Robot-assisted or pure laparoscopic nerve-sparing radical prostatectomy: what is the optimal procedure for the surgical margins? A single center experience.

OBJECTIVES: To compare positive surgical margin rates after robot-assisted and pure laparoscopic radical prostatectomy when neurovascular bundles are preserved, and to identify parameters affecting surgical margin status. METHODS: From March 2004 to January 2009, 279 consecutive prostatectomies with preservation of neurovascular bundles were carried out by the same surgeon: 175 robot-assisted radical prostatectomies and 104 laparoscopic radical prostatectomies. An intraperitoneal Montsouris's technique was used for all cases. Patient's age, body mass index, prostate weight, prostate-specific antigen level, clinical stage, preoperative and postoperative Gleason score, percentage of positive biopsies, pathological stage, and positive surgical margin status were prospectively recorded in an institutional database. The two groups were retrospectively analyzed and compared. RESULTS: Positive surgical margin rates were 17% and 13% for the robot-assisted radical prostatectomy and laparoscopic radical prostatectomy group (P = 0.4), respectively. At multivariable analysis, only prostate-specific antigen level and prostate weight significantly affected the surgical margin status, where the type of procedure (robotic vs laparoscopic) did not have any effect. CONCLUSION: In our single-surgeon experience, prostate-specific antigen levels and prostate weight are predictive of positive surgical margin in patients undergoing nerve-sparing radical prostatectomy, whereas there seems to be no difference between the robot-assisted radical prostatectomy and the laparoscopic radical prostatectomy techniques.

Effect of genetic variability within 8q24 on aggressiveness patterns at diagnosis and familial status of prostate cancer.

PURPOSE: Recently, two independent loci located at 8q24 that contribute to prostate cancer risk in men of European origin were identified. EXPERIMENTAL DESIGN: Using Bayesian probability network and logistic regression model, we searched for associations between 34 single-nucleotide polymorphisms (SNP) located at 8q24 and the aggressiveness patterns of prostate adenocarcinoma or familial history of cancers in 823 White Caucasian French men. RESULTS: Probability network according to the Markov chain algorithm separated the SNPs into two main groups: The first one was linked to the locus marked by rs6983267 and the second one was linked to the locus marked by rs1447295. When the patients were stratified according to tumor stage and prostate-specific antigen value, the association between the variant genotypes from six SNPs located in the second network and prostate cancer risk was strongest or confined to the patients from the more aggressive classes. However, the association between prostate cancer risk and the CC genotype of rs7841264, which marked the recombination hotspot at 8q24, was confined to patients with the highest Gleason score (odds ratio, 2.15; 95% confidence interval, 1.27-3.64; P=0.004). Interestingly, the G allele of rs6983267 was associated with familial prostate cancer risk. CONCLUSIONS: Our data further support that variability at 8q24 is associated with a high risk of aggressive prostate cancer at diagnosis and is linked with familial history of prostate cancer. These results corroborate that 8q24 SNPs must be evaluated in terms of prostate cancer aggressiveness markers to optimize early diagnosis procedures and management of the disease.

Input of a Multi-Disciplinary Meeting in the Treatment of Osteoarticular Infections in French War Casualties.

INTRODUCTION: Extremity war-wounds present an elevated risk of infection and compromise reconstructive procedures. In a French military hospital, a multi-disciplinary meeting (MDM) was created to standardize the care given to soldiers with osteoarticular infection. The aim of this study was to evaluate the usefulness of MDM decisions. METHODS: An observational case study was performed including the French wounded at war treated for an osteoarticular infection between 2004 and 2016. They were separated into two groups according to their time of management: before (group A) or after (group B) the MDM creation in September 2010. Various operative and bacteriological parameters were analyzed retrospectively. A questionnaire was created to evaluate healthcare professionals' satisfaction toward the usefulness of the MDM on their practice. RESULTS: During the study period, 38 patients were included: 19 in group A and 19 in group B. Initial tests found an infection with one pathogen in 15 patients, an infection with 2 pathogens in 11 patients, and an infection with 3 or more pathogens in 12 patients. Enterobacter cloacae was the most common pathogen. Pseudomonas aeruginosa and Escherichia coli were also frequent. The mean number of samples taken to conduct the bacteriological tests per operating session was significantly higher for group B than for group A. Twelve of the 14 questioned healthcare professionals believed the MDM was very useful in their patient management. CONCLUSION: The MDM seems to have had a beneficial impact on orthopedic surgeon practices. A significant increase of the number of samples taken was the most obvious sign that the French recommended practices for osteoarticular infections were followed since the creation of MDM.

