Postoperative nomogram to predict cancer-specific survival after radical nephroureterectomy in patients with localised and/or locally advanced upper tract urothelial carcinoma without metastasis.

OBJECTIVE: To propose and validate a nomogram to predict cancer-specific survival (CSS) after radical nephroureterectomy (RNU) in patients with pT1-3/N0-x upper tract urothelial carcinoma (UTUC). PATIENTS AND METHODS: The international and the French national collaborative groups on UTUC pooled data from 3387 patients treated with RNU. Only 2233 chemotherapy naïve pT1-3/N0-x patients were included in the present study. The population was randomly split into the development cohort (1563) and the external validation cohort (670). To build the nomogram, logistic regressions were used for univariable and multivariable analyses. Different models were generated. The most accurate model was assessed using Harrell's concordance index and decision curve analysis (DCA). Internal validation was then performed by bootstrapping. Finally, the nomogram was calibrated and externally validated in the external dataset. RESULTS: Of the 1563 patients in the nomogram development cohort, 309 (19.7%) died during follow-up from UTUC. The actuarial CSS probability at 5 years was 75.7% (95% confidence interval [CI] 73.2-78.6%). DCA revealed that the use of the best model was associated with benefit gains relative to prediction of CSS. The optimised nomogram included only six variables associated with CSS in multivariable analysis: age (P < 0.001), pT stage (P < 0.001), grade (P < 0.02), location (P < 0.001), architecture (P < 0.001) and lymphovascular invasion (P < 0.001). The accuracy of the nomogram was 0.81 (95% CI, 0.78-0.85). Limitations included the retrospective study design and the lack of a central pathological review. CONCLUSION: An accurate postoperative nomogram was developed to predict CSS after RNU only in locally and/or locally advanced UTUC without metastasis, where the decision for adjuvant treatment is controversial but crucial for the oncological outcome.

Survey on vasectomy practices in France in 2022.

OBJECTIVES: Prior to the publication of the recommendations of the French Association of Urology (AFU) on vasectomy, we conducted a survey to assess current practices and required training interventions in France regarding vasectomy. METHOD: An invitation with a link to a 38-item questionnaire on MonkeySurvey was sent in November 2022 to the 1760 urologist members of the AFU. RESULTS: A total of 352 (20%) urologists completed the survey. Among the participants, 20% reported refusing the surgery to patients aged 25 to 30 years old and 17% if they had no children, respectively. Three quarters of participants mentioned systematically performing a scrotal exam at the time of the pre-vasectomy consultation. Forty-one percent of respondents reported systematically performing vasectomy under general anesthesia. While 56% of participants mentioned performing a minimally invasive technique for exposing the vas, 70% said they were willing to learn the no-scalpel technique for this purpose. The most frequently reported occlusion techniques combine excision of a vas segment and ligation of both ends of the divided vas. Only 26% reported performing fascial interposition and 4% using the "open end" technique. A post-vasectomy semen analysis showing less than 100,000 non-motile sperm per millilitre makes only 38% of respondents recommending stopping other contraceptive methods. Half of the respondents considered that current reimbursement fee structure for the procedure restrains the development of this clinical activity. CONCLUSION: Our survey suggests that vasectomy practice and services in France do not meet the international standards. We identified the clinical and organizational changes needed to improve practices and access to vasectomy services in France. LEVEL OF EVIDENCE: Grade 3.

Prediction of cancer specific survival after radical nephroureterectomy for upper tract urothelial carcinoma: development of an optimized postoperative nomogram using decision curve analysis.

