A multicentric study on accurate grading of prostate cancer with systematic and MRI/US fusion targeted biopsies: comparison with final histopathology after radical prostatectomy.

OBJECTIVE: To evaluate the accuracy in histologic grading of MRI/US image fusion biopsy by comparing histopathology between systematic biopsies (SB), targeted biopsies (TB) and the combination of both (SB + TB) with the final histopathologic outcomes of radical prostatectomy specimens. MATERIALS AND METHODS: Retrospective, multicentric study of 443 patients who underwent SB and TB using MRI/US fusion technique (Urostation® and Trinity®) prior to radical prostatectomy between 2010 and 2017. Cochran's Q test and McNemar test were conducted as a post hoc test. Uni-multivariable analyses were performed on several clinic-pathological variables to analyze factors predicting histopathological concordance for targeted biopsies. RESULTS: Concordance in ISUP (International Society of Urological Pathology) grade between SB, TB and SB + TB with final histopathology was 49.4%, 51.2%, and 63.2% for overall prostate cancer and 41.2%, 48.3%, and 56.7% for significant prostate cancer (ISUP grade ≥ 2), respectively. Significant difference in terms of concordance, downgrading and upgrading was found between SB and TB (ISUP grade ≥ 2 only), SB and SB + TB, TB and SB + TB (overall ISUP grade and ISUP grade ≥ 2) (p < 0.001). Total number of cores and previous biopsies were significant independent predictive factors for concordance with TB technique. CONCLUSION: In this retrospective study, combination of SB and TB significantly increased concordance with final histopathology despite a limited additional number of cores needed.

Live surgery: highly educational or harmful?

PURPOSE: Live surgery (LS) is considered a useful teaching opportunity. The benefits must be balanced with patient safety concerns. To evaluate the rate of complications of a series of urologic LS performed by experts during the Congress Challenge in Laparoscopy and Robotics (CILR). METHODS: We present a large, multi-institution, multi-surgeon database that derives from 12 CILR events, from 2004 to 2015 with a total of 224 cases. Radical prostatectomy (RP) was the most common procedure and a selection of complex cases was noted. The primary measure was postoperative complications and use of a Postoperative Morbidity Index (PMI) to allow quantitative weighing of postoperative complications. RESULTS: From 12 events, the number of cases increased from 11 in 2004 to 27 in 2015 and a total of 27 surgeons. Of 224 cases (164 laparoscopic and 60 robotic), there were 26 (11.6%) complications: 5 grade I, 5 grade II, 3 grade IIIa, 12 grade IIIb and 1 grade V, the latter from laparoscopic cystectomy. Analysis of PMI was 23 times higher from cystectomy compared to RP. CONCLUSIONS: In the setting of live surgery, the overall rate of complications is low considering the complexity of surgeries. The PMI is not higher in more complex procedures, whereas RP seems very safe.

Elastic fusion biopsy versus systematic biopsy for prostate cancer detection: Results of a multicentric study on 1,119 patients. / Evaluación de la biopsia de fusión elástica vs. biopsia sistemática para la detección del cáncer de próstata: resultados de un estudio multicéntrico en 1.119 pacientes.