Differential expression of genes related to androgen and estrogen metabolism in hereditary versus sporadic prostate cancer.

The hereditary predisposition to prostate cancer is rare and accounts for <5% of cases. Except for younger age at diagnosis, no phenotypic features have been clearly associated with hereditary prostate cancer. The aim of the study was to analyze the expression of genes related to androgen and estrogen metabolism in both hereditary and sporadic prostate cancers in patients matched for clinicopathologic features. Tissues were obtained from patients included in a national familial prostate cancer registry. From the 120 cases of hereditary forms suggesting autosomal dominant Mendelian inheritance, 21 patients were treated by radical prostatectomy for whom formalin-fixed tissue was available. Twenty-one sporadic cases were then matched according to age, Gleason score, and pathologic stage. Immunohistochemistry was done on tissue microarray using antibodies directed against androgen receptor (AR), estrogen receptor alpha (ERA), estrogen receptor beta, 5alpha-reductase I and II, aromatase, and the proliferation marker Ki67. The percentage of AR-positive cancer cells was higher in hereditary cancer compared with sporadic cases (P < 0.004). In contrast, the mean number of ERA-positive stromal cells was lower in hereditary versus sporadic cancer (P < 0.03). This differential expression of AR and ERA suggests that a specific pattern of hormone receptors is associated with hereditary predisposition to prostate cancer.

PGE2 and LTB4 tissue levels in benign and cancerous prostates.

PGE2 and LTB4 are involved in inflammation and carcinogenesis in several tissues but have not been studied in prostate cancer and hyperplasia until now. We therefore measured PGE2 and LTB4 productions in a total of 206 prostate tissues from 116 patients including benign hyperplastic (90), pericancerous (106) and cancerous samples (10). We also analysed the influence of inflammation levels, prostate volume and glandular to epithelial ratio. PGE2 and LTB4 concentrations were measured using specific enzyme immunoassay kits. There was a correlation between PGE2 level, prostatic volume, inflammation score, and decreased glandular surface. By contrast, there was no correlation between LTB4 levels and inflammation or PGE2 production. Cancerous samples had higher LTB4 levels than pericancerous samples, but there was no difference in PGE2 levels. PGE2 and inflammation may be associated to stromal benign prostatic hyperplasia whereas LTB4 may play a role in prostate carcinogenesis.

Sequential management of tibial fractures using a temporary unicortical external fixator.

INTRODUCTION: The development of damage control orthopedics (DCO) procedures has led to the development of temporary unicortical external fixators (TUEFs) intended to limit deep infectious complications and facilitate early conversion to internal fixation. METHODS: A retrospective study was conducted in two French military trauma centers, including on patients being treated for tibial fractures with a TUEF (UNYCO® - Orthofix®) followed by an early conversion to intramedullary nailing. RESULTS: Eleven patients with an average age of 41 were included between September 2015 and June 2017. A total of 12 TUEFs were implanted for one closed fracture and 11 open fractures, including one type I, eight types II, and two Gustilo types IIIB. The indication of DCO was related to hemodynamic instability in three cases, to the severity of soft tissue lesions in eight cases, and to the context of treatment in one case. The conversion to IM nailing was made after an average of 7.6 days. No significant loss of reduction was observed until internal osteosynthesis, which was performed with "fixator in place" in ten cases. The coverage of Gustilo type III injuries was performed by free flap transfers at the same time as IM nailing. All the patients were reviewed with an average follow-up of 16.5 months. Bone union was achieved in all cases. Two IM nailing dynamizations were carried out, but no bone grafting was required. Two cases of pandiaphysitis were observed and treated without functional complications. DISCUSSION: Despite a limited number of patients, this study demonstrates the reliability of the TUEF to maintain the reduction of tibial fractures and facilitate early conversion to IM nailing. Unicortical fixation does not prevent septic complications related to the severity of soft tissue injuries.

