Baptiste Albouy

Positive Surgical Margin Appears to Have Negligible Impact on Survival of Renal Cell Carcinomas Treated by Nephron-Sparing Surgery

BACKGROUND The occurrence of positive surgical margins (PSMs) after partial nephrectomy (PN) is rare, and little is known about their natural history. OBJECTIVE To identify predictive factors of cancer recurrence and related death in patients having a PSM following PN. DESIGN, SETTING, AND PARTICIPANTS Some 111 patients with a PSM were identified from a multicentre retrospective survey and were compared with 664 negative surgical margin (NSM) patients. A second cohort of NSM patients was created by matching NSM to PSM for indication, tumour size, and tumour grade. MEASUREMENTS PSM and NSM patients were compared using student t tests and chi-square tests on independent samples. A Cox proportional hazards regression model was used to test the independent effects of clinical and pathologic variables on survival. RESULTS AND LIMITATIONS Mean age at diagnosis was 61+/-12.5 yr. Mean tumour size was 3.5+/-2 cm. Imperative indications accounted for 39% (43 of 111) of the cases. Some 18 patients (16%) underwent a second surgery (partial or total nephrectomy). With a mean follow-up of 37 mo, 11 patients (10%) had recurrences and 12 patients (11%) died, including 6 patients (5.4%) who died of cancer progression. Some 91% (10 of 11) of the patients who had recurrences and 83% of the patients (10 of 12) who died belonged to the group with imperative surgical indications. Rates of recurrence-free survival, of cancer-specific survival, and of overall survival were the same among NSM patients and PSM patients. The multivariable Cox model showed that the two variables that could predict recurrence were the indication (p=0.017) and tumour location (p=0.02). No other variable, including PSM status, had any effect on recurrence. None of the studied parameters had any effect on the rate of cancer-specific survival. CONCLUSIONS PSM status occurs more frequently in cases in which surgery is imperative and is associated with an increased risk of recurrence, but PSM status does not appear to influence cancer-specific survival. Additional follow-up is needed.

Comparison of oncological outcomes after segmental ureterectomy or radical nephroureterectomy in urothelial carcinomas of the upper urinary tract: results from a large French multicentre study.

Study Type – Therapy (multi‐centre retrospective cohort)

Partial Versus Radical Nephrectomy in Patients With Adverse Clinical or Pathologic Characteristics

OBJECTIVES To assess cancer-specific survival of partial nephrectomy (PN) patients with >or= 7-cm lesions or unfavorable pathology (stage T3a or Fuhrman grades III-IV). MATERIAL AND METHODS At 13 participation centers, 4072 partial or radical nephrectomies (RN) were performed for RCC between 1984 and 2001. Of all procedures, 925 (22.7%) were for tumors > 7 cm, 973 (23.9%) had Fuhrman grades III or IV, and 861 (21.1%) had stage pT3a. None had nodal or distant metastases. Matched (age, gender, tumor size, T stage, histologic subtype, and Fuhrman grade [FG]) survival analyses addressed the effect of nephrectomy type (partial vs radical) on cancer-specific mortality. RESULTS Partial nephrectomy for tumors > 7 cm was associated with higher mortality than RN (HR = 5.3; P = .025). No significant cancer-specific survival differences were recorded after PN for FG III-IV (HR = 0.7, P = .5) or for pT3a lesions (HR = 2.5, P = .9). CONCLUSIONS Partial nephrectomy may undermine cancer control in patients with tumors > 7 cm. Conversely, after PN, the same cancer control rates as after RN may be expected in patients with Fuhrman grades III-IV or with pT3a histology.

Clinicopathological features and prognosis of synchronous bilateral renal cell carcinoma: an international multicentre experience.

An interesting group of papers in this section is headed by two papers on synchronous bilateral renal tumours, one from an international group of authors and one from Germany. The large series of patients are examined carefully by both groups, and the findings should be useful for all who are interested in this area.

Predictive Factors for Ipsilateral Recurrence After Nephron-sparing Surgery in Renal Cell Carcinoma