OBJECTIVES: To assess the accuracy of targeted and systematic biopsies for the detection of prostate cancer (PCa) and clinically significant PCa (csPCa) in the everyday practice, evaluating the need for additional systematic biopsies at the time of targeted biopsy. PATIENTS AND METHODS: From our multicentric database gathering data on 2,115 patients who underwent fusion biopsy with Koelis™ system between 2010 and 2017, we selected 1,119 patients who received targeted biopsies (a median of 3 for each target), followed by systematic sampling of the prostate (12 to 14 cores). Overall and clinically significant cancer detection rate (CDR) of Koelis™ fusion biopsies were assessed, comparing target and systematic biopsies. Secondary endpoint was the identification of predictors of PCa detection. RESULTS: The CDR of targeted biopsies only was 48% for all cancers and 33% for csPCa. The performance of additional, systematic prostate sampling improved the CDR of 15% for all cancers and of 12% for csPCa. PCa was detected in 35%, 69%, and 92% of patients with lesions scored as PI-RADS 3, 4 and 5, respectively. Elevated PI-RADS score and positive digital rectal examination were predictors of PCa, whereas biopsy-naïve status was associated with csPCa. CONCLUSION: In the everyday practice target biopsy with Koelis™ achieves a good CDR for all PCa and csPCa, which is significantly improved by subsequent systematic sampling of the prostate. The outstanding outcomes of fusion biopsy are confirmed also in biopsy-naïve patients. Elevated PI-RADS score and positive digital rectal examination are strongly associated with presence of PCa.

[Kidney cancer management in 2007: news and recommendations]. / Prise en charge du cancer du rein en 2007: actualités et recommandations.

In case of a single renal cell carcinoma strictly located in the kidney, the radical nephrectomy remains the treatment of choice. However, it has been estimated that nearly 30 to 40 % of renal cell carcinoma are about to recur after primitive surgery. In certain cases, conservative surgery can be discussed as an alternative to radical treatment, especially in case of exophytic renal tumour or less than 4 cm in diameter. New ablative techniques (radiofrequency and cryoablation) have shown promising results but the follow-up is still very limited. French national recommendation regarding kidney cancer have been updated in 2007 and following the development of clinical trials using antiangiogenic agents. Regarding the use of antiangiogenic agents, several points have to be taken into account: existence of renal cell carcinoma, presence of metastasis, number of metastasis, location and risk factor prognosis determination.

Oncological and functional results of robotic salvage radical prostatectomy after permanent brachytherapy implants.

PURPOSE: To evaluate the feasibility of robotic salvage prostatectomy for local recurrence after permanent brachytherapy implants for prostate cancer. PATIENTS AND METHODS: Seven patients were operated by robotic salvage prostatectomy with or without pelvic lymph node dissection between October 2007 and March 2012, for a local recurrence after iodine 125 permanent brachytherapy implants. Local recurrence was proved by prostate biopsies, once biochemical relapse was diagnosed and imaging assessment performed. RESULTS: The average age of a patient at the time of diagnosis was 66 years (62-71 years). The median nadir prostate specific antigen (PSA) serum concentration after brachytherapy was 1.29ng/mL (0.6-2.1ng/mL), obtained after a median of 12 months (7-21 months). The average [PSA] before robotic salvage prostatectomy was 6.60ng/mL (4.17-13.80ng/mL). [PSA] at 1 and 3 months after prostatectomy was less than 0.05ng/mL in five patients. [PSA] remained below 0.05ng/mL for six patients at 12 and 24 months. One month after robotic salvage prostatectomy, all patients had at least partial urinary incontinence. At 12 and 24 months after robotic salvage prostatectomy four patients have regained full urinary continence. In terms of erectile function at 24 months, three patients retained erectile function with possible sexual intercourse. CONCLUSION: Robotic salvage prostatectomy appears to be a reliable treatment in terms of oncological outcome with convincing results both for urinary continence and erectile function for selected patients with local recurrence after permanent brachytherapy implants.

[Laparoscopic promontofixation technique]. / Technique de promontofixation laparoscopique Laparoscopic promontofixation technique.

