B. Pradere

Impact of ischaemia time on renal function after partial nephrectomy: a systematic review.

To assess the impact of ischaemia on renal function after partial nephrectomy (PN).

Complications Associated With Photoselective Vaporization of the Prostate: Categorization by a Panel of GreenLight Users According to Clavien Score and Report of a Single-center Experience

OBJECTIVE To devise and validate a system to categorize GreenLight photoselective vaporization of prostate (PVP) complications according to Clavien score (CS), to report complications of PVP using this categorization, and to determine risk factors. MATERIALS AND METHODS A survey questionnaire was distributed to all participants of the second meeting of the Group of GreenLight Users. They were asked to grade PVP complications according to CS. We calculated the mode CS for each complication from the survey data to propose a categorization system for complications of PVP. Complications encountered in a large single-center cohort of 370 patients were reported according to this system. We assessed the reproducibility of CS by estimating inter-rater agreement by the Fleiss kappa. We performed univariate and multivariate analyses to determine risk factors for complications. RESULTS Of the 67 meeting participants, 42 (62.7%) completed the survey. Overall agreement between urologists was fair (Fleiss kappa = 0.356). Among the 370 patients, 21 (5.7%) had intraoperative complications, 147 (39.7%) had postoperative complications, and 70 (18.9%) had long-term complications. Among the postoperative complications, 125 patients (33.8%) were classified as Clavien grade I, 58 (15.7%) as Clavien grade II, 4 (1.1%) as Clavien grade IIIb, 5 (1.3%) as Clavien grade IVa, 1 (0.3%) as Clavien grade IVb, and 1 (0.3%) as Clavien grade V. In multivariate analysis, the only predictor of overall complications was a polymicrobial preoperative urine culture. CONCLUSION The grading of PVP complications by CS is fairly reproducible. We are the first to propose a system for the categorization of PVP complications. PVP complications are frequent but most often minor.

Benefits and Harms of Treatment of Asymptomatic Bacteriuria: A Systematic Review and Meta-analysis by the European Association of Urology Urological Infection Guidelines Panel

People with asymptomatic bacteriuria (ABU) are often unnecessarily treated with antibiotics risking adverse effects and antimicrobial resistance. We performed a systematic review to determine any benefits and harms of treating ABU in particular patient groups. Relevant databases were searched and eligible trials were assessed for risk-of-bias and Grading of Recommendations, Assessment, Development and Education quality. Where possible, a meta-analysis of extracted data was performed or a narrative synthesis of the evidence was presented. After screening 3626 articles, 50 studies involving 7088 patients were included. Overall, quality of evidence ranged from very low to low. There was no evidence of benefit for patients with no risk factors, patients with diabetes mellitus, postmenopausal women, elderly institutionalised patients, patients with renal transplants, or patients prior to joint replacement, and treatment was harmful for patients with recurrent urinary tract infection (UTI). Treatment of ABU resulted in a lower risk of postoperative UTI after transurethral resection surgery. In pregnant women, we found evidence that treatment of ABU decreased risk of symptomatic UTI, low birthweight, and preterm delivery. ABU should be treated prior to transurethral resection surgery. In addition, current evidence also suggests that ABU treatment is required in pregnant women, although the results of a recent trial have challenged this view. PATIENT SUMMARY We reviewed available scientific studies to see if people with bacteria in their urine but without symptoms of urinary tract infection should be treated with antibiotics to eliminate bacteria. For most people, treatment was not beneficial and may be harmful. Antibiotic treatment did appear to benefit women in pregnancy and those about to undergo urological surgery.

Off-Clamp versus On-Clamp Robotic Partial Nephrectomy: A Multicenter Match-Paired Case-Control Study