BACKGROUND Ipsilateral recurrence after nephron-sparing surgery (NSS) is rare, and little is known about its specific determinants. OBJECTIVE To determine clinical or pathologic features associated with ipsilateral recurrence after NSS performed for renal cell carcinoma (RCC). DESIGN, SETTING, AND PARTICIPANTS We analysed 809 NSS procedures performed at eight academic institutions for sporadic RCCs retrospectively. MEASUREMENTS Age, gender, indication, tumour bilaterality, tumour size, tumour location, TNM stage, Fuhrman grade, histologic subtype, and presence of positive surgical margins (PSMs) were assessed as predictors for recurrence in univariate and multivariate analysis by using a Cox proportional hazards regression model. RESULTS AND LIMITATIONS Among 809 NSS procedures with a median follow-up of 27 (1-252) mo, 26 ipsilateral recurrences (3.2%) occurred at a median time of 27 (14.5-38.2) mo. In univariate analysis, the following variables were significantly associated with recurrence: pT3a stage (p=0.0489), imperative indication (p<0.01), tumour bilaterality (p<0.01), tumour size >4cm (p<0.01), Fuhrman grade III or IV (p=0.0185), and PSM (p<0.01). In multivariate analysis, tumour bilaterality, tumour size >4cm, and presence of PSM remained independent predictive factors for RCC ipsilateral recurrence. Hazard ratios (HR) were 6.31, 4.57, and 11.5 for tumour bilaterality, tumour size >4cm, and PSM status, respectively. The main limitations of this study included its retrospective nature and a short follow-up. CONCLUSIONS RCC ipsilateral recurrence risk after NSS is significantly associated with tumour size >4cm, tumour bilaterality (synchronous or asynchronous), and PSM. Careful follow-up should be advised in patients presenting with such characteristics.

Évaluation prospective des effets du stage d’initiation pratique sur le recrutement des internes d’urologie à Paris : résultats définitifs

Resume Objectifs Evaluer les effets d’un stage d’initiation pratique a l’urologie sur le recrutement des internes parisiens depuis la mise en place de l’Examen National Classant (ENC). Materiels et methodes Depuis 2004, tous les internes nommes en chirurgie a Paris ont participe a un stage d’initiation a l’urologie avant de prendre leur fonction hospitaliere. Un questionnaire leur a ete remis. L’enquete prospective s’est interessee a : l’âge, le sexe, l’existence d’un stage d’urologie pendant l’externat et au souhait d’orientation au sein des 11 disciplines chirurgicales. Les internes ont ete recontactes annuellement pour connaitre l’evolution de leur orientation professionnelle. Resultats Population. Deux cent cinquante cinq internes ont participe dont 145 femmes (56,9%) et 110 hommes (43,1%). L’âge moyen etait de 24,6 ± 5 ans (22-31). 173 internes etaient issus d’un CHU parisien (67,8%) et 82 (32,2%) d’un CHU de province. Cinquante deux internes (21,2%) avaient effectue au moins un stage dans un service d’urologie pendant leur externat. Disciplines chirurgicales. L’orthopedie a ete le plus souvent citee (n=48; 28,9%). L’urologie a ete choisie par 32 internes (12,5%) qui avaient effectue un stage d’externe dans la specialite dans 28 cas. A la fin du stage, 18 internes etaient tentes par l’urologie. A un an, 31 internes134 (91,2%) ont confirme leur choix pour I’urologie. Conclusion La realisation d’un stage pratique intervenant tres tot dans la formation des jeunes chirurgiens est une bonne solution pour les initier a l’urologie. En beneficiant d’un choix eclaire, les internes les plus motives sont incites a rejoindre volontairement notre discipline.

La formation chirurgicale des urologues français est-elle plus efficace que celle des autres pays européens ?

Resume Objectif Comparer le niveau de formation chirurgicale des internes francais avec celui des autres pays d’Europe. Materiel et methodes Entre 2005 et 2006, un questionnaire exhaustif ( www.esru.net ) a ete remis a 188 jeunes urologues repartis dans 30 pays Europeens. Les internes ont ete repartis en 3 groupes : France (groupe 1, n=28), Europe de l’ouest (groupe 2, n=75) et Europe de l’est (groupe 3, n=85). Les items concernant la pratique chirurgicale ont ete analyses. Resultats Dans les groupes 1 a 3 : l’âge moyen des internes etait de 30,8 ans (25,7-35,8), 34,6 ans (27,4-48,0) et 31,3 ans (25,3-51,3). Le nombre moyen de mois passe en urologie etait respectivement de 28 mois (6-60), 44 mois (6-72) et 37 mois (2-120). Le duree moyenne du travail hebdomadaire etait de 70 heures (40-90), de 60 heures (35-90) et de 65 heures (40-100). Les francais etaient techniquement plus a l’aise que les groupes 2 ou 3 pour tous les actes de chirurgie (ouverte, laparoscopique, endo-urologique). Certains criteres etaient significativement (p Conclusion Les internes francais semblent apprehender les actes de chirurgie urologique avec moins de difficultes que les autres internes europeens. Les facteurs associes a une meilleure formation etaient la densite de la formation, la diversite des stages, le nombre limite d’interne par stage, l’utilisation du cahier de l’interne et la presence d’un tuteur actif.