Laparoscopic promontofixation often remains possible whatever the previous history of pelvic surgery, including the placing of prosthetic material. Preoperative care is standardized and is accompanied by antibiotic prophylaxis, preventive antithrombotic treatment and in the event of a history of pelvic surgery, a digestive preparation. Positioning of the patient must plan a 30 degrees Trendelenbourg position. After the introduction of trocars, initial surgery comprises interrectovaginal dissection to free the whole posterior surface of the vagina. This is followed by the installation of a posterior mesh pre-cut in an arch. The anterior face of the promontory is then freed after incision of the posterior peritoneum with the patient placed beforehand in a Trendelenbourg position. After intervesical vaginal dissection, the anterior prosthesis comprising a precut polyester mesh is fixed avoiding excess traction. The end of the surgery involves careful reperitonization of all the prosthetic parts. Possible specific surgical complications are vascular and visceral wounds. Postoperative secondary haemorrhage and gastrointestinal occlusion may occur. Occurrence of an inflammatory syndrome and low back pain suggests spondylodicitis and MRI should be performed. Vaginal erosion on the prosthesis (1.6 to 10% depending on the series) may occur after several months and seems relatively independent of the prosthetic material used.

[Vesical replacement by ileo-caecal graft detubulized after total prostato-cystectomy]. / Remplacement vésical par greffon iléo-caecal détubulisé après prostatocystectomie totale.

Following total prostato-cystectomy, the nearest substitute to a physiological reservoir is a constructed ileo-caecal pouch. The non-mesenteric sides of the caecum and ileum are incised on a length of 15 cm for each apex of the caecum which is anastomosed with the urethra, respecting the striated sphincter. The ureters are implanted into the caecal portion of the pouch. Owing to the length of the ileo-caecal mesenterium, this technique can be used in every case of prostato-cystectomy. Twelve cases followed up for 6 to 18 months are reported.

[Experience in the treatment of erectile impotence by the intracavernous auto-injection of vasoactive substances]. / Vécu du traitement de l'impuissance érectile par auto-injection intracaverneuse de substances vaso-actives.

Eleven selected patients participated in a programme of intracavernous auto-injections for erectile impotence. This treatment provided these patients with an erection allowing sexual relations which were considered to be satisfactory at the beginning, but more than one half of them progressively abandoned the technique after six months; as the majority of partners expressed feelings of frustration. Auto-injections represent a valid alternative in the treatment of erectile impotence of essentially neurological origin.

[Bladder tumors in subjects younger than 40 years of age]. / Les tumeurs de vessie chez le sujet de moins de quarante ans.

Analysis of nine cases of bladder tumors in patients under 40 years of age leads to the following conclusions: the tumors are invariably urothelial papillary lesions, which do not affect the muscularis. Multiple locations with a high recurrence potential are by no means an exception. Laser therapy may well prove the decisive weapon against recurrence.

[Renal cancer in the pregnant woman]. / Le cancer du rein chez la femme enceinte.

The authors report three cases of adrenal cancer in pregnant women. The diagnostic, pathogenic and therapeutic problems are discussed with particular emphasis on the considerable interest of ultrasound scanning. The surgical indications are always difficult and depend on the stage of evolution of the cancer, and the term of the pregnancy.

[Treatment of intradiverticular pyelocaliceal stones]. / Traitement des lithiases intra-diverticulaires pyélo-calicielles.

Nine patients with symptomatic intradiverticular stones have been treated, 3 by open surgery (excluded cavity and abscess formation) and 6 by endoscopy. When possible (4 cases), direct puncture of the diverticular cavity seems to be much simpler and more effective than indirect intrarenal access. The percutaneous approach constitutes a valuable alternative to open surgery in the treatment of symptomatic intra-diverticular stones, although secondary obliteration of the cavity is not always obtained, which leaves a potential risk of long term recurrent stones.

[Bladder replacement with colon segments]. / Remplacement de vessie à base de côlon.

The authors report their experience of 81 cases of bladder replacement with colonic grafts between 1980 and 1986. The operative technique is presented and its complications and functional results analysed. Bladder tumors were the most frequent indication although some cases of tuberculosis, bilharziosis and neurogenic bladder were also included. After a critical study of the literature, the authors state that the ileocecal segment has become their preferred material. Over the last fourty months, 42 patients have been treated by the latter form of bladder replacement.

[Apparently isolated tumors of the adrenal gland. Apropos of 12 cases surgically treated]. / Les tumeurs de la surrénale apparemment isolées. A propos de douze cas opérés.

