Benoit Peyronnet

Early unclamping technique during robot-assisted laparoscopic partial nephrectomy can minimise warm ischaemia without increasing morbidity.

To compare perioperative outcomes of early unclamping (EUC) vs standard unclamping (SUC) during robot‐assisted partial nephrectomy (RAPN), as early unclamping of the renal pedicle has been reported to decrease warm ischaemia time (WIT) during laparoscopic PN.

High rates of advanced disease, complications, and decline of renal function after radical nephroureterectomy

OBJECTIVES Recurrences remain common following radical nephroureterectomy (RNU) for locally advanced upper-tract urothelial carcinoma (UTUC). We review a cohort of RNU patients to identify the incidence of locally advanced disease, decline in renal function, complications, and utilization of adjuvant chemotherapy (AC). METHODS Institutional databases from 7 academic medical centers identified 414 RNU patients treated between 2003 and 2012 who had not received neoadjuvant chemotherapy. Glomerular filtration rate was estimated using the Modification of Diet in Renal Disease equation. Complications were classified according to the modified Clavien system. Cox proportional hazard modeling and Kaplan-Meier analysis determined factors associated with cancer-specific survival. RESULTS Of 414 patients, 177 (43%) had locally advanced disease, including 118 pT3N0/Nx, 13 pT4N0/Nx, and 46 pTanyN+. Estimated 3- and 5-year cancer-specific survival was 47% and 34%, respectively. Only 31% of patients with locally advanced UTUC received AC. Mean estimated glomerular filtration rate declined from 59 to 51 ml/min/1.73 m(2) following RNU, including a new-onset decline below 60 and 45 ml/min/1.73 m(2) in 25% and 15% of patients, respectively (P<0.001 for both). Complications occurred in 46 of 177 (26%) patients, of which one-quarter were grade III or IV. Increasing age (Hazard Ratio (HR) 1.4, P = 0.03), positive surgical margins (HR 2.1, P = 0.01), and positive lymph nodes (HR 4.3, P<0.001) were associated with an increased risk of death from UTUC, whereas receipt of AC (HR 0.85, P = 0.05) was associated with a decrease in UTUC mortality. CONCLUSIONS Under one-third of RNU patients with locally advanced UTUC cancers received AC. Perioperative complications and decline in renal function may have contributed to this low rate. Such data further underscore the need for continued discussion regarding the use of chemotherapy in a neoadjuvant setting for appropriately selected patients with UTUC.

Accuracy of Magnetic Resonance Imaging/Ultrasound Fusion Targeted Biopsies to Diagnose Clinically Significant Prostate Cancer in Enlarged Compared to Smaller Prostates

PURPOSE We assessed the accuracy of magnetic resonance imaging/transrectal ultrasound fusion biopsies to diagnose prostate cancer according to gland size. MATERIALS AND METHODS A prospective study was performed in 232 men with a first round biopsy, multiparametric magnetic resonance imaging with a lesion, a Likert score of 2 or greater and prostate specific antigen less than 10 ng/ml. All men underwent a standard 12-core protocol plus a protocol of 2 or 3 targeted cores. Significant prostate cancer was defined as at least 1 core with a Gleason score of 7 (3 + 4) or 6 with a greater than 4 mm maximal cancer core length. RESULTS Mean ± SD patient age was 64 ± 6.4 years, mean prostate specific antigen was 6.65 ± 1.8 ng/ml and mean prostate volume was 40 ± 24.3 ml. The overall detection rate of clinically significant prostate cancer was 44%. The detection rate of clinically significant prostate cancer by magnetic resonance imaging-transrectal ultrasound fusion guided biopsy was 77% for prostate glands less than 30 cm(3), and 61%, 47% and 34% for glands 30 to less than 38.5, 38.5 to less than 55 and 55 to 160 cm(3), respectively (p = 0.001). Differences in prostate cancer detection rates between the standard and targeted protocols were not significant for patients with a prostate volume of 40 cm(3) or less (p = 0.8). Conversely 12 patients with a prostate volume greater than 40 cm(3) had clinically significant prostate cancer using the targeted but not the standard protocol and in 3 prostate cancer was detected by the standard but not the targeted protocol (p = 0.04). CONCLUSIONS Magnetic resonance imaging-transrectal ultrasound fusion biopsies increased the yield of first round prostate biopsies in patients with a prostate volume greater than 40 cm(3).

