Renal tumor biopsy does not increase the risk of surgical complications of minimally invasive partial nephrectomy.

BACKGROUND: For patients with cT1 renal lesions, Partial Nephrectomy (PN) is the gold standard treatment. However, 20% of small renal masses are benign, situation in which the PN is an overtreatment. The percutaneous Renal Tumor Biopsy (RTB) may lower the risk of overtreatment as there is a 90% concordance rate on histotype between the RTB and the final pathology. It has been suggested that the RTB could increase the difficulty of the PN and increase the risk of surgical complications. OBJECTIVE: To compare surgical outcomes and complications of PN with or without previous RTB. DESIGN, SETTING, AND PARTICIPANTS: monocentric retrospective review of patients who underwent laparoscopic or robotic-assisted PN between January 2012 and December 2019. MEASUREMENTS: perioperative complications were recorded using Clavien-Dindo classification, peroperative data included operative time, clamping time and blood loss, and histological outcomes of RTB and PN. RESULTS AND LIMITATIONS: In total, 163 patients were included in our study. There were significantly less benign lesions in PN with prior RTB: 7% (4/56) vs. 20% (22/107) without prior RTB (P=0.03). There were no significant differences regarding Clavien-Dindo>2 perioperative complications with respectively 7% (4/56) vs. 10% (11/107) (P=0.57). Same goes for peroperative data such as duration of surgery (P=0.81), warm ischemia (P=0.07) and blood loss (P=0.13). CONCLUSIONS: RTB does not increase the risk of surgical complications of PN and may reduce the risk of small renal masses overtreatment.

[Rectourethral fistula treatment using the modified York Mason technique: Failure factors assessment]. / Cure de fistule recto-urétrale par la technique modifiée de York Mason : évaluation des facteurs d'échec.

OBJECTIVES: To assess surgical outcomes and failure factors in the management of rectourethral fistulas treated surgically with the modified York Mason technique based on our center's 25 years of experience. METHODS: From 1997 to 2021, in a single center study, a total of 35 consecutive patients, underwent rectourethral fistula cure, using the modified York Mason technique. Preoperative patient data, surgical outcomes and failure factors were assessed. RESULTS: Of the 35 patients, 28 were successfully managed without the need of further intervention (80%). Median age was 67 years (IQR 62-72) and median follow-up time was 71 months (IQR 30-123). There was no significant difference between the patients that had recurrence or not after the first York Mason. CONCLUSIONS: The modified York Mason technique offers a high success rate for the cure of iatrogenic rectourethral fistulas. No predictive factor of failure, after a first cure of recto-uretral fistula by modified York-Mason technique was reported. LEVEL OF EVIDENCE: 3.

Renal Tumor Biopsy: Rationale to Avoid Surgery in Small Renal Masses.

PURPOSE OF REVIEW: The use of renal tumor biopsy (RTB) for small renal masses (SRMs) in daily practice, although safe and accurate, is unusual. Considering the large number of benign tumors in patients with renal masses < 4 cm, some patients with benign tumors are directly referred for surgery instead. This study aimed to report the diagnostic rates of RTB, determine the concordance with surgical pathology, and assess the number of procedures that could have been avoided. We retrospectively studied 255 patients who underwent RTB at our institution in 2010-2019. Of them, 73 were excluded from the analysis (exclusion criteria: > 4 cm, cystic lesion, missing data). The remaining 182 with undetermined SRMs ≤ 4 cm underwent RTB under computed tomography guidance. RECENT FINDINGS: Biopsies were diagnostic in 154/182 (84.6%) cases. Of the non-diagnostic biopsies, 11 were diagnostic when repeated. When RTB was performed of all undetermined SRMs, active treatment (surgery or cryotherapy) was avoided in 50/182 patients (27.5%) because of a benign diagnosis, while 9/182 patients (4.9%) underwent surveillance after a shared multidisciplinary decision. The overall diagnostic rate was 90.6%. All adverse events (approximately 4%) were Clavien-Dindo grade I and did not require active treatment. RTB histology results and nuclear grade were highly concordant with the final pathology (96% and 86.6%, respectively). On univariate logistic regression analysis, male sex was the only contributing factor of diagnostic biopsy. RTB of SRMs should be performed more frequently as part of a multidisciplinary decision-making process since it avoided unnecessary surgical treatment in 1 of 3 patients in our institution.