12 patients with an adrenal tumour were observed in the absence of any known history of neoplasm at the stage of dissemination. In 9 cases the tumour was discovered accidentally. On the basis of the conclusions of the histological analysis following surgical exploration, the authors define the respective advantages of various examinations: laboratory assays, ultrasonography, CT scan, NMR and discuss the management of chance discovery of an adrenal mass.

[Cisplatin-based chemotherapy in the treatment of advanced-stage tumors of the bladder]. / Chimiothérapie a base de cisplatine dans le traitement des tumeurs de vessie a un stade avancé.

Since October 1984, 39 patients have been treated with cisplatin based chemotherapy for advanced bladder tumour of for pelvic recurrence or metastasis after total cystectomy. Cisplatin-methotrexate protocol (23 cases): 2 cases died during the first two cycles and 21 were evaluated after three cycles: only 39% of objective responses (2 CR-5 PR-2 MR) were observed with a mean survival not exceeding 12.6 months (7 deaths, 2 patients alive at the present time). All of the non-responders died within 4 to 16 months following the start of treatment (mean survival: 8.7 months). These particularly disappointing results led to the suspension of this protocol. Cisplatin-methotrexate-vinblastine protocol: 16 cases since September 1986. Eleven patients have been evaluated after three cycles: 3 CR-3 PR-5 PROG. The C.M.V. protocol appears to have a superior efficacy, principally on bladder, lymph node or lung lesions, at the cost of a higher but acceptable toxicity. Hepatic and central nervous system metastases were observed secondarily in this case.

[Current strategy in the treatment of urinary calculi since the introduction of the EDAP lithotripter]. / Stratégie actuelle dans le traitement des lithiases urinaires depuis l'implantation du lithotripteur EDAP.

The extracorporeal lithotripter has radically changed the treatment of urinary stones. Three-hundred and seventy-four stones in 356 patients were treated over an eight-month period. Extracorporeal lithotripsy (262 cases) is mainly indicated in pelvic and calyceal stones measuring less than 2.5 cm, stones located in the lumbar ureter and previously flushed, and some stones of the pelvic ureter. Analysis of results showed that extracorporeal lithotripsy achieved fragmentation in 80% of cases and complete elimination 3 months after the procedure in 70% of cases. Repeat procedures were needed in 23% of patients. Complementary procedures were required to relieve obstruction in 4% of patients. Percutaneous nephrolithotomy now has very few indications but remains useful in large pelvic stones, failures of EDAP (7 cases), and some staghorn stones with few ramifications. Open surgery (24 cases) is still useful for complex staghorn stones, soft stones in febrile patients, calyceal stones with destruction of the neighboring renal parenchyma, incarcerated lumbar stones, and stones associated with an obstructive malformation of the urinary tract. Ureteroscopy (69 cases) proved highly reliable in stones located in the pelvic ureter. An improvement, therefore, but no miracle.

[Use of the laser in urology]. / Application du laser en urologie.

The usage of laser therapy in urology is based upon thermal effects that lead to tissue destruction by coagulation necrosis and volatilization. The endoscopic treatment of bladder tumors has been its most important utilization. The authors report their experience with 681 bladder tumors in 198 patients and present the technical details of laser therapy, the indications and the results. The recurrence rate at the previously treated tumor area was found to be rather improved: 0.75/100 months/patient for stage pTa and 0.92/100 months/patient for stage pT1. Other utilizations for laser therapy exist: upper tract urothelial tumors mainly in selected cases as solitary kidney; urethral localizations of urothelial tumors and condylomata acuminata; urethral stenosis, as a complement of optical urethrotomy; hemorrhagic cystitis after radiotherapy and some forms of chemotherapy. The pulsed dye laser may become an important advance in endoscopic treatment of ureteral calculi.