PURPOSE: We conceived and proposed a unique and optimized nomogram to predict cancer specific survival after radical nephroureterectomy in patients with upper tract urothelial carcinoma by merging the 2 largest multicenter data sets reported in this population. MATERIALS AND METHODS: The international and the French national collaborative groups on upper tract urothelial carcinoma pooled data on 3,387 patients treated with radical nephroureterectomy for whom full data for nomogram development were available. The merged study population was randomly split into the development cohort (2,371) and the external validation cohort (1,016). Cox regressions were used for univariable and multivariable analyses, and to build different models. The ultimate reduced nomogram was assessed using Harrell's concordance index (c-index) and decision curve analysis. RESULTS: Of the 2,371 patients in the nomogram development cohort 510 (21.5%) died of upper tract urothelial carcinoma during followup. The actuarial cancer specific survival probability at 5 years was 73.7% (95% CI 71.9-75.6). Decision curve analysis revealed that the use of the best model was associated with benefit gains relative to the prediction of cancer specific survival. The optimized nomogram included only 5 variables associated with cancer specific survival on multivariable analysis, those of age (p = 0.001), T stage (p <0.001), N stage (p = 0.001), architecture (p = 0.02) and lymphovascular invasion (p = 0.001). The discriminative accuracy of the nomogram was 0.8 (95% CI 0.77-0.86). CONCLUSIONS: Using standard pathological features obtained from the largest data set of upper tract urothelial carcinomas worldwide, we devised and validated an accurate and ultimate nomogram, superior to any single clinical variable, for predicting cancer specific survival after radical nephroureterectomy.

A systematic review of the tools available for predicting survival and managing patients with urothelial carcinomas of the bladder and of the upper tract in a curative setting.

OBJECTIVES: To identify the predictive tools which have emerged recently in the field of urothelial carcinomas. MATERIALS AND METHODS: We performed a thorough MEDLINE literature review using a combination of the following keywords: urothelial carcinoma, transitional cell carcinoma, bladder, renal pelvis, ureter, predictive tools, predictive models and nomograms. We found 117 articles, but only the relevant reports were selected. RESULTS: The majority of available tools are prediction models, particularly nomograms. These models combine good performance accuracy with ease of use. They appear to be more accurate than risk grouping or tree modeling and are more suitable for clinicians than artificial intelligence. The most recent nomograms have been designed to be used in daily clinical practice and are even available as computer or smartphone applications. They focus on pathological outcomes or more frequently on survival statistics or recurrence risk after surgery. They provide an accurate prediction of disease evolution and may help clinicians to choose the most appropriate treatment option. However, these prediction tools still need to be validated and regularly utilized. CONCLUSION: Predictive tools represent very helpful clinical decision-making aids but need to be validated in larger populations.

A direct comparison of the diagnostic accuracy of three prostate cancer nomograms designed to predict the likelihood of a positive initial transrectal biopsy.

BACKGROUND: Several tools have been developed to predict the outcome of prostate biopsies performed to diagnosis prostate cancer (PCa). However, few studies have focused on the comparative accuracy of these predictive tools. We aim to establish the predictive accuracy of three commonly used nomograms by comparing their prostate biopsy outcome predictions with actual pathological results. METHODS: From January 2008 to December 2010, 708 consecutive patients with an elevated serum PSA level and/or abnormal DRE were referred to our institution. All data were collected prospectively. All patients underwent a TRUS 12-core biopsy. Probability of a positive biopsy was predicted using three online risk calculation nomograms. The discriminative ability of the nomograms was assessed via AUC and the most accurate model was calibrated and compared to actual biopsy results. RESULTS: Of 667 patients fulfilling all three nomograms criteria, 384 (57.5%) had PCa and 283 (42.5%) did not. AUC for the PCPT-CRC, SWOP-PRI, and Montreal nomograms was 0.68 (95% CI, 0.63-0.72), 0.72 (95% CI, 0.68-0.76), and 0.79 (95% CI, 0.76-0.82), respectively. A comparison of the three models' performance showed that the Montreal model provided the greatest predictive accuracy (P = 0.03). CONCLUSIONS: External validation of three commonly used nomograms designed to predict the likelihood of a positive prostate biopsy reveals the Montreal model was more accurate than either the PCPT-CRC or SWOP-PRI models. The Montreal nomogram achieves a diagnostic accuracy of 79% and is superior to PSA alone though we await further research to define the probability (of cancer) threshold above which a prostate biopsy would be advised.

A 970 Hounsfield units (HU) threshold of kidney stone density on non-contrast computed tomography (NCCT) improves patients' selection for extracorporeal shockwave lithotripsy (ESWL): evidence from a prospective study.