Intérêt de la néphrectomie partielle pour la préservation de la fonction rénale des patients ayant une tumeur rénale de plus de 4 cm

OBJECTIVE The objective of the present study was to analyse whether nephron-sparing surgery (NSS) was superior to radical nephrectomy (RN) in preserving renal function outcome in tumors larger than 4cm. METHODS The data from 888 patients who had been operated upon at eight french university hospitals were retrospectively analyzed. Glomerular filtration rate (GFR) pre- and post-surgery was calculated with the abbreviated Modification of Diet in Renal Disease (MDRD) equation. For a fair comparison between the two techniques, all imperative indications for NSS and all GFR<30 mL/min/1.73 m(2) were excluded from analysis. A shift to a less favorable DFG group following surgery was considered clinically significant. RESULTS Seven hundred and thirty patients were suitable for comparison. Median age at diagnosis was 60 years (19-88). Tumors measuring more than 4cm represented 359 (49.2%) cases. NSS and RN were performed in 384 (52.6%) and 346 (47.4%) patients, respectively. In univariate analysis, patients undergoing NSS had a smaller risk than RN of developing significant GFR change following surgery. This was true for tumors≤4cm (P=0.0001) and for tumors>4cm (P=0.018). In multivariate analysis, the following criteria were independent predictive factors for developing significant postoperative GFR loss: the use of RN (P=0.001), decreased preoperative DFG (P=0.006), increased age at diagnosis (P=0.001) and increased ASA score (P=0.004). CONCLUSION The renal function benefit offered by elective NSS over RN persists even when expanding NSS indications beyond the traditional 4 cm cut-off.

Élargir les indications de la néphrectomie partielle induit-il un surcroît de morbidité ? ☆: Une étude multicentrique française

OBJECTIVE To evaluate the morbidity of partial nephrectomy (PN) according to tumour size and the type of indication based on a multicentre retrospective study. MATERIALS AND METHODS Seven French teaching hospitals participated in this study. Data concerning tumour size, indication for PN (elective or necessity), age, gender, TNM stage, histological type, Fuhrman grade, ASA score and performance status (ECOG) were analysed. Medical and surgical complications, intraoperative blood loss, blood transfusion rate and length of hospital stay were also studied. Statistical analysis of qualitative and quantitative variables was performed with Chi-square test (Fishers test) and Student t-test. RESULTS Six hundred and ninety one patients were included. The median tumour diameter was 3cm (0.4-18). Tumours measuring less or equal to 4cm and incidental tumours represented 77.7 and 80.7% of cases, respectively. Clear cell carcinomas represented 75.1% of malignant tumours. Some 89.1% of tumours were T1, 1.6% were N+ and 2.3% were M+. In the 486 elective indications: the operating time (p = 0.03), mean blood loss (p = 0.04), and urinary fistula rate (p = 0.01) were significantly higher in tumours greater than 4cm. These differences were not associated with an increase in the medical (p = 0.7) or surgical complication rate (p = 0.2), or the length of hospital stay (p = 0.4). CONCLUSION Broader indications for elective PN is associated with an increased morbidity but which remains acceptable. This is an important point for patient information and to guide the choice of surgical strategy, particularly in elderly, frail patients or patients with major comorbidities.

Comment se comparent néphrectomies partielles et élargies pour le traitement des carcinomes papillaires pT1aN0M0 ? Étude comparative rétrospective de 277 cas

PURPOSE Our objective was to compare oncologic results of nephron sparing surgery (NSS) versus radical nephrectomy (RN) in T1aN0-x M0 papillary renal cell carcinoma (PRCC). PATIENTS AND METHODS We retrospectively reviewed 277 patients treated for a pT1aN0M0 PRCC selected from an academic database from 12 centres. We compared the clinico-pathological features by using Chi-square and Student statistical analyses. Survivals analyses using Kaplan-Meier and Log-rank models were performed. RESULTS The two groups were composed by 186 patients treated by NSS and 91 by RN. The TNM stage was fixed and the two groups were, in terms of age and Fuhrman grade, comparable. Median age at diagnosis was 59 years (27-85). Median tumor size was 2.7 cm (0.4-4). The average follow-up was 49 months (1-246). Very few events arose in both groups: two local recurrences were observed in the NSS group (1.07%), three patients died of cancer in the NSS treated group (1.6%) and five in the RN treated group (5.5%). The five and 10 cancer-specific survival rate were comparable in the two groups (98% vs. 100% and 98% vs. 97%). The specific survival curves were perfectly similar for both groups (log rank test, p=0.25). CONCLUSION NSS is equivalent to RN as far as oncologic control of pT1aN0M0 PRCC is concerned.