Oncologic Outcomes of Kidney-sparing Surgery Versus Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Systematic Review by the EAU Non-muscle Invasive Bladder Cancer Guidelines Panel

CONTEXT There is uncertainty regarding the oncologic effectiveness of kidney-sparing surgery (KSS) compared with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). OBJECTIVE To systematically review the current literature comparing oncologic outcomes of KSS versus RNU for UTUC. EVIDENCE ACQUISITION A computerised bibliographic search of the Medline, Embase, and Cochrane databases was performed for all studies reporting comparative oncologic outcomes of KSS versus RNU. Approaches considered for KSS were segmental ureterectomy (SU) and ureteroscopic (URS) or percutaneous (PC) management. Using the methodology recommended by the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, we identified 22 nonrandomised comparative retrospective studies published between 1999 and 2015 that were eligible for inclusion in this systematic review. A narrative review and risk-of-bias (RoB) assessment were performed using cancer-specific survival (CSS) as the primary end point. EVIDENCE SYNTHESIS Seven studies compared KSS overall (n=547) versus RNU (n=1376). Information on the comparison of SU (n=586) versus RNU (n=3692), URS (n=162) versus RNU (n=367), and PC (n=66) versus RNU (n=114) was available in 10, 5, and 2 studies, respectively. No significant difference was found between SU and RNU in terms of CSS or any other oncologic outcomes. Only patients with low-grade and noninvasive tumours experienced similar CSS after URS or PC when compared with RNU, despite an increased risk of local recurrence following endoscopic management of UTUC. The RoB assessment revealed, however, that the analyses were subject to a selection bias favouring KSS. CONCLUSIONS Our systematic review suggests similar survival after KSS versus RNU only for low-grade and noninvasive UTUC when using URS or PC. However, selected patients with high-grade and invasive UTUC could safely benefit from SU when feasible. These results should be interpreted with caution due to the risk of selection bias. PATIENT SUMMARY We reviewed the studies that compared kidney-sparing surgery versus radical nephroureterectomy for upper tract urothelial carcinoma. We found similar oncologic outcomes for favourable tumours when using ureteroscopic or percutaneous management, whereas indications for segmental ureterectomy could be extended to selected cases of aggressive tumours.

Contemporary role of lymph node dissection at the time of radical nephroureterectomy for upper tract urothelial carcinoma

AbstractPurposeTo review the contemporary data on the role of lymph node dissection (LND) at the time of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). MethodsA computerized bibliographic search using the following protocol (“Nephroureterectomy”) AND (“Lymphadenectomy” OR “Lymph node” OR “Lymphatic”) was performed in MEDLINE to identify all original and review articles that addressed the role of LND for UTUC. ResultsRegional lymph node (LN) boundaries of UTUC have been recently investigated in mapping studies to propose anatomic templates of LND according to the laterality and location of primary tumor. Although these anatomic templates remained poorly described, most reports supported the staging benefit of LND that allowed for risk stratification of patients with (pN+) or without (pN0) LN metastases from those who did not undergo such a procedure (pNx). In addition, the therapeutic benefit of LND at the time of RNU was supported by better oncological outcomes obtained after complete LND when compared to incomplete or no LND, especially in the group of patients with advanced disease. The number of LNs removed was also correlated with both, more accurate staging and greater cancer-specific survival after LND, whose feasibility and safety have been validated in prospective studies.ConclusionsDespite mostly based on data with level of evidence 3, our comprehensive review of the literature supports the staging and therapeutic benefits of LND at the time of RNU for UTUC, which are particularly significant for patients with muscle-invasive or locally advanced disease.

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).

Preliminary results of botulinum toxin A switch after first detrusor injection failure as a treatment of neurogenic detrusor overactivity

To assess the results of onabotulinum toxin detrusor injections when abobotulinum toxin detrusor injection failed.

