G. Pignot

The oncologic impact of a delay between diagnosis and radical nephroureterectomy due to diagnostic ureteroscopy in upper urinary tract urothelial carcinomas: results from a large collaborative database.

ObjectivesAccording to the current upper urinary tract urothelial carcinomas (UTUC) guidelines, ureteroscopic evaluation (URS) is recommended to improve diagnostic accuracy and obtain a grade (by biopsy or cytology). However, URS may delay radical surgery [e.g., nephroureterectomy (RNU)]. The objective of this study was to evaluate the influence of URS implementation before RNU on patient survival.MethodsA French multicentre retrospective study including 512 patients with nonmetastatic UTUC was conducted between 1995 and 2011. Achievement of ureteroscopy (URS), treatment time (time between imaging diagnosis and RNU), tumour location, pT–pN stage, grade, lymphovascular invasion (LVI) and the presence of invaded surgical margins (R+) were evaluated as prognostic factors for survival using univariate and multivariate Cox regression analyses. Cancer-specific survival (CSS), recurrence-free survival (RFS) and metastasis-free survival (MFS) were calculated using the Kaplan–Meier method.ResultsA total of 170 patients underwent ureteroscopy prior to RNU (URS+ group), and 342 did not undergo URS (URS−). The median treatment time was significantly longer in the URS+ group (79.5 vs. 44.5xa0days, pxa0=xa00.04). Ureteroscopic evaluation was correlated with ureteral location and lower stage and tumour grade (pxa0=xa00.022, 0.005, 0.03, respectively). Tumour stage, LVI+ and R+ status were independently associated with CSS (pxa0=xa00.024, 0.049 and 0.006, respectively). The 5-year CSS, RFS and MFS did not differ between the two groups (pxa0=xa00.23, 0.89 and 0.35, respectively). These results were confirmed for muscle-invasive (MI) UTUC (pxa0=xa00.21, 0.44 and 0.67 for CSS, RFS and MFS, respectively).ConclusionsDespite the increased time to radical surgery, diagnostic ureteroscopy can be systematically performed for the appraisal of UTUC to refine the therapeutic strategy without significantly affecting oncological outcomes, even for MI lesions.

Influence of preoperative hydronephrosis on the outcome of urothelial carcinoma of the upper urinary tract after nephroureterectomy: the results from a multi-institutional French cohort

ObjectivesRecent publications have assessed the prognostic significance of hydronephrosis in the outcome of upper tract urothelial carcinoma (UUT-UC). Our study sought to determine the prognostic impact of hydronephrosis on UUT-UC survival and its relationship to the clinicopathological features.Materials and methodsA retrospective, multi-institutional French study was conducted on 401 patients who underwent radical nephroureterectomy for non-metastatic UUT-UC. Hydronephrotic status was determined using preoperative imaging reports. Univariate and multivariate analyses were conducted to identify factors associated with survival.ResultsPreoperative hydronephrosis was present in 74 patients. Median follow-up was 26xa0months. Hydronephrosis was associated only with ureteral localisation (pxa0<xa00.001). No difference was observed in 5-year cancer-specific survival (CSS) between the hydronephrosis group (80.1xa0%) and the no hydronephrosis group (83.6xa0%) (pxa0>xa00.05). Only age (pxa0=xa00.02) and pT stage (pxa0=xa00.01) were independent predictors of CSS. Hydronephrosis was not a significant predictor of CSS in the univariate and multivariate analyses (pxa0=xa00.87 and pxa0=xa00.66). No significant difference was observed for 5-year metastasis-free survival (MFS) between the hydronephrosis group (69.8xa0%xa0±xa06.6xa0%) and the no hydronephrosis group (80.5xa0%xa0±xa03xa0%) (pxa0=xa00.052). Hydronephrosis was not a significant predictor of MFS in the univariate and multivariate analyses (pxa0=xa00.16 and pxa0=xa00.36). Multifocality (pxa0=xa00.02), pT stage (pxa0<xa00.001) and positive surgical margins (pxa0=xa00.02) were independent predictors of MFS. For the pelvic tumours subgroup, hydronephrosis was an independent predictor of MFS (pxa0=xa00.01) but not CSS (pxa0=xa00.86).ConclusionPreoperative hydronephrosis was not associated with survival. However, among tumours presenting with hydronephrosis, pelvicalyceal tumours appear to have a worse prognosis than ureteral tumours.