UNLABELLED: What's known on the subject? and What does the study add? Stone density on non-contrast computed tomography (NCCT) is reported to be a prognosis factor for extracorporeal shockwave lithotripsy (ESWL). In this prospective study, we determined that a 970 HU threshold of stone density is a very specific and sensitive threshold beyond which the likelihood to be rendered stone free is poor. Thus, NCCT evaluation of stone density before ESWL may useful to identify which patients should be offered alternative treatment to optimise their outcome. OBJECTIVE: • To evaluate the usefulness of measuring urinary calculi attenuation values by non-contrast computed tomography (NCCT) for predicting the outcome of treatment by extracorporeal shockwave lithotripsy (ESWL). PATIENTS AND METHODS: • We prospectively evaluated 50 patients with urinary calculi of 5-22 mm undergoing ESWL. • All patients had NCCT at 120 kV and 100 mA on a spiral CT scanner. Patient age, sex, body mass index, stone laterality, stone size, stone attenuation values (Hounsfield units [HU]), stone location, and presence of JJ stent were studied as potential predictors. • The outcome was evaluated 4 weeks after the ESWL session by NCCT. • ESWL success was defined as patients being stone-free (SF) or with remaining stone fragments of <4 mm, which were considered as clinically insignificant residual fragments (CIRF). RESULTS: • Our survey concluded that 26 patients (52%) were SF, 12 (24%) had CIRF and 12 (24%) had residual fragment on NCCT after a one ESWL treatment. • Stones of patients who became SF or had CIRF had a lower density compared with stones in patients with residual fragments [mean (sd) 715 (260) vs 1196 (171) HU, P < 0.001]. • The Youden Index showed that a stone density of 970 HU represented the most sensitive (100%) and specific (81%) point on the receiver-operating characteristic curve. • The stone-free rate for stones of <970 HU was 96% vs 38% for stones of ≥ 970 HU (P < 0.001). A linear relationship between the calculus density and the success rate of ESWL was identified. CONCLUSION: • The use of NCCT to determine the attenuation values of urinary calculi before ESWL helps to predict treatment outcome, and, consequently, could be helpful in planning alternative treatment for patients with a likelihood of a poor outcome from ESWL.

Low accuracy of routine ultrasound-guided systematic 12-core biopsies in prostate tumor mapping.

INTRODUCTION: To determine the accuracy of a 12-core biopsy protocol in assessing the location of prostate tumors within radical prostatectomy (RP) specimens. MATERIALS AND METHODS: A consecutive series of patients with T1c stage prostate cancer who had undergone 12 ultrasound-guided prostate biopsies prior to RP was considered. The locations of the biopsies from prostate gland mapping were compared with the locations of tumor tissues obtained after analysis of the prostate specimens. RESULTS: Overall, 78 patients (27.4%) were included. The median PSA level was 6 ng/mL. The median prostate weight was 45 g (range 22 to 102). Overall, 936 biopsies were performed in the 78 men, of which 254 biopsies were positive. The mean number of positive biopsies per patient was 3.7 (range 1 to 12). Pathologic examination of the surgical specimens revealed that 58 (74.4%) patients had pT2 disease and 20 patients (25.6%) had locally advanced disease (pT3). The biopsy protocol's sensitivity, specificity and positive predictive value for tumor location were 0.34, 0.83 and 0.84. The performance of the protocol was modest in assessing the exact tumor location (area under curve (AUC) 0.581, 95% confidence interval (CI) 0.489-0.719). CONCLUSIONS: Routine, ultrasound-guided, systematic 12-core biopsies lack precision in prostate tumor mapping.

Impact of elective versus imperative indications on oncologic outcomes after open nephron-sparing surgery for the treatment of sporadic renal cell carcinomas.