[Impact of obesity on PSA in prostate cancer screening]. / Impact de l'obésité sur le PSA lors du dépistage du cancer de la prostate.

OBJECTIVE: Obesity is associated with changes of serum levels of androgens and oestrogens which could modulate prostate metabolism. The objective of this study was to investigate a possible correlation between the PSA level and the degree of obesity in a candidate population for prostate cancer screening in order to determine whether the PSA level needs to be adapted before performing biopsy. MATERIAL: During a screening campaign in a French district, serum PSA results and body mass index (BMI) were available for 541 men. These men were divided into 4 groups of corpulence: Normal (BMI < 25), Overweight (25 < or = BMI < 30), Stage I obesity (30 < or = BMI < 35), Stage II + III obesity (BMI > or = 35). The PSA levels of these various groups were compared, and a correlation between BMI and PSA was investigated. RESULTS: The mean PSA in each group was inversely proportional to BMI, with mean PSA levels of 3.7, 2.9, 2.6 and 1.5 for Normal, Overweight, Obesity I and Obesity II + III groups, respectively. A significant difference was observed between these groups (p = 0.03) and an inverse correlation was also observed between BMI and PSA (r = 0.1, p = 0.01). CONCLUSION: In a population submitted to prostate cancer screening, PSA is lower as BMI increases. An adaptation of the PSA screening cutoff value according to BMI should be investigated.

[How is prostate cancer screening perceived by men 50 to 70 years of age? Analysis based on 1,774 screened individuals]. / Comment le dépistage du cancer de la prostate est-il perçu par les hommes de 50 a 70 ans Analyse a partir de 1774 individus dépistés.

INTRODUCTION: The rationale for mass screening for prostate cancer remains controversial. Apart from the scientific debate, we wanted to evaluate the opinion of prostate cancer screening candidates concerning the practical modalities of this screening and assess the impact of various personal, medical or social factors on their replies. MATERIAL AND METHOD: Following a screening campaign in a French district, 1,774 men, 50 to 70 years of age, who completed screening were interviewed by questionnaire concerning the duration, frequency, mode of blood sampling and the cost of screening. Medical history, family history and lifestyle were also evaluated. RESULTS: Among 1,774 candidates who returned an interpretable questionnaire during the screening campaign (participation rate: 31%), 27.1% of subjects interviewed declared that the personal financial cost would be an obstacle to screening, 5.1% considered that collection of a blood sample from the cubital fossa would be an obstacle to screening, 6.5% considered that one PSA per year was too frequent, and 8.1% considered that screening between the ages of 50 and 70 years was too long. CONCLUSION: More than 90% of men who participated in a prostate cancer screening campaign appear to be in favour of continuation of screening according to the current modalities provided it is free of charge. The acceptance rate was better for men with a family history of prostate cancer, men who had already had a PSA assay, men living alone and men under 60 years of age.

[Cystomanometric study of bladder sensation during sacral neuromodulation test]. / Etude cystomanométrique de la sensation vésicale pendant le test de neuromodulation sacrée.

PURPOSE: Prospective clinical and urodynamic study evaluating modification of bladder sensation during sacral neuromodulation (SNM). MATERIALS AND METHODS: 24 consecutive patients with non-neurological hyperactive bladder underwent an SNM test. Questioned about their symptoms before and during the test by the urinary handicap assessment scale, patients were divided into two groups: A (improved) and B (not improved). Group A consisted of patients obtaining 50% improvement of their symptoms with SNM followed by return of symptoms at the end of the test, while the other patients constituted group B. We then compared the cystomanometric results according to their clinical response. RESULTS: The mean age was 53 years: 10 patients with a good response constituted group A (n=10, i.e. 42%) and 14 patients with a poor response constituted group B (n=14, i.e. 58%). Clinically, in patients with a good response, SNM decreased urge incontinence by 100%, day-time frequency by 89% and protections by 55%. Urodynamic assessment in group A during the test demonstrated a significant increase of +23% of bladder capacity (p<0.01), +57% of the volume of onset of the first unstable contraction (p<0.004), +83% of bladder volume to the first urge to urinate BI (p<0.001) and +46% to urgency B3 (p<0.04). During SNM, cystometry revealed that 1 or 2 bladder filling volumes were increased at B1 and/or B3 in 100% of improved subjects. In contrast, 1 or 2 volumes decreased at B1 and/or B3 in 58% of non-improved subjects. No significant difference of intensity of unstable contractions was observed between the 2 groups during SNM (p=0.31). CONCLUSION: A significant correlation was observed between the two methods of clinical and urodynamic assessment. Our results suggest the use of the cystomanometric increase of bladder volume at B1 and B3 as selection criterion for candidates for SNM with non-neurological hyperactive bladder.