Implants péniens hydrauliques: résultats, complications et facteurs pronostiques

OBJECTIVEnTo identify the main prognostic factors influencing the immediate and long-term results of inflatable penile prosthesis implantation.nnnPATIENTS AND METHODSnBetween February 1999 and December 2007, 118 inflatable penile prostheses were implanted, by the same operator, on 96 patients with a mean age of 54.4 years. One third of the implanted patients had had previous penile surgery. Three different penile implants were used: TITAN alpha1 (N = 32), EXCEL (N = 6), and TITAN RESIST (N = 80).nnnRESULTSnMedian follow-up was 25 months [6-114]. One patient with sickle-cell disease died from a massive pulmonary embolism. Seven patients (7.3%) had a postoperative scrotal haematoma. Eleven patients (11.5%) had a postoperative infection. Fourteen patients (14.6%) had a material migration. Sixteen patients (16.7%) had a surgical revision for mechanical dysfunctions after a mean period of 21 months. The rate of postoperative complications was significantly increased in case of prior penile surgery (p = 0.049) or in case of associated surgical procedure (p = 0.0095). The rate of migration was significantly more important in case of postpriapism erectile dysfunction (p = 0.00035). The risk of mechanical dysfunctions was significantly increased in case of Peyronies disease. In the end of the follow-up, 85% of patients (and 91% of first-time implantations) had a functional prosthesis.nnnCONCLUSIONnThe long-term functional results of inflatable penile prosthesis are suitable but the postoperative complications are frequent in case of prior penile surgery, associated surgical procedure, Peyronies disease, or postpriapism implantation.

Recommandations en onco-urologie 2016-2018 du CCAFU : Tumeurs de la vessie

OBJECTIVEnThe purpose of the guidelines national committee CCAFU on bladder cancer was to propose updated french guidelines for non-muscle invasive (NMIBC) and invasive (MIBC) bladder cancers.nnnMETHODSnA Medline search was achieved between 2013 and 2016, as regards diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.nnnRESULTSnDiagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumour. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment : instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on pelvic-abdominal and thoracic CT-scan; MRI and FDG-PET remain optional. Cystectomy associated with extensive pelvic lymph nodes resection is considered the gold standard for non metastatic MIBC. An orthotopic bladder substitution should be proposed to both male and female patients lacking any contraindications and in cases of negative frozen urethral samples. The interest of neoadjuvant chemotherapy is well known for all MIBC, wathever the stage. Thus, neoadjuvant chemotherapy is recommended for all eligible patients according PS (PS <2) and renal function (clearance > 60ml/mn). As regards metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC). In second line treatment, only chemotherapy using vinflunine has been validated to date, even if results of immunotherapy clinical trials are encouraging.nnnCONCLUSIONnThese updated french guidelines will contribute to increase the level of urological care for the diagnosis and treatment for NMIBC and MIBC.

RecommandationRecommandations du comité de cancérologie de l’Association française d’urologie (CC-AFU) pour la bonne pratique des instillations endovésicales de BCG et de mytomycine C dans le traitement des tumeurs de la vessie n’envahissant pas le muscle (TVNIM)Guidelines for good practice of intravesical instillations of BCG and mitomycin C from the French national cancer committee (CC-AFU) for non-muscle invasive bladder cancer

INTRODUCTIONnIntravesical BCG immunotherapy and mitomycin C are considered as the standard treatment for non-muscle invasive bladder cancer. These guidelines aim to describe the optimal condition to perform intravesical instillation of BCG or mitomycin C in order to increase its oncologic efficiency and to decrease its morbidity.nnnMETHODSnOnline systematic literature search was performed on PubMed(®) until Aprilxa02010. Regulation texts, published guidelines and results of recent urologists practice study were taken into consideration. Level of evidence was assigned to each recommendation. A bibliographic research in French and English using Medline(®) and Embase(®) with the keywords BCG, mitomycin C, bladder, complication, toxicity, adverse reaction, prevention and treatment was performed.nnnRESULTSnPatient information must be prior to the first intravesical instillation and should be given through a medical exam by the physician performing the procedure. The check for formal contra-indication to BCG is systematically mandatory by the physician during the medical exam. Intravesical instillation must be realized in a health center where urologic endoscopic procedures are made frequently. A recent urine culture has to be checked systematically before any instillation done either by the urologist or a specialized nurse. Contingent upon a bladder catheter has been inserted in the bladder without any injury of the lower urinary tract, the instillation can be done. The pharmaceutical agent needs to be kept two hours in the bladder. After instillation, the patient must be seated to void and also has to keep in mind that he needs to drink at least 2xa0liters of water per day for 2xa0days.nnnCONCLUSIONnTo improve the oncologic performance and to reduce the risk of complication and adverse event, achievement of intravesical instillations of BCG and/or mitomycin C should follow a standardized procedure.

