carcinoma less than or equal to 4cm was a heterogeneous group including locally advanced and aggressive or metastatic tumors. For localized forms, surgical excision provided an effective long-term treatment regardless the histological type or the tumor grade.

[How radical nephrectomy compares to partial nephrectomy for the treatment of pT1a papillary renal cell carcinomas?]. / Comment se comparent néphrectomies partielles et élargies pour le traitement des carcinomes papillaires pT1aN0M0? Etude comparative rétrospective de 277 cas.

PURPOSE: Our objective was to compare oncologic results of nephron sparing surgery (NSS) versus radical nephrectomy (RN) in T1aN0-x M0 papillary renal cell carcinoma (PRCC). PATIENTS AND METHODS: We retrospectively reviewed 277 patients treated for a pT1aN0M0 PRCC selected from an academic database from 12 centres. We compared the clinico-pathological features by using Chi-square and Student statistical analyses. Survivals analyses using Kaplan-Meier and Log-rank models were performed. RESULTS: The two groups were composed by 186 patients treated by NSS and 91 by RN. The TNM stage was fixed and the two groups were, in terms of age and Fuhrman grade, comparable. Median age at diagnosis was 59 years (27-85). Median tumor size was 2.7 cm (0.4-4). The average follow-up was 49 months (1-246). Very few events arose in both groups: two local recurrences were observed in the NSS group (1.07%), three patients died of cancer in the NSS treated group (1.6%) and five in the RN treated group (5.5%). The five and 10 cancer-specific survival rate were comparable in the two groups (98% vs. 100% and 98% vs. 97%). The specific survival curves were perfectly similar for both groups (log rank test, p=0.25). CONCLUSION: NSS is equivalent to RN as far as oncologic control of pT1aN0M0 PRCC is concerned.

[Results of fine-needle aspiration cytology (FNAC) in the diagnosis of indeterminate solid renal tumours]. / Résultats de l'aspiration cytologique à l'aiguille fine dans le diagnostic des tumeurs solides du rein de nature indéterminée.

OBJECTIVE: To evaluate the accuracy of fine-needle aspiration cytology for the diagnosis of imaging indeterminate solid renal tumours. MATERIALS AND METHODS: From February 2003 to February 2009, 60 cytoaspirations have been performed to 20 female and 40 male patients (average age: 62.0+/-14.2 years) with an indeterminate solid renal mass by imaging. The average tumour size was 3.4+/-2.8 cm. The cytoaspiration was performed through a 22 Gauge needle under CT (n=39) or US (n=21) guidance. Papanicolaou staining was used. All slides were examined by one experienced cytologist without any clinicoradiological information. The results were given as malignant, benign, suspect or non significant. A classification of subtypes of renal cancer might be added by the cytologist. RESULTS: Twenty-one cytoaspirations (35%) were non significant while 39 (65%) showed cells of interest. Among these 39 cellular cytoaspirations, the specificity for malignancy or benignity was 89.7%. The proportion of non-significant samples was the same in tumors lesser than 2 cm (38.4%) as in tumors 2-4 cm (38.8%) (p=1.000, Fisher's exact test). Subtype identification was only reliable for clear cell carcinomas. No complication was observed. CONCLUSION: The fine-needle aspiration cytology is an auxiliary technique for the diagnosis of indeterminate solid renal tumours. This simple and mini-invasive technique had a high specificity but a low sensitivity in our experience. Fine-needle aspiration is complementary to core biopsy which remains the gold standard of percutaneous sampling.

[French urologist's opinion on testosterone deficiency syndrome: Afu's andrology committee survey]. / Opinion des urologues français sur le syndrome de déficit en testostérone: enquête du comité d'andrologie de l'Afu.