Impact of constitutional genetic variation in androgen/oestrogen-regulating genes on age-related changes in human prostate.

OBJECTIVE: Benign prostatic hyperplasia (BPH) is the most common benign tumour in ageing men. While the etiopathology remains unsolved, a disruption in the endocrine/autocrine-paracrine prostatic homeostasis, involving steroid hormones, contributes to the pathogenesis of BPH. DNA polymorphisms in genes involved in hormone synthesis, signalling and metabolism may, therefore, be responsible for these changes. We have evaluated the correlation between specific genotypes in androgen- and oestrogen-regulating genes (AR, SRD5A2, CYP17 and CYP19), and age-related prostatic changes. METHODS: We have tested genetic susceptibility to morphological and pathological criteria in 195 French Caucasians, using allelic variants for candidate genes involved in androgen/oestrogen prostatic activity: androgen receptor (CAG repeats), 5alpha-reductase type 2 (TA repeats, V89L and A49T mutations), A2 variant of the 17alpha-hydroxylase (CYP17) and the simple tandem repeat polymorphism (STRP) aromatase (CYP19) polymorphisms. RESULTS: The A2 variant of 17alpha-hydroxylase (CYP17) and allele 191 of STRP aromatase (CYP19) showed an opposite effect on age-related prostate hyperplasia: CYP17 being associated with increased risk of prostate enlargement and CYP19 with reduced risk. The 5alpha-reductase type II variants studied did not show links with prostate hyperplasia. The androgen receptor gene CAG repeat length showed a low correlation with the increase of prostate weight, suggesting some effect on age-related prostate growth. CONCLUSION: These results suggested that common variants of the CYP17 gene are associated with prostate enlargement and therefore may increase the risk of development of BPH in this population, while infrequent variants of the aromatase gene (CYP19) could be of a protective nature.

[Vaginal delivery in a patient with an artificial urinary sphincter and augmentation enterocystoplasty]. / Accouchement par voie basse chez une patiente porteuse d'un sphincter artificiel urinaire et d'une entérocystoplastie d'agrandissement.

Few cases of management of pregnancy in patients with an artificial sphincter (AS) have been reported in the literature, but this situation is very likely to become increasingly frequent with the more frequent use of AS in children. The authors report the case of a pregnancy in a 36-year-old woman with lumbosacral spina bifida, treated by artificial urinary sphincter and augmentation enterocystoplasty. The pregnancy and vaginal delivery did not raise any particular problems. Vaginal delivery is possible provided several precautions are observed: pelvimetry, MRI at the 8th month of pregnancy and close collaboration between urologists and obstetricians near term. Emergency caesarean section should be avoided due to the risk of lesions caused by elements of the AS and the surgical difficulties related to the presence of the augmentation enterocystoplasty.

[Robot-assisted (Da Vinci) laparoscopic uretero-pelvic junction repair. Results of experimental surgery in a series of 14 pigs]. / Cure de JPU coelioscopique assistée par robot (Da Vinci). Résultats en chirurgie expérimentale, à propos de 14 cas chez le porc.