Direct Comparison of GreenLight Laser XPS Photoselective Prostate Vaporization and GreenLight Laser En Bloc Enucleation of the Prostate in Enlarged Glands Greater than 80 ml: a Study of 120 Patients

PURPOSE We compare patient outcomes after 180 W XPS™ GreenLight™ photoselective vaporization of the prostate and GreenLight laser enucleation of the prostate used to surgically manage benign prostatic obstruction. MATERIALS AND METHODS Two groups of 60 consecutive patients with enlarged glands (greater than 80 ml) underwent GreenLight laser prostate enucleation or photoselective prostate vaporization (performed by the same surgeon and including the learning curve) and were retrospectively evaluated. Perioperative data from both groups were compared. RESULTS The operative time was significantly shorter in the GreenLight laser prostate enucleation group (60 vs 82 minutes, p <0.0001). Complication rates were comparable between the groups. At 2 months the rate of urinary incontinence was significantly higher in the GreenLight laser prostate enucleation group (25% vs 3.4%, p <0.0001) but incontinence rates were similar at 6 months (3.4% vs 0%, p=0.50). At 6 months International Prostate Symptom Score quality of life and post-void residual urine volume had similarly decreased in the 2 groups after the procedure (compared to baseline), whereas the maximum urinary flow rate had greatly improved, significantly favoring the GreenLight laser prostate enucleation group (+78% vs +64%, p <0.0001). Prostate size and prostate specific antigen reductions were significantly higher in the GreenLight laser prostate enucleation group (74% vs 57%, p <0.0001 and 67% vs 40%, respectively, p=0.007). The unplanned hospital readmission rates were similar in both groups (16.7% vs 6.7%, p=0.16). CONCLUSIONS Photoselective vaporization of the prostate and GreenLight laser enucleation of the prostate are safe and provide satisfactory short-term functional outcomes in patients with a prostate volume greater than 80 ml. However, the surgical time was longer in the photoselective prostate vaporization group, which also had a higher rate of unplanned hospital readmission, and lower decreases in prostate specific antigen and prostate size.

Trends in the Use of the GreenLight Laser in the Surgical Management of Benign Prostatic Obstruction in France Over the Past 10 Years

Photoselective vaporization of the prostate (PVP), introduced in the late 1990s, is now considered a valuable alternative to transurethral resection of the prostate (TURP) [1]. Although several studies conducted in Asia and North America have highlighted the expanding role of laser prostatectomy [2,3], specific epidemiological data in Europe are critically lacking. We describe the trends in the surgical management of benign prostatic obstruction (BPO) in France over the past 10 yr, with a specific focus on the use of the GreenLight laser. We analyzed data from a national comprehensive administrative claim database (previously described by Lukacs et al [4]) to estimate the number of endoscopic procedures (whatever the technique) and open prostatectomy surgeries performed each year between 2005 and 2014. We concurrently analyzed data from the manufacturer regarding use of the GreenLight laser fibers (American Medical Systems, Minnetonka, MN, USA) in France during the same period. PVP numbers were subtracted from the group of endoscopic procedures. Because enucleation was introduced in France only very recently, the remaining endoscopic procedures were hereafter designated as TURP. For the 2014 figures, data were extrapolated from those obtained for the period from January to September. The overall number of BPO surgical procedures in France remained stable during the study period (61 993 in 2005 and 60 184 in 2014). During the past decade, the share of PVP has dramatically increased from 0.2% in 2005 to 22.9% of all procedures in 2014, whereas the number of TURPs and open prostatectomies conducted per year decreased from 52 828 to 40 436 and from 9069 to 5948 (34.4% reduction), respectively (Fig. 1A). In 2014, TURP, open prostatectomy, and PVP accounted for 67.2%, 9.9%, and 22.9%, respectively, of all benign prostatic hyperplasia surgeries. The fibers used were mostly KTP 80 W between 2005 and 2006, HPS 120 W between 2007 and 2010, and XPS 180 W between 2011 and 2014 (Fig. 1B). The increased use of PVP thus mainly occurred during the XPS era. Our results are consistent with previous findings outside Europe [2,3,5]. However, in 2014, the rate of TURP remained

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.