INTRODUCTION: The knowledge of professional practices is necessary for defining educational needs. The topic to explore was testosterone deficiency syndrome. MATERIAL AND METHODS: An opinion survey on testosterone deficiency syndrome was conducted on the internet among urologists members of the French Urological Association. Two hundred and thirty-six urologists filled in a questionnaire exploring the perception of the concept, the clinical and biological components of diagnosis, and finally the means and aim of management. RESULTS: The variety of denominations for a single disease and the predominance of sexual and functional symptoms were highlighted. Difficulties in biochemical diagnosis seemed to be linked to the different circulating fractions of serum testosterone, with bioavailable testosterone being too much prescribed as a first line test. Decision to treat, after contraindications have been ruled out, was mainly based on a decreased quality of life, on sexual dysfunction and patient request. Three urologists out of four gave recommendations for life hygiene and eight out of ten managed themselves testosterone replacement treatment. CONCLUSION: Overall, French urologists showed a fairly good knowledge of testosterone deficiency syndrome and a strong will for a treatment tailored to patients requirements and symptomatic efficiency.

[What is the clinical practice of partial nephrectomy in France?]. / Quelle pratique de la néphrectomie partielle en France ?

OBJECTIVE: To describe the practice of partial nephrectomy (PN) in France and assess its results in terms of morbidity and cancer control. MATERIAL AND METHOD: Seven French University Hospitals in which nephron sparing surgery represents at least 30% of the total number of nephrectomies for renal tumour, participated in this study. All centres included, as exhaustively as possible, all their PN cases. For each patient, 70 variables were harvested in order to characterize the patient population, the indications, the operative technique, the per- and postoperative course and complications, the tumor specificities, the carcinologic control and renal function follow-up. RESULTS: Seven hundred and forty-one PN, of which 579 for malignant tumours were analysed. The mean tumour size was 3.4+/-2.1 cm (0.1-18) and 20.8% of the tumours were larger than 4 cm. In 30.1% of cases, the indication was imperative. Among the PN, 12.2% were performed laparoscopically. The mean operating time was 151+/-54.2 min (55-420). The medical and surgical complications rates were respectively 15.2 and 14.7%. At a mean 38 months follow-up, the local recurrence rate was 3.5% and the specific death rate was 4.5%. CONCLUSION: PN is nowadays getting a more and more widely used technique in France. This expansion is completely justified by its results and urologists must consider nephron sparing surgery as the gold standard treatment for renal tumours measuring less than 4 cm.

[Do broader indications for partial nephrectomy result in excess morbidity?]. / Elargir les indications de la néphrectomie partielle induit-il un surcroît de morbidité? Une étude multicentrique française.

OBJECTIVE: To evaluate the morbidity of partial nephrectomy (PN) according to tumour size and the type of indication based on a multicentre retrospective study. MATERIALS AND METHODS: Seven French teaching hospitals participated in this study. Data concerning tumour size, indication for PN (elective or necessity), age, gender, TNM stage, histological type, Fuhrman grade, ASA score and performance status (ECOG) were analysed. Medical and surgical complications, intraoperative blood loss, blood transfusion rate and length of hospital stay were also studied. Statistical analysis of qualitative and quantitative variables was performed with Chi-square test (Fisher's test) and Student t-test. RESULTS: Six hundred and ninety one patients were included. The median tumour diameter was 3cm (0.4-18). Tumours measuring less or equal to 4cm and incidental tumours represented 77.7 and 80.7% of cases, respectively. Clear cell carcinomas represented 75.1% of malignant tumours. Some 89.1% of tumours were T1, 1.6% were N+ and 2.3% were M+. In the 486 elective indications: the operating time (p = 0.03), mean blood loss (p = 0.04), and urinary fistula rate (p = 0.01) were significantly higher in tumours greater than 4cm. These differences were not associated with an increase in the medical (p = 0.7) or surgical complication rate (p = 0.2), or the length of hospital stay (p = 0.4). CONCLUSION: Broader indications for elective PN is associated with an increased morbidity but which remains acceptable. This is an important point for patient information and to guide the choice of surgical strategy, particularly in elderly, frail patients or patients with major comorbidities.

[Optimal evaluation of the infertile male. 2007 French urological association guidelines]. / Evaluation de l'homme infertile: recommandations AFU 2007.