OBJECTIVE: Experimental feasibility of repair of the ureteropelvic junction syndrome by robot. MATERIAL AND METHODS: 14 procedures were performed in 14 pigs by a laparoscopic technique using the Da Vinci robot in the experimental surgery laboratory. RESULTS: This robot provides real 3D vision by means of articulated intracorporeal instruments controlled from a console. It can be used to perform laparoscopic procedures almost as easily as open surgery. Operators with no previous experience of laparoscopic surgery were able to rapidly perform relatively complex procedures. CONCLUSION: This technique should allow a reduction of the learning curve and should facilitate operations that are difficult to perform by conventional laparoscopic surgery, especially when reconstruction is necessary, with decreased fatigue for the surgeon.

[Relationship between the Area Under the Curve of detrussor contraction during micturition and the usual parameters of flow-pressure rate in women]. / Relations entre l'Aire Sous la Courbe de la contraction du détrusor pendant la miction et les paramètres usuels de l'examen pression-débit chez la femme.

OBJECTIVES: The aim of this work was to assess the relationship between a new urodynamic parameter Area Under Curve of detrusor pressure during voiding (AUCdet) and the usual pressure flow study parameters. MATERIAL AND METHODS: 103 women with various urinary symptoms (incontinence, dysuria, chronic bladder pain or frequent urinary infection) had a urodynamic evaluation with pressure flow analysis. The intravesical pressure was measured through a 6CH Porges Neoplex and the intra-abdominal pressure through a 6CH rectal catheter in an empty rectum. Pressure-flow study was performed one time in each patient. The maximum flow rate (Qmax), the detrusor pressure at maximal flow (PdetQmax), the vesical pressure at maximal flow (PvesQmax), the urethral resistance defined as the ratio between the PvesQmax and Qmax2 (RU) and the AUCdet/Vol were recovered. RESULTS: 85 women were included and mean age was 55 years old. The averages were 19.42 for Qmax, 28.91 for PdetQmax, 63.85 for PvesQmax, 2.10 for RU and 7.83 for AUCdet/Vol. The correlation with AUCdet/Vol were for Qmax -0.80 p < 0.0001, for PdetQmax 0.71 p < 0.0001, for PvesQmax 0.42 p < 0.001 and for RU 0.84 p < 0.0001. CONCLUSIONS: AUCdet/Vol is the first urodynamic parameter which takes into account the whole detrusor contraction during voiding. AUCdet/Vol is relatively close to the urethral resistance. The very high degree of correlation between RU and AUCdet/Vol confirms clinically this definition of the RU. Further studies are needed to assess the validity of AUCdet/Vol.

[Evaluation of the accuracy of four-channel multidetector CT for investigation of the renal arterial blood supply]. / Evaluation de la précision du scanner à quatre détecteurs dans l'exploration de la vascularisation artérielle rénale.

OBJECTIVE: To evaluate the accuracy of four-channel multidetector CT for investigation of the proximal and distal renal arterial blood supply. MATERIAL AND METHOD: Four-channel multidetector CT was performed in 51 patients prior to nephrectomy (3 bilateral nephrectomies). The anatomy of the renal pedicle was described intraoperatively and arteriography of the nephrectomy specimen was performed immediately postoperative. Preoperative CT data were compared to intraoperative anatomical findings and arteriography findings on 54 nephrectomy specimens. Concordance analysis (determination of the kappa coefficient) was based on 4 criteria: number of renal arteries, position of the artery with respect to the vein, the intra-sinus or extra-sinus situation of the division of the artery and the number of first order branches. RESULTS: The concordance between CT and intraoperative anatomical findings was good for number of renal arteries (kappa = 0.78) and moderate for the position of the artery with respect to the vein (kappa = 0.65). The concordance between CT and arteriography was poor for the intra-sinus or extra-sinus situation of the division of the renal artery (kappa = 0.5) and for the number of first order branches of the renal artery (kappa = 0.41). CONCLUSION: Four-channel multidetector CT precisely visualizes the proximal renal arterial blood supply, but remains less accurate than arteriography for investigation of the distal arterial blood supply.

[Contribution of the latest generation CT in preoperative assessment of kidney cancer]. / Apport du scanner de dernière génération dans le bilan pré-opératoire du cancer du rein.