PURPOSE: To determine the effect of nephron-sparing surgery (NSS) on cancer control in renal cell carcinomas (RCC) and to compare the outcomes of patients who had elective versus imperative indications for surgery. METHODS: We performed a retrospective review of the data for patients treated with open NSS between 1980 and 2005 for sporadic RCCs. The following data were analyzed: age, intraoperative parameters, tumor size, Fuhrman grade, tumor, node, metastasis system disease stage, pathological data, and outcome. RESULTS: A total of 155 patients with a median age of 60 years were included. The mean preoperative and postoperative creatinine levels were 1.1 ± 0.3 mg/dl (range 0.6-2.6 mg/dl) and 1.2 ± 0.4 mg/dl (range 0.5-3.4 mg/dl), respectively. The mean tumor size was 3.8 ± 2 cm (range 1-10 cm). Margin status was positive in 15 cases (9.70%), and multifocal RCCs were observed in 36 patients (23.2%). Overall, NSS indications were elective in 96 cases (61.9%) and imperative in 59 cases (38.1%). Univariate analysis found that elective cases were associated with better perioperative outcomes (P = 0.01). In univariate analysis, tumor, node, metastasis system disease stage, multifocality, and indication were associated with recurrence (P < 0.05). In the multivariate analysis, only multifocality status and imperatives indications were significant (P < 0.05). The mean follow-up was 118.2 ± 151 months. The 5- and 10-year tumor-free survival rates were 81.8% and 78.7% in elective and imperatives cases, respectively. CONCLUSIONS: Oncologic control seems to be better for cases of elective open NSS. Thus, NSS should be advocated as soon as it is technically possible, regardless of the size of the tumor.

Pathological findings and oncological control afforded by radical prostatectomy in men with high-risk prostate cancer: a single-centre study.

OBJECTIVE: To assess pathological findings and oncological control afforded by radical prostatectomy (RP) in high-risk prostate cancers (PCa) at our institution. MATERIALS AND METHODS: We performed a retrospective review of prostate cancer patients who underwent RP between 1995 and 2006 for a high-risk prostate cancer (i.e., PSA >20 or biopsy Gleason ≥8 or clinical stage ≥T2c). Biochemical recurrence was defined as a single rise in PSA levels over 0.2 ng/ml after surgery. Survival curves were elaborated by the Kaplan-Meier method and Cox proportional hazard regression analysis. For each patient, a prognostic score for recurrence was estimated, and a prediction model was then constructed. RESULTS: Overall, 138 patients were included and followed for a median time of 53 months. Mean age at diagnosis was 63.4 years (range 39-80) and mean pre-operative PSA was 15.5 ng/ml (range 7.4-31). The median follow-up was 53 months (range 6-166). Overall, 82 patients (59%) had biochemical recurrence. The five-year PSA recurrence-free survival rate was 40%. In univariate analysis, clinically palpable tumours (T2-T3) (P = 0.032), biopsy Gleason score ≥8 (P = 0.031), seminal vesicle invasion (pT3b), positive margins and positive lymph nodes (P < 0.001) were significantly associated with recurrence. In multivariate analysis, the biopsy Gleason score ≥8, seminal vesicle invasion, positive margins and positive lymph nodes predicted recurrence (P < 0.05). CONCLUSIONS: RP affords an acceptable oncological control at first-line treatment of selected patients with high-risk PCa. However, in certain cases, surgery alone might not be sufficient and may be part of a multimodal treatment including either adjuvant radiotherapy or androgen deprivation.

Long-term outcomes after nephron sparing surgery for renal cell carcinoma larger than 4 cm.

PURPOSE: We determined the cancer control provided by nephron sparing surgery for renal cell carcinoma greater than 4 cm. MATERIALS AND METHODS: We performed a retrospective review of data on patients treated between 1980 and 2005. The case characteristics analyzed were patient age, surgical procedure, intraoperative parameters, complications, tumor size, Fuhrman grade, TNM stage, pathological data and outcome. Kaplan-Meier survival curves were generated. RESULTS: Median age of the 61 patients was 64 years (range 40 to 83). Mean +/- SD intraoperative blood loss was 622 ml +/- 691 (range 50 to 4,800) and mean operative time was 155.7 +/- 82 minutes (range 52 to 360). Mean creatinine preoperatively and immediately postoperatively was 1.16 and 1.25 mg/dl, respectively. Mean renal cell carcinoma size was 56.3 +/- 18 mm (range 41 to 100). Margin status was positive in 11 cases (18%). Median followup was 70.7 months. The 5 and 10-year cancer specific survival rate was 81% and 78%, respectively. The tumor-free survival rate was 92% at 5 years and 88% at 10 years. On univariate analysis tumor size more than 7 cm (p = 0.002), pathological stage (p = 0.001) and Fuhrman grade (p = 0.004) were associated with survival. On multivariate analysis only pathological stage and Fuhrman grade were significant (p <0.0001 and 0.007, respectively). CONCLUSIONS: Our results support the fact that nephron sparing surgery is a useful and acceptable approach to renal cell carcinoma greater than 4 cm. When technically possible, nephron sparing surgery provides acceptable long-term cancer specific survival rates. However, oncological safety is less evident in cases of renal cell carcinoma greater than 7 cm. To date in such cases nephron sparing surgery should only be considered for absolute indications.