[Management of ablative therapies in prostate cancer]. / Traitements ablatifs pour cancer de prostate : modalités de prise en charge.

OBJECTIVES: To describe the specific modalities of ablative therapies management in prostate cancer. MATERIALS AND METHODS: A review of the scientific literature was performed in Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of keywords. Publications obtained were selected based on methodology, language and relevance. After selection, 61 articles were analysed. RESULTS: Development of innovations such as ablative therapies in prostate cancer induces specific modalities in their management, during pre-, per- and post-procedure. More than for classical and well-known treatments, the decision to propose an ablative therapy requires analysis and consensus of medical staff and patient's agreement. Patient's specificities and economical aspects must also be considered. Procedures and follow-up must be realized by referents actors. CONCLUSION: Indication, procedure and follow-up of ablative therapies in prostate cancer require specific modalities. They must be respected in order to optimize the results and to obtain a precise and objective evaluation for defining future indications.

[Effect of wound infiltration of ropivacaine in postoperative pain after extraperitoneal laparoscopic radical prostatectomy]. / Effet de l'infiltration pariétale d'anesthésique local (ropivacaïne) sur la douleur postoperatoire après prostatectomie radicale laparoscopique sous-péritonéale.

PURPOSE: Evaluation of the efficiency of wound infiltration of ropivacaine in postoperative pain after extraperitoneal laparoscopic radical prostatectomy. MATERIAL AND METHODS: Prospective single institution study included 130 patients treated by extraperitoneal laparoscopic radical prostatectomy from January to March 2007. One hundred and two patients were included and randomised in two groups according to the year of birth (pair or impair). Only patients from the first group (year pair) had wound infiltration at the end of the procedure. The second group (year impair) was the control group. An analogic visual scale (EVA) permitted evaluation of pain at 30 minutes, 1, 6 and 12 hours after the procedure. Use of analgesics after procedure were noted for each patient. RESULTS: In the first group, the median of EVA was 1.44, 1.34, 1.72 and 1.51 respectively at 30 minutes, 1, 6 and 12 hours. In the second group, the median of EVA was 1.28, 1.36, 1.46 and 1.44. We found no statistically significant difference for pain and use of analgesic between the two groups (p=0.71, 0.96, 0.47 and 0.86 respectively at 30 minutes, 1, 6 and 12 hours). CONCLUSION: Ropivacaine in wound infiltration did not decrease significantly the postoperative pain and must not be used systematically.

Oncological outcomes and pathological characteristics of cT1 upstaging to pT3a renal cell carcinoma compared with de novo pT3a tumors. / Resultados oncológicos y características patológicas de la sobrestadificación de cT1 a carcinoma de células renales pT3a en comparación con los tumores pT3a de novo.

INTRODUCTION: The significance of upstaging of cT1 renal tumors to pT3a is not clear. We evaluate the incidence of upstaging, identify predictors and analyze oncological outcomes of these patients versus those who did not upstage. We also compared the oncological outcomes of cT1 upstaging to pT3a with de novo pT3a renal tumors. METHODS: From a database of 1021 renal tumors with complete available follow-up data, 517 patients had cT1. Patients upstaging to pT3a were compared to those who did not. Baseline clinical, perioperative, histopathologic features and oncological outcomes were analysed. RESULTS: Out of 517 cT1 patients, 105 (20.3%) upstaged to pT3a and 412 (79.7%) did not. Proportion of patients in each group undergoing partial and radical nephrectomy, postoperative tumor size, histology, margin status and lymph node involvement were similar. Among upstaged, 9 patients (8.6%) developed first recurrence as compared to only 3 (0.7%) in those not upstaging (P <0.001). The median time to recurrence (57 vs. 107 months; P <0.001) was lesser in de novo pT3a renal tumors. CONCLUSIONS: Pathological upstaging from cT1 to pT3a and necrosis on histopathology were associated with recurrence. Advanced age, smoking, necrosis on histopathology, clear cell histology and higher Fuhrman grades contributed to pathological upstaging of cT1 tumors. De novo pT3a RCC had worse survival when compared to cT1 patients upstaging to pT3a RCC.