Introduction: The aim of this study was to compare the outcomes of on-clamp and off-clamp robotic partial nephrectomy (RPN). Materials and Methods: The charts of all patients who underwent an RPN at 8 institutions between 2010 and 2014 were retrospectively reviewed. The patients who underwent an off-clamp RPN were matched to on-clamp RPN in a 1-4 fashion according to the following variables: RENAL score, tumor size and surgeons experience. Pre-, intra-, and postoperative data were compared between both groups. Results: Among 525 RPN, 26 were performed off-clamp (5%). They were matched to 104 on-clamp RPN. The complications rate (15.5 vs. 7.7%, p = 0.53), major complications rate (4.9 vs. 3.9%; p = 0.82), and transfusions rate (0 vs. 4.9%; p = 0.58) did not differ significantly between the clamped and unclamped groups. Conversely, estimated blood loss was higher in the off-clamp group (266.4 vs. 284.6 mL, p = 0.048) and so was the rate of conversion to radical nephrectomy (0 vs. 7.7%, p = 0.04). Postoperative preservation of renal function was comparable in both groups. Conclusion: Off-clamp RPN is feasible for a small subgroup of renal tumors without increased risk of postoperative complications but at the cost of higher estimated blood loss and increased risk of conversion to radical nephrectomy.

Prise en charge de la nycturie : une entité nosologique au sein des troubles mictionnels de l’homme

AIM To review the definition, pathophysiology, impact and management of nocturia in men METHODS We conducted a literature review using Medline and Embase with the following keywords: nocturia or nocturnal polyuria. RESULTS Nocturia in men is a multifactorial condition that may results from prostate but also kidney, bladder, heart, or lung diseases. It affects up to 60 % of men over 70 years and is responsible for major morbidity (sleep disorders, depression, falls, fractures), especially in the elderly. Pathophysiologically, we distinguish nocturia related to excessive urine production from those resulting from a reduction in the maximum voided volume. Thus, the first and most important workup is a frequency-volume chart conducted on a 72-hour-period. The initial assessment should then be continued to clearly identify the factors contributing to polyuria (disturbance of the pattern of endogenous production of arginine vasopressin, obstructive sleep apnea...) or to a reduction in the maximum voided volume (benign prostatic hyperplasia, overactive bladder). Treatment is then targeted: treatment of benign prostatic hyperplasia, antimuscarinic in case of overactive bladder, analogue of arginin vasopressin (demopressine) if nocturnal polyuria is involved, or continuous positive airway pressure in case of a sleep apnea syndrome. CONCLUSION Nocturia is a common and serious condition due to its morbidity. Its understanding and management have evolved significantly in recent years and are now based on a multimodal approach.

Does training of fellows affect peri-operative outcomes of robot-assisted partial nephrectomy?

To evaluate the impact of fellows’ involvement on the peri‐operative outcomes of robot‐assisted partial nephrectomy (RAPN).

Lynch syndrome in upper tract urothelial carcinoma: significance, screening, and surveillance.

Purpose of review Lynch syndrome is a genetic syndrome that integrates a large spectrum of cancers caused by germline mutations in mismatch repair genes. Its incidence is underestimated due to a lack of systematic screening in the population. Because upper tract urothelial carcinoma is the third-most common cancer associated with the syndrome, urologists should be aware of the diagnostic pathway. Recent findings Lynch syndrome can be positively diagnosed after the three following distinct steps: meeting the clinical criteria, tissue and genetic testing, and familial genetic counseling. It must be suspected for patients with upper tract urothelial carcinoma before the age of 60 years and in cases of evocative personal/familial medical histories. When a diagnosis is suspected, immunohistochemistry and Polymerase Chain Reaction are the next steps to confirm the diagnosis. After confirmation, the key to management is a good surveillance to prevent disease recurrence using urinary analysis and imaging as well as screening of first-degree relatives. Summary Despite the lack of high-level studies of upper tract urothelial carcinoma in Lynch syndrome, its prevalence is not negligible. Thus, expert recommendations are required for its management. Individuals and family should be informed of the importance of close screening and surveillance.

Impact of Anticoagulant and Antiplatelet Drugs on Perioperative Outcomes of Robotic-assisted Partial Nephrectomy