Article originalImplants péniens hydrauliques : résultats, complications et facteurs pronostiquesInflatable penile prostheses: Results, complications and prognostic factors☆

OBJECTIVEnTo identify the main prognostic factors influencing the immediate and long-term results of inflatable penile prosthesis implantation.nnnPATIENTS AND METHODSnBetween February 1999 and December 2007, 118 inflatable penile prostheses were implanted, by the same operator, on 96 patients with a mean age of 54.4 years. One third of the implanted patients had had previous penile surgery. Three different penile implants were used: TITAN alpha1 (N = 32), EXCEL (N = 6), and TITAN RESIST (N = 80).nnnRESULTSnMedian follow-up was 25 months [6-114]. One patient with sickle-cell disease died from a massive pulmonary embolism. Seven patients (7.3%) had a postoperative scrotal haematoma. Eleven patients (11.5%) had a postoperative infection. Fourteen patients (14.6%) had a material migration. Sixteen patients (16.7%) had a surgical revision for mechanical dysfunctions after a mean period of 21 months. The rate of postoperative complications was significantly increased in case of prior penile surgery (p = 0.049) or in case of associated surgical procedure (p = 0.0095). The rate of migration was significantly more important in case of postpriapism erectile dysfunction (p = 0.00035). The risk of mechanical dysfunctions was significantly increased in case of Peyronies disease. In the end of the follow-up, 85% of patients (and 91% of first-time implantations) had a functional prosthesis.nnnCONCLUSIONnThe long-term functional results of inflatable penile prosthesis are suitable but the postoperative complications are frequent in case of prior penile surgery, associated surgical procedure, Peyronies disease, or postpriapism implantation.

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.

Intérêt du curage ganglionnaire dans les tumeurs urothéliales infiltrantes de la vessie (TVIM) et de la voie excrétrice supérieure (TVES) : article de revue du Comité de cancérologie de l’Association française d’urologie

INTRODUCTIONnLymph node dissection during radical cystectomy or nephroureterectomy confers improved prognosis and eventually therapeutic advantage. The aim of this update is to clarify the anatomical limits of the lymph node dissection, imaging related techniques, possible difficulties related to pathological analysis, its prognostic value and adjuvant treatments.nnnMETHODnA literature review was performed using PubMed database with a combination of the following keywords: urothelial carcinoma, lymph node excision, imaging, pathology analysis, prognosis, chemotherapy and radiotherapy.nnnRESULTSnRegarding bladder tumours, extended lymph node dissection is usually performed up to the division of the iliac vessels and the crossing of the ureters. The CT scan is the recommended imaging technique for lymph node staging but its sensitivity is low. Pathological examination should include perivesicle lymph nodes analysis and report the number of normal and metastatic lymph nodes separately. The prognosis is correlated to the total number of lymph nodes removed and to the extent of the excision. The lymph node density (number of metastatic nodes/normal nodes) is the most important prognosis factor. Adjuvant chemotherapy has not demonstrated a clear advantage. Its most efficient modality is a combination including cisplatin. For upper urinary tract tumours, lymph node dissection may have an impact on survival but definitive conclusion is limited by the lack of surgical technique and indications standardisation.nnnCONCLUSIONnExtended lymph node dissection improves survival of bladder cancer and prognosis assessment that could eventually be used to stratify patient requiring adjuvant treatment (level of evidence 3). Improvement on survival was also suggested for upper urinary tract tumors (level of evidence 4).

Cicatrisation et thérapies ciblées : quelles précautions en période périopératoire ?

INTRODUCTIONnIn the era of new-targeted therapies and neoadjuvant strategies, this article highlights the role of angiogenesis in the process of physiological wound healing with a review of literature about parietal complications under anti-angiogenic therapies.nnnMETHODSnResearch on Medline was carried out using the terms renal cell carcinoma, angiogenesis, wound healing, targeted therapies, and complications.nnnRESULTSnThe frequency of these complications varies between 5 and 50% in recent series. These results depend on half-lives of each drug and perioperative management (before and after surgical procedure).nnnCONCLUSIONnIn the absence of current recommendations, it is advised to stop bevacizumab at least five weeks before a surgical intervention and to take it back 4 weeks later. For the tyrosine kinase inhibitors, the treatment can be stopped 24-48 hours before the surgery and taken back 3-4 weeks later. Finally, for the mTOR inhibitors, it is advised to stop the treatment 7-10 days before and to take back it at least 3 weeks later.

Mélanome métastatique aux voies excrétrices supérieures. À propos de trois cas et revue de la littérature

Melanoma is a slowly growing malignancy, with potential distant metastasis at various sites. In this article, we reported three original cases of melanoma metastases in the upper urinary tract, and we achieved a literature review. Symptoms are inconstant and non-specific (pain or haematuria). Nephroureterectomy is performed in the majority of cases. Even if this metastatic location remains uncommon, it should be timely detected in order to allow an appropriate management and to improve the prognostic of melanoma.