Immediate versus delayed prostatectomy and the fate of patients who progress to a higher risk disease on active surveillance. / Prostatectomía inmediata versus demorada en pacientes que progresan a una enfermedad de mayor riesgo en vigilancia activa.

INTRODUCTION: Oncological outcomes of radical prostatectomy (RP) in patients progressing on active surveillance (AS) are debated. We compared outcomes of AS eligible patients undergoing RP immediately after diagnosis with those doing so after delay or disease progression on AS. METHODS: Between 2000 and 2014, 961 patients were AS eligible as per EAU criteria. RP within 6 months of diagnosis (IRP) or beyond (DRP), RP without AS (DRPa) and AS patients progressing to RP (DRPb) were compared. Baseline PSA, clinical and biopsy characteristics were noted. Oncological outcomes included adverse pathology in RP specimen and biochemical recurrence (BCR). Matched pair analysis was done between DRPb and GS7 patients undergoing immediate RP (GS7IRP). RESULTS: IRP, DRP, DRPa and DRPb had 820 (85%), 141 (15%), 118 (12.24%) and 23 (2.7%) patients respectively. IRP, DRPa and DRPb underwent RP at a median of 3, 9 and 19 months after diagnosis respectively. Baseline characteristics were comparable. DRP vs. IRP had earlier median time (31 vs. 43 months; p<.001) and higher rate of progression to BCR (7.6 vs. 3.9%;p=.045). DRPb showed higher BCR (19 vs. 5%;p=.021) with earlier median time to BCR, compared to IRP and DRPa (p=.038). There was no difference in adverse pathology and BCR rates, but time to BCR was significantly lesser in DRPb (49 vs. 6 months;p<.001), compared to GS7IRP. CONCLUSIONS: Patients progressing on AS had worst oncological outcomes. RP for GS7 progression and matched pair of GS7 patients had similar outcomes. Worse oncological outcomes in AS progressors cannot be explained by a mere delay in RP.

Systematic review of perioperative outcomes and complications after open, laparoscopic and robot-assisted radical cystectomy. / Revisión sistemática de resultados perioperatorios y complicaciones después de cistectomía radical abierta, laparoscópica y asistida por robot.

Radical cystectomy and regional lymph node dissection is the standard treatment for localized muscle-invasive and for high-risk non-muscle-invasive bladder cancer, and represents one of the main surgical urologic procedures. The open surgical approach is still widely adopted, even if in the last two decades efforts have been made in order to evaluate if minimally invasive procedures, either laparoscopic or robot-assisted, might show a benefit compared to the standard technique. Open radical cystectomy is associated with a high complication rate, but data from the laparoscopic and robotic surgical series failed to demonstrate a clear reduction in post-operative complication rates compared to the open surgical series. Laparoscopic and robotic radical cystectomy show a reduction in blood loss, in-hospital stay and transfusion rates but a longer operative time, while open radical cystectomy is typically associated with a shorter operative time but with a longer in-hospital admission and possibly a higher rate of high grade complications.

High intensity focused ultrasound with Focal-One® device: Prostate-specific antigen impact and morbidity evaluation during the initial experience. / Ultrasonido focalizado de alta intensidad con el dispositivo Focal-One®: impacto sobre el antígeno prostático específico y evaluación de la morbilidad durante la experiencia inicial.