Cross-cultural validation of a prognostic tool: example of the Kattan preoperative nomogram as a predictor of prostate cancer recurrence after radical prostatectomy.

OBJECTIVE: To establish the predictive accuracy of the Kattan preoperative nomogram by comparing predictions at 5 years with actual progression in patients who had a radical prostatectomy (RP). MATERIALS AND METHODS: We reviewed the data for 928 patients treated by RP as a first-line treatment for localized prostate cancer, between 1994 and 2005. Recurrence was defined as one prostate-specific antigen (PSA) level of >0.4 ng/mL. The 5-year progression-free probability (PFP) rate was evaluated on censured data using the Kaplan-Meier method. Relationships between all predictor variables included in the Kattan nomogram (PSA level, biopsy Gleason scores and clinical stage) and survival were evaluated by Cox proportional-hazards regression analysis. The discriminating ability of the nomogram was assessed by the concordance index (c-index). Bootstrapping was used to assess confidence intervals (CIs), and then the calibration was assessed. RESULTS: The median follow-up was 60 months. Overall, 177 (19%) patients had a recurrence; the 5-year PFP rate (95% CI) was 80.9 (78-83)%. Of the three variables included in the nomogram, all were associated with recurrence in a multivariate analysis (P < 0.001). The c-index (95% CI) was only 0.664 (0.584-0.744). In general, the nomogram was not well calibrated. CONCLUSIONS: There was a discrepancy between the predicted PFP as estimated by the Kattan nomogram and actual relapse in this group of patients. Clinicians should be aware that the nomogram is less accurate when used outside the population used to formulate the nomogram. Although more accurate tools are needed, the Kattan nomogram is still the best choice for urologists so far.

Comparison of mid-term carcinologic control obtained after open, laparoscopic, and robot-assisted radical prostatectomy for localized prostate cancer.

OBJECTIVE: To determine the cancer control afforded by radical prostatectomy in patients who underwent either an open, laparoscopic, or robotic procedure for localized prostate cancer. METHODS: We collected data on all patients treated between 2000 and 2004. We recorded age, BMI, PSA, Gleason score and 2002 TNM stage, type of surgery, perioperative parameters, postoperative complications, pathological data, recurrence and outcome. RESULTS: Data were analyzed for 239 patients. Overall, the mean follow-up was 49.7 (18-103) months. Surgical procedures were open in 83 patients, laparoscopic in 85, and robot-assisted in 71. The transfusion rate was 5.6% for robotic cases, 5.9% for laparoscopic cases and 9.6% for open prostatectomy (p = 0.03). The positive margin rates in open, laparoscopic, and robotic cases were 18.1, 18.8, and 16.9% (p = 0.52), respectively. Only margin status, PSA level (>10), and Gleason score (>7) were associated with recurrence in univariate analysis (p < 0.05), and only the margin status and the Gleason score were significant in multivariate analysis. The statistical power was 0.7. Overall, the 5-year PSA-free survival rate was 88%. The 5-year PSA-free survival rates for the specific surgical approaches were 87.8% in open cases, 88.1% in laparoscopic cases, and 89.6% in robot-assisted prostatectomies, and there was no statistical difference between the approaches (p = 0.93). CONCLUSION: Although open radical prostatectomy remains the gold standard procedure, we found no differences between these three techniques regarding early oncologic outcomes. These results are still preliminary, however, and further studies of larger populations with a longer follow-up are needed to make any statement regarding surgical strategy.

Promoter hypermethylation in circulating blood cells identifies prostate cancer progression.