OBJECTIVE To evaluate the impact of anticoagulant (AC) or antiplatelet (AP) therapy on the morbidity of robot-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS From 2011 to 2015, we retrospectively analyzed a prospectively maintained institutional review board-approved database of RAPN from 2 academic departments of urology. We evaluated the occurrence of overall complications and hemorrhagic complications (pseudoaneurysm, arteriovenous fistula, hematoma, transfusion). Patients with therapeutic AC or AP, stopped or not before surgery, were compared with patients without therapeutic AC or AP. A logistic regression model was used to identify predictors of complications. RESULTS Out of 533 patients who underwent RAPN, 70 had AC or AP (50% aspirin, 25% clopidogrel, 28% AC, 8% direct oral AC). Clopidogrel, AC, and direct oral AC were always stopped preoperatively. Aspirin was continued in 25% of the cases. In univariate analysis, overall complications (39.2% vs 17.4%; P = .001) and hemorrhagic complications (32.7% vs 9.6%; P <.001) were higher in patients on AC or AP. Hospital stay was longer in the group with therapeutic AC or AP treatment (5.1 vs 3.9 days; P <.001). In multivariate analysis, predictors of complications were intake of therapeutic AC (odds ratio [OR] = 4.3, IC95% [1.2-15.9], P = .03) and tumor size (OR = 1.8, IC95% [1.3-7.2], P = .03). Patients on aspirin tended to have more complications (OR = 2.4; IC95% [0.4-9.3]; P = .15). CONCLUSION AP and therapeutic AC increase the morbidity of RAPN. These treatments should be taken into account in treatment decision-making algorithm of small renal masses.

Photovaporisation prostatique au laser Greenlight® : évaluation des pratiques françaises en 2015

INTRODUCTION Photovaporization of the prostate by the Greenlight(®) laser (GL) has been strongly developed this past few years in France, representing nearly 30% of surgery for BPH, making France the second GL user worldwide after USA. The objective of this study was to assess the French surgeons practices with the Greenlight(®) laser. MATERIAL AND METHODS During the 4th meeting of French Greenlight(®) users group (GUGL), was proposed a questionnaire on the management of patients and the GL technique. The questionnaire covered the operators characteristics (age, experience with the GL, etc.), the treatment strategy, preoperative management (anticoagulants…) and postoperative management (ambulatory, removal catheter…) as well as the surgical technique (fiber type, energy used, etc.). RESULTS Among the 117 participants, 64 answered to the questionnaire (55%). Fifty-six percent chose GL, whatever was the prostate volume, simple prostatectomy was the most commonly alternative used for high prostate size (39%). The aspirin was pursued by 89% of practitioners perioperatively. Conversely, clopidogrel was continued by only 19% and anticoagulant by only 14%. Seventy-three percent of participants commonly used classic vaporization and only 3% used new techniques (GreenLEP). During procedure, 72% used energy between 120W and 160W. Sixty percent used transrectal ultrasound during surgery (32% throughout the procedure). Only 16% of surgeons made ambulatory procedure and almost 33% never. Surgeons with over 3years of experience (vs.<3years) used the technique regardless of the volume in 67% vs. 23.5% (P=0.002). CONCLUSION In France Greenlight use is still heterogeneous for the patients management. New techniques which are currently developing (GreenLEP, vapo-enucleation) are still marginal. Ambulatory is still insufficiently used and need to be developed. The experienced surgeon led to wider indication for the technique. LEVEL OF EVIDENCE 3.

Photoselective Vaporization of the Prostate in Men With Refractory Urinary Retention

OBJECTIVE To assess the efficacy of photoselective vaporization of the prostate (PVP) and the predictive factors of treatment failure in patients with refractory urinary retention. MATERIALS AND METHODS From January 2006 to December 2013, we prospectively included all patients treated by PVP preoperatively catheterized for urinary retention. The primary end point was the number of patients free of indwelling catheters 3 months after the procedure. Univariate and multivariate analyses were performed to identify the predictive factors of treatment failure. RESULTS One hundred fifty-two patients were included in the final analysis. The percentage of patients free of indwelling catheters was 91.5% 3 months after PVP. Two factors were identified as predictive of treatment failure at 3 months in multivariate analysis: a smaller preoperative ultrasonographic prostate volume (UPV; odds ratio [OR] = 0.91; P = .008) and a higher volume of primary urinary retention (OR = 1.03; P = .003). Forty-two patients (27.6%) required early recatheterization within 7 days after surgery. Smaller UPV was the only predictive factor of treatment failure in the early postoperative in multivariate analysis (OR = 0.97; P = .01). CONCLUSION Nearly one-third of patients treated for refractory urinary retention fail the first trial without catheter after PVP, but 91.5% are free of indwelling catheter 3 months after surgery. A smaller preoperative UPV and a higher retention volume were predictive of PVP failure in patients with preoperative indwelling catheters.