[Oncocytic tumors of the kidney. 11 cases (1978-1987)]. / Tumeurs rénales oncocytaires. Onze cas (1978-1987).

Analysis of this series of cases reveals the following points: complementary investigations (computed tomography, magnetic resonance imaging) sometimes suggest the diagnosis, the oncocytic nature is often a surprise pathological finding, it is difficult to determine whether the lesion is a pure oncocytoma and the exact grade cannot be determined on frozen section, the choice between radical surgery and conservative surgery is made even more difficult, the study of the course of the disease raises the question of whether the term of oncocytoma should not be reserved to low grade tumours.

[Bilateral cancer of the kidney and cancer of a solitary kidney]. / Cancers du rein bilatéraux et sur rein unique.

The analysis of a series of 31 cases of bilateral renal cancers and cancers of solitary kidneys revealed the following findings: 1) conservative in situ surgery with clamping of the renal pedicle and dopamine, when it is possible, appears to be by far the most logical and simplest solution (17 cases); 2) ex-vivo surgery with auto-grafting represents an extreme solution (2 cases); 3) cases of technical impossibility, in the absence of distant metastases, require radical nephrectomy followed by dialysis (3 cases); 4) in advanced forms, surgical abstention followed by hormone therapy (8 cases) or highly selective embolisation (1 case) sometimes provides surprising survivals.

[Diagnostic and therapeutic strategy in injuries of the kidney. Apropos of a series of 248 cases]. / Stratégie diagnostique et thérapeutique dans les traumatismes du rein. A propos d'une série de 248 cas.

The analysis of a series of 248 cases led to the following conclusions: intravenous pyelography, together with nephrotomography and ultrasonography represent, the pillars of emergency assessment; computed tomography, performed systematically since 1985, is the most appropriate examination for the precise assessment of the lesions in a functioning kidney; arteriography is still essential in cases of urographically silent kidneys. The choice of therapeutic approach essentially depends on the type of the lesion: severe parenchymal lesions (type III) (58 cases) and certain cases of type II trauma (25 cases) underwent a deferred emergency operation which was as conservative as possible; pedicle lesions (type IV) and serious haemorrhagic lesions required emergency surgery (11 cases); type I or type II lesions with moderate hematomas were usually treated by simple observation (145 cases); cases of trauma seen at the stage of sequelae (8 cases) sometimes required a surgical solution (arteriovenous fistula, segmental ischaemia of the parenchyma with hypertension, encysted urinoma).

[Clinical stage T3 prostate cancer: natural history, therapeutic choices and their results]. / Cancer de prostate de stade T3 clinique: histoire naturelle, les choix thérapeutiques et leurs résultats.

Clinical stage T3 prostate cancer is ambiguous both in terms of its definition and its place in the natural history of the disease, and there is no consensus concerning its treatment. In a review of the literature, 148 articles were selected and analysed from the Medline database over a 14-year period (1983-1997). Single-agent therapy: Radiotherapy and radical prostatectomy: it is unlikely that these treatments can cure clinical stage T3 prostatic cancer, except perhaps for a small minority of patients actually presenting with overstaged pT2 disease or certain forms of low-grade pT3. Neither treatment appears to have any advantage over the other-Endocrine therapy: it has been proposed as exclusive treatment at this stage. Few studies have been reported. However, many authors consider this choice to be legitimate, because one-half of patients already have lymph node involvement. Combination therapy: Radiotherapy and endocrine therapy: recent studies comparing exclusive external beram radiotherapy with endocrine therapy show an advantage in favour of combination therapy. Total prostatectomy and endocrine therapy: neoadjuvant endocrine therapy does not provide any advantage. Adjuvant endocrine therapy improves local control and progression-free survival. Adjuvant radiotherapy and radical prostatectomy provides no advantage for T3. The choice of treatment for stage T3, N0, M0 obviously depends on the patient's general state and life expectancy. If the option of a curative treatment in a young subject can be reasonably considered, combination therapy should be preferred.