Grégory Johann Wirth

Advances in the management of blunt traumatic bladder rupture: experience with 36 cases

Study Type – Therapy (case series)
Level of Evidence 4

A close surgical margin after radical prostatectomy is an independent predictor of recurrence.

PURPOSE The term close surgical margin refers to a tumor extending to the inked margin of the specimen without reaching it. Current guidelines state that a close surgical margin should simply be reported as negative. However, this recommendation remains controversial and relies on limited evidence. We evaluated the impact of close surgical margins on the long-term risk of biochemical recurrence after radical prostatectomy. MATERIALS AND METHODS We identified 1,195 consecutive patients who underwent