OBJECTIVE: We report our initial experience in the treatment of prostate cancer (PCa) with high-intensity focused ultrasound (HIFU) using the Focal-One® device. MATERIAL AND METHODS: Retrospective review of the prospectively populated database. Between June 2014 to October 2015, 85 patients underwent HIFU (focal/whole-gland) treatment for localized PCa. Preoperative cancer localization was done with multiparametric magnetic resonance imaging (mpMRI) and transperineal mapping biopsies. Treatment was carried out using the Focal-One® device under general anesthesia. Oncological follow-up: PSA measurement and control biopsy with mpMRI according to protocol. Questionnaire-based functional outcome assessment was done. Complications were reported using Clavien classification. RESULTS: The median PSA was 7.79ng/ml (IQR 6.32-9.16), with a median prostate volume of 38cc (IQR: 33-49.75). Focal and whole-gland therapy was performed in 64 and 21 patients respectively. Ten patients received salvage HIFU. Complications were encountered in 15% of cases, all Clavien 2 graded. Mean hospital stay was 1.8 days (0-7) and bladder catheter was removed on day 2 (1-6). Mean percentage reduction of PSA was 54%. Median follow-up was 3 months (IQR: 2-8). Functional outcomes: All patients were continents at 3 months and potency was maintained in 83% of the preoperatively potent. CONCLUSIONS: Focal-One® HIFU treatment appears to be a safe procedure with few complications. Functional outcomes proved no urinary incontinence and sexual function were maintained in 83%.

Robotics in urological surgery: evolution, current status and future perspectives.

CONTEXT: Robotic surgery is rapidly evolving and has become an essential part of surgical practice in several parts of the world. Robotic technology will expand globally and most of the surgeons around the world will have access to surgical robots in the future. It is essential that we are updated about the outcomes of robot assisted surgeries which will allow everyone to develop an unbiased opinion on the clinical utility of this innovation. OBJECTIVE: In this review we aim to present the evolution, objective evaluation of clinical outcomes and future perspectives of robot assisted urologic surgeries. ACQUISITION OF EVIDENCE: A systematic literature review of clinical outcomes of robotic urological surgeries was made in the PUBMED. Randomized control trials, cohort studies and review articles were included. Moreover, a detailed search in the web based search engine was made to acquire information on evolution and evolving technologies in robotics. SYNTHESIS OF EVIDENCE: The present evidence suggests that the clinical outcomes of the robot assisted urologic surgeries are comparable to the conventional open surgical and laparoscopic results and are associated with fewer complications. However, long term results are not available for all the common robotic urologic surgeries. There are plenty of novel developments in robotics to be available for clinical use in the future. CONCLUSION: Robotic urologic surgery will continue to evolve in the future. We should continue to critically analyze whether the advances in technology and the higher cost eventually translates to improved overall surgical performance and outcomes.

Urinary tract infection prophylaxis in transurethral surgery: oral lomefloxacin versus parenteral cefuroxime.

The purpose of this study was to compare the efficacy and safety of single-dose oral lomefloxacin and single-dose parenteral cefuroxime for the prevention of urinary tract infection following transurethral surgery. A total of 63 patients were enrolled in this prospective, randomized open-label study, which was conducted at two medical centers in France. Patients were randomized to receive either 400 mg of oral lomefloxacin 2-6 hours before surgery or 1.5 g parenteral cefuroxime 30-90 minutes before surgery. Postoperative clinical evaluation was performed daily, and bacteriologic evaluation included urine cultures performed 24 hours after surgery, just before and 1 day after removal of the indwelling catheter, and 3-5 days after surgery. Another urine culture was optionally performed 1-3 months after surgery. Infection was defined as a urinary bacteria count greater than or equal to 10(5) colony-forming units (CFU)/mL of urine. Of the 63 patients enrolled, 54 were evaluable for efficacy, 27 in each group. The success rate of prophylaxis was 88.9% in the lomefloxacin group and 88.5% in the cefuroxime group (p = nonsignificant). None of the 16 lomefloxacin-treated patients who were re-cultured at 1-3 months was found to be infected. Adverse events were minor in both groups. A single oral dose of lomefloxacin was as efficacious and as safe as a single intravenous dose of cefuroxime for prevention of postoperative urinary tract infection in patients undergoing transurethral surgery.

[Functional renal failure caused by vascular diversion. The role of a hypervascular renal tumor]. / Insuffisance rénale fonctionnelle par détournement vasculaire. Rôle d'une tumeur rénale hypervascularisées.