An infertility evaluation should be performed if a couple has not achieved conception after one year of unprotected intercourse. An evaluation should be performed earlier if male or female infertility risk factors exist and if the couple questions its fertility potential. The initial screening of the male should include a reproductive history and a physical examination performed by a urologist or a specialist in male fertility and two semen analyses. Additional procedures and testing may be used to elucidate problems discovered during the full evaluation. The minimal initial endocrine evaluation should include serum total testosterone and serum follicle-stimulating hormone levels. An endocrine evaluation should be performed if sperm concentration is abnormally low, sexual function is impaired, and when other clinical findings suggest a specific endocrinopathy. A postejaculatory urinalysis should be performed if ejaculate volume is less than 1 mL, except in patients with bilateral vasal agenesis or possible hypogonadism. With a diagnosis of retrograde ejaculation, specific management should be considered before advising assisted reproductive technology. Scrotal ultrasonography is indicated when physical examination of the scrotum is difficult or inadequate, or when a testicular mass is suspected. Transrectal ultrasonography (TRUS) is indicated in patients who are azoospermic or have a low ejaculate volume. Specialized testing of semen is not required for routine diagnosis of male infertility. However, some tests may be useful for a few patients to identify a male factor contributing to unexplained infertility, or to select therapy (e.g., assisted reproductive technology). Before performing intracytoplasmic sperm injection, karyotyping and Y-chromosome analysis should be offered to men who have nonobstructive azoospermia and severe oligospermia. Genetic testing for gene mutations of the ABCC7 (ex-CFTR) gene should be offered to male and female partners before proceeding with treatments that use the sperm of men with congenital bilateral absence of the vasa deferentia or congenital unilateral abnormality of the seminal tract. Genetic counseling may be offered when a genetic abnormality is suspected in the male or female partner, and it should be provided when a genetic abnormality is detected. Genetic testing in the female partner, when non symptomatic, should only be advised by a physician from a multidisciplinary team registered by the ministry of health. Evaluation by testis biopsy and deferentography should be performed by a urologist or an andrologist registered for sperm retrieval.

S100A1: a powerful marker to differentiate chromophobe renal cell carcinoma from renal oncocytoma.

AIMS: The common subtypes of renal tumours are conventional, papillary, chromophobe carcinoma and oncocytoma. The morphological differentiation between chromophobe carcinoma and oncocytoma may be difficult. The aim was to evaluate S100A1 as a new marker for the differentiation of the two subtypes. METHODS AND RESULTS: Thirty-nine tumour samples [nine clear cell renal cell carcinomas (RCCs), six papillary RCCs, nine chromophobe RCCs and 15 oncocytomas] were studied. The protein expression of S100A1 was evaluated by immunohistochemistry. The gene expression of S100A1 was analysed by reverse transcriptase-polymerase chain reaction. Nine oncocytomas showed strong immunoreactivity for S100A1. Four oncocytomas were scored as moderate and one as weak reactivity. In total, 14/15 (93%) of oncocytomas were considered to be immunopositive. In contrast, all nine chromophobe RCCs were considered to be immunonegative. There was a significant difference in the positive percentages of staining of S100A1 between these two subtypes (P < 0.01). S100A1 immunoreactivity was observed in 6/9 clear cell and 4/6 papillary carcinomas. The results of S100A1 gene expression corresponded well with the results of immunohistochemistry. CONCLUSION: S100A1 may be a potentially powerful marker to differentiate the chromophobe RCC from renal oncocytoma.

S100A1 and KIT gene expressions in common subtypes of renal tumours.

AIM: The aim of this study is to evaluate the S100A1 and KIT as gene markers for the differentiation of common subtypes of renal tumours. METHODS: Fifty-five tissue samples (15 clear cell RCCs, 15 papillary RCCs, 7 chromophobe RCCs, 8 oncocytomas and 10 normal renal tissues) were studied The gene expressions of S100A1 and KIT were analysed by one-step RT-PCR by using the specific primers. RESULTS: S100A1 was expressed in 2/15 clear cell RCCs, 11/15 papillary RCCs, 7/8 oncocytomas and in 0/7 chromophobe RCCs. KIT gene was expressed in 6/7 chromophobe RCCs and 7/8 oncocytomas while 0/15 clear cell RCCs and 1/15 papillary RCCs expressed kit gene. Normal tissue expressed neither S100A1 nor KIT gene. CONCLUSION: S100A1 and KIT can be used as gene markers for the differentiation of common subtypes of renal tumours.