Technological progress in medical imaging runs in parallel to progress in computers, with an ever-increasing image acquisition rate and increasingly fine image reconstruction. Following the appearance, several years ago, of spiral acquisition CT, the multiplication of detectors (multi-array CT) has opened up new possibilities for investigation, especially in the field of renal tumours, where CT is now the first-line investigation due to the information obtained for characterization, vascular anatomical relations, and staging. The development of partial surgery (in which the detection of satellite lesions is essential) and minimally invasive laparoscopic surgery will be able to take full advantage of this progress in imaging by anticipating operative difficulties (number of tumours, situation and branches of arteries and veins or their collaterals, venous thrombus, relations with the urinary tract). Volume acquisition allows representation of these elements in the various dimensions, facilitating interpretation of the images.

[Prostate cancer screening]. / Dépistage du cancer de la prostate.

Prostate cancer has become the most frequent cancer and the second cause of cancer mortality in men. This public health problem is becoming increasingly important due to the increasing life expectancy. At the present time, prostate cancer will be discovered in one in every eight men during their lifetime. Prostate cancer represents 25% of all new cases of male cancers. Prostate cancer screening is designed to detect early stage, asymptomatic prostate cancer, as the patient's chances of cure are higher when the cancer is diagnosed at an early stage. The conclusions of the ANAES evaluation in 1998 did not recommend mass screening for prostate cancer. Several international prospective randomized studies based on serum PSA assay, sometimes associated with digital rectal examination, are currently underway. France is participating in the European ERSPC study (European Randomized Study of Screening for Cancer Prostate) and is organizing a national study on high-risk populations. While waiting for the final results of these studies, a recommendation needs to be proposed to inform general practitioners and specialists about optimal use of the currently available tests. Based on the conclusions of its oncology committee (composed of urologists, medical oncologists, radiotherapists, pathologists and radiologists), the Association Française d'Urologie proposes a recommendation concerning prostate cancer screening and defines its modalities, especially concerning the target population, screening tests and the information given to men before screening. The Association Française d'Urologie recommends prostate cancer screening by PSA assay (prostate specific antigen) and digital rectal examination annually between the ages of 50 and 75 years, and from the age of 45 years in men with a family or ethnic risk. If total PSA is above the normal value of the test or if digital rectal examination is abnormal, referral to a urologist is recommended. Information concerning the limits, benefits and risks of screening and the available treatment options must be given before performing these examinations.

Association between estrogen and androgen receptor genes and prostate cancer risk.

OBJECTIVE: Prostate cancer (PC) is one of the principal causes of death among men. Steroid hormones are involved in normal prostate growth and carcinogenesis. The purpose of our study was to investigate the effects on PC risk of polymorphisms from three steroid hormone receptor genes: the androgen (AR), and the alpha (ESR1) and beta (ESR2) estrogen receptors. DESIGN AND METHODS: The study was performed on a Caucasian population of 1045 PC patients and 814 controls. Using a logistic regression model, the different alleles and genotypes from those polymorphisms were analyzed according to case/control status, the tumor aggressiveness, and the age at onset. RESULTS: A significant association between PC risk and the pooled 4/5, 5/6, and 6/6 genotypes of the GGGA repeat located in the first intron of ESR1 (odds ratio (OR)=3.00, 95% CI=1.32-6.82, P=0.008) was observed. When we stratified the cases, this association was confined to patients with a Gleason score of 2-4 (OR=8.34, 95% CI=2.91-23.91, P<0.0001) or late onset PC (OR=2.91, 95% CI=1.22-6.93, P=0.016). An association between a short AR CAG repeat (less than 17 repeats) was also observed among patients with late onset PC (OR=2.34, 95% CI=1.15-4.76, P=0.019). CONCLUSIONS: These findings suggest that the GGGA repeat from ESR1 and the CAG repeat from AR may be associated with risk of late onset PC.

BRCA2 mutation screening is clinically relevant in breast and early prostate cancer families.

It is known that in some families an association exists between breast and prostate cancer. Several reports have suggested that BRCA2 mutations may be associated with an increased risk of these cancers. Herein, we report three cases of early onset of prostate cancer in families with female and male breast cancers. In each case, the familial phenotype is associated with a mutation of the BRCA2 gene. More generally, genetic counseling, including screening for BRCA2 mutations, should become standard practice in kindred with prostate and breast cancers.