Promoter hypermethylation of circulating cell DNA has been advocated as a diagnostic marker for prostate cancer, but its prognostic use is currently unclear. To assess this role, we compared hypermethylation of circulating cell DNA from prostate cancer patients with (Group 1, n = 20) and without (Group 2, n = 22) disease progression and age-matched controls (benign prostatic hyperplasia, Group 3, n = 22). We measured hypermethylation of 10 gene promoters in 2 sequential venous samples, obtained at diagnosis and during disease progression (median time, 15 months later). Matched time samples were obtained in the nonprogressing patients. We found that more hypermethylation was detected in the diagnostic sample from the patients with cancer than in controls for GSTP1, RASSF1 alpha, APC and RAR beta (p < 0.0001). Patients undergoing disease progression had a significant increase in methylation levels of these 4 genes when compared to the other patients (p < 0.001). Patients at risk of disease progression have higher detectable concentrations of circulating cell hypermethylation, than those without progression. The extent of this hypermethylation increases during disease progression and can be used to identify the extent and duration of treatment response in prostate cancer.

A comparison of the performance of microsatellite and methylation urine analysis for predicting the recurrence of urothelial cell carcinoma, and definition of a set of markers by Bayesian network analysis.

OBJECTIVE: To compare the potential of two diagnostic methods for detecting recurrence of urothelial cell carcinoma (UCC) of the bladder, by (i) detecting alterations in microsatellite DNA markers and loss of heterozygosity (LOH), and (ii) detecting aberrant gene hypermethylation, as UCC has a high recurrence rate in the urinary tract and the disease can invade muscle if new tumours are overlooked. PATIENTS AND METHODS: Over 1 year, urine samples were retrieved from 40 patients already diagnosed with bladder UCC (30 pTa, two pTis, eight pT1). Samples were collected 6 months after bladder tumour resection, during the follow-up schedule. We used samples to analyse nine microsatellite markers and the methylation status of 11 gene promoters. Receiver operating characteristic curves were generated and Bayesian statistics used to create an interaction network between recurrence and the biomarkers. RESULTS: During the study, 15 of the 40 patients (38%) had a tumour recurrence and 14 were identified by cystoscopy (reference method). Overall, microsatellite markers (area under curve, AUC 0.819, 95% confidence interval, CI, 0.677-0.961) had better performance characteristics than promoter hypermethylation (AUC 0.448, 0.259-0.637) for detecting recurrence. A marker panel of IFNA, MBP, ACTBP2, D9S162 and of RASSF1A, and WIF1 generated a higher diagnostic accuracy of 86% (AUC 0.92, 0.772-0.981). CONCLUSION: Microsatellite markers have better performance characteristics than promoter hypermethylation for detecting UCC recurrence. These data support the further development of a combination of only six markers from both methods in urinary DNA. Once validated, it could be used routinely during the follow-up for the early detection and surveillance of UCC from the lower and upper urinary tract.

Molecular detection of localized prostate cancer using quantitative methylation-specific PCR on urinary cells obtained following prostate massage.

PURPOSE: The diagnosis of localized prostate cancer is difficult due to a lack of cancer-specific biomarkers. Many patients require repeat prostate biopsies to diagnose the disease. We investigated whether aberrant promoter hypermethylation in prostatic fluid could reliably detect prostate cancer. EXPERIMENTAL DESIGN: Urine samples were collected after prostate massage from 95 patients with localized prostate cancer undergoing radical prostatectomy (63 pT(1), 31 pT(2), and 1 pT(3)) and from 38 control patients. Ten genes (GSTP1, RASSF1a, ECDH1, APC, DAPK, MGMT, p14, p16, RARbeta2, and TIMP3) were investigated using quantitative real-time methylation-specific PCR. Receiver operator curves were generated. RESULTS: The frequency of gene methylation ranged from 6.3% (p14) to 83.2% (GSTP1) in prostate cancer patients. At least one gene was hypermethylated in 93% of cancer patients. The specificity of methylation was 0.74. Methylation was significantly more frequent (P < 0.05) in cancer than control patients for all genes except p14 and p16. According to receiver operator curve analysis, the four-gene combination of GSTP1 (0.86), RASSF1a (0.85), RARbeta2 (0.80), and APC (0.74) best discriminated malignant from nonmalignant cases. The sensitivity and accuracy of this four-gene set were 86% and 89%, respectively. CONCLUSIONS: The presence of aberrant methylation in urinary cells obtained after prostate massage is significantly associated with prostate cancer. A panel of four genes could stratify patients into low and high risk of having prostate cancer and optimize the need for repeat prostatic biopsies.

[Sporadic bilateral kidney tumour: practical approach and place of conservative surgery]. / Tumeur renale bilatérale non héréditaire: attitude pratique et place de la chirurgie conservatrice.

OBJECTIVE: To study the specific features of the sporadic form of bilateral renal cell carcinoma (RCC). MATERIAL AND METHOD: Twenty-six patients presented bilateral RCC among a total of 759 patients operated for RCC in our institution between 1985 and 1998. The mean follow-up for 23 patients (3 were lost to follow-up) was 56.5 months. Actuarial survival was estimated by the Kaplan-Meier method and comparisons between the various groups were performed with a Mann-Whitney test. RESULTS: This series comprised 10 asynchronous tumours and 16 synchronous tumours. The mean diameter of synchronous tumours was significantly greater than that of asynchronous tumours (61 vs 33.5 mm). Histology revealed 16 clear cell carcinomas (CCC), 7 tubulopapillary carcinomas (TPC), 2 cases with CCC and TPC, and one bilateral oncocytoma. Malignant tumours were classified as stage T1-T2 (n=23) or T3 (n=2). TPC was more frequently bilateral than CCC (7.9% vs. 2.8%). Forty-four surgical operations (19 radical nephrectomies and 24 partial nephrectomies) were performed. The mean interval between two operations for asynchronous tumours was 85.2 months. Follow-up demonstrated 15 remissions and 6 deaths, including 5 deaths due to RCC, one local recurrence and one local recurrence with metastases. One-year specific survival was 96% and 5-year survival was 74%. Age, gender, histological type and the asynchronous or synchronous mode did not induce any significant difference on survival. CONCLUSION: The surgical approach must therefore be resolutely conservative in view of the good 5-year survival rate and the low local recurrence and metastasis rates.

[The choice of a medical career in a population of 600 second-cycle French medical students preparing the national-ranking exam]. / Souhaits professionnels de 600 etudiants en médecine français préparant les epreuves classantes nationales.

OBJECTIVES: To analyse the choice of career of a sample of second-cycle French medical students following the implementation of the recent national-ranking exam (NRE). METHODS: All the medical students registered in a cycle of conferences to prepare for the NRE filled-in a self-administered, anonymous, questionnaire in Paris and the provinces during the university year 2004. The items concerned the choice of career, according to the NRE discipline selected, and the mobility required for the success of the project. RESULTS: Six hundred students were included in the study; 398 were women (66%) and 202 were men (34%), with a mean age of 23.2 +/- 6 years (21-29). Two hundred were at the end of their first cycle (33%) and 400 at the end of their third cycle (67%). Two hundred came from the provinces (33%) and 400 from Paris. Regarding the disciplines selected, medical specialisation predominated (36.2%) followed by surgical specialisation (15.5%) and general medicine (11.3%); psychiatry ranked lowest (4.5%). Psychiatry ranked lowest in Paris (4.8%) and gynaecology-obstetrics in the provinces (3.5%). Regarding geographical mobility, 83.3% of Parisians and 16.8% of provincials refused the idea of completing their third cycle anywhere other than in their area of origin. CONCLUSION: The NRE permitted the integration of general medicine among all the other clinical specialisations. Surgery retained a place of choice among the disciplines selected by the students. However, many Parisian students will be obliged to take on a residency in a hospital other than their original university hospital.

[Kidney tumours: single-centre study of 810 patients. Changing features over a period of 15 years]. / Tumeurs du rein: etude monocentrique de 810 patients: evolution sur 15 ans.

OBJECTIVE: The Association Française d 'Urologie conducted a national epidemiological study in 1997. Using our database, we compared our results, up-dated the epidemiological data and evaluated the differences observed over a period of 15 years. PATIENTS AND METHODS: 844 patients operated for kidney tumour between 1985 and 2000 were analysed and 810 were included in this study. Survival analysis was performed according to the Kaplan-Meier method. Relative risks were determined by the Log-Rank test and multivariate analysis was performed with the Cox regression model. The limit of significance was 0.05. RESULTS: The mean age at the time of diagnosis was 59.6 years (range: 14.6-90.2). Most tumours were discovered incidentally by ultrasound. The mean tumour diameter was 61.7 mm (range: 20-230). The most frequent surgical operation was radical nephrectomy, but there was a tendency towards an increasing number of conservative operations. Histology revealed 94% of renal cell carcinomas, with 73% of conventional cell carcinomas. The mean follow-up was 49 months (range: 0-197) and 5-year and 10-year survival rates were 74.9 months and 62.6 months, respectively. Multivariate statistical analysis confirmed the prognostic significance of N and M stage, Fuhrman grade, histological type, as well as renal capsule invasion. CONCLUSION: Our data largely confirm those of the last national study conducted in 1997 as well as those of the international literature. Kidney tumours are increasingly discovered incidentally, but tumour size and the age of patients remain stable, while the number of conservative procedures continues to increase each year In addition to the usual prognostic factors, we found that renal capsule invasion was an independent prognostic factor.