Tumorectomy was performed in a patient with hypervascular renal carcinoma on a solitary kidney. Prior to surgery, this patient had mild renal impairement (plasma creatinine 195 mumol/l, creatinine clearance 48 ml/min), but it was noted that 45 days after surgery his renal function had improved (plasma creatinine 142 mumol/l, creatinine clearance 63 ml/min). The hypothesis of a prerenal model of renal impairment is put forward, the probable physiopathological mechanism being a diversion of blood flow from the healthy kidney to the hypervascularized tumoral kidney.

[Natural history of renal calcium lithiasis. Data obtained from a cohort of 667 patients]. / Histoire naturelle de la lithiase rénale calcique. Données obtenues à partir d'une cohorte de 667 malades.

Between January 1st, 1988 and May 31st, 1989, 667 patients (419 men, 248 women) with radioopaque, non cystinic and apparently idiopathic (lack of severe renal disease) renal stones were entered in a prospective study. The data obtained at entry enabled us to build up, retrospectively, a quantified presentation of the natural history of calcium nephrolithiasis. At the time the disease was discovered the patients' mean age was 40.4 years, and its presence had been known for 7.9 years on average in both sexes. The mean number of stones formed by the patients was 3.5. In 218 of the 277 patients who had only one stone the nephrolithiasis had been present for less than 3 years, as compared with at least 6 years in the 184/252 patients who had 3 stones or more; this suggests that in many of the patients studied the stones had rapidly become symptomatic. Women had a significantly (chi 2: P less than 10(-3)) more frequent history of urinary tract infection than men, and notably more frequent episodes of febrile infection (31.5 percent in women, 7.1 percent in men). A familial history of nephrolithiasis was found in 34.7 percent of women and 31 percent of men, but its presence had no influence on the number of stones formed or on the duration of the disease. On the other hand, the stones were discovered significantly earlier in men who has a familial history of nephrolithiasis (37.3 years) than in those who had no such history (42 years; P less than 10(-3)). These data will be used as baselines to a prospective evaluation of the course of nephrolithiasis in these patients.

[Technique and results of the "Mini-Bricker" urinary tract diversion after total cystectomy for bladder tumors]. / Technique et résultats du "Mini-Bricker" dans la dérivation des voies urinaires après cystectomie totale pour tumeur de vessie.

The authors have performed a "Mini-Bricker" operation in 24 patients with bladder cancer. This technique consists of urinary diversion in which the size of the intestinal loop is reduced to an average of 4 cm and the ureteroileal anastomosis is performed end-to-end in order to allow subsequent endourological procedures, if necessary. The postoperative course was uneventful in 71% of cases. Seven early complications were reported: 3 infectious, 1 thromboembolic and 2 hernias. In the medium term, one case of disturbances and 2 stenoses of the ureteroileal anastomosis were treated by endoscopic dilatation. The median follow-up is 3 years and 5 patients have died. A retrospective survey of quality of life revealed that 86% of patients were satisfied with their diversion and rapidly acquired autonomy following cystectomy without the need for retraining and without having to get up at night.

Use of antibiotics in the conjunction with extracorporeal lithotripsy.

The first 400 patients treated on an inpatient basis at our center underwent bacteriological follow-up after extracorporeal lithotripsy (ECL) for ureteric or renal stones. 278 patients did not have any urinary tract infection on the urine culture before ECL. They did not receive any antibiotic prophylaxis and 4.8% of the patients developed infectious problems, with significant bacteriuria in only 1.5% of the cases. 89 patients had urinary tract infection on the preoperative cultures. 21.3% developed either fever or significant bacteriuria and this virtually always occurred in patients who were treated for less than 4 days before ECL, with septicemia in 4.5% of the cases. 33 patients with sterile urine received flush antibiotic prophylaxis and none of them developed postoperative infection. Two of these patients had infection at the time of the flush: one of them, who, by error, did not receive antibiotic treatment prior to ECL, developed bacteremia after the procedure. The rational use of antibiotics in conjunction with ECL should ensure effective prevention of urinary tract infections without requiring the excessive use of antibiotics.