[Value of infrared spectrophotometry morpho-constitutional analysis of double J stent encrustations for indirect determination of urinary stone composition]. / Intérêt de l'analyse morpho-constitutionnelle par spectrophotométrie infra-rouge des incrustations des sondes double J pour la détermination indirecte de la composition des calculs urinaires.

INTRODUCTION: A single stone analysis is necessary during the patient's clinical history in order to institute specific drug treatment and health and dietary measures to prevent stone recurrence. In practice, only one in every two stones is recovered for morpho-constitutional analysis. The objective of this study was to determine the place of double J stent encrustation analysis for indirect determination of stone composition. MATERIAL AND METHODS: Double J stents and stones from all patients treated in the same centre over 24 months were consecutively analysed by infrared spectrophotometry. The correlation coefficient 1, evaluating the concordance between the composition of stones and double J stent encrustation was estimated statistically by SPSS 12.0 software (0<1<1; 1=0: no concordance; 1=1: perfect concordance). RESULTS: 45 males and 27 females with a mean age of 45.3 years (range: 29-70) were included Double J stents were placed for: febrile obstruction (N=52; 72%), acute renal colic (N=15; 21%) and impaired renal function (N=5; 7%). Calculated values for 1 were: 0.78 for the concordance between the predominant constituent of the stone and the encrustation (N=72; p < 0.0005); 0.91 for the concordance between the nature of the encrustation of the upper loop and that of the lower loop of the stent (N=30, p < 0.0005). CONCLUSION: The composition of mineral encrustation of double J stents is a good marker of stone formation. This constitutes an alternative method that can be used by urologists when no stone is available for spectrophotometric analysis.

[Hereditary renal cell carcinoma: results and place of conventional conservative surgery]. / Carcinomes à cellules rénales héréditaires: résultats de la chirurgie conservatrice conventionnelle.

OBJECTIVES: To report the results of conservative surgery for the treatment of hereditary renal cell carcinoma (RCC) and to define its place with respect to new less invasive treatment options. MATERIAL AND METHOD: Over a period of 14 years, 30 women and 26 men were operated for one or several hereditary RCC, either by radical nephrectomy or nephron-sparing excision, via a lumbar or subcostal incision, when the diameter of at least one RCC was greater than 2.5 cm. RESULTS: 92 operations were performed: 62 local excisions and 30 nephrectomies. The TNM stage was: 75 pT1, 14 pT2, 3 pT3b; 4 N+; 3 M+. 26 patients (46%) were operated at least twice. Two or more RCC were resected in 43 cases (47%). In the case of nephron-sparing surgery, mean blood loss was 175 +/- 231.7 cc (range: 50-1300 cc); mean pedicle clamping time (97% of cases) was 32 +/- 10.4 min (range: 10-50 min); mean preoperative serum creatinine was 85 +/- 18 micromol/L (range: 52-150 micromol/L) and mean postoperative serum creatinine was 105 +/- 80 micromol/L (range: 59-576 micromol/L); the calculated tumour recurrence rate was 24% at 5 years and 80% at 8 years; overall 5-year survival was 100% and overall 10-year survival was 67%. The median follow-up was 55.9 months. CONCLUSION: When hereditary RCCs are situated between 2.5 cm and 6 cm in diameter, nephron-sparing surgery is the reference treatment. Modern imaging and genetic screening should allow early detection of increasingly smaller RCCs. In the future, less invasive treatment options could replace surveillance for RCCs less than 2 cm and eventually reduce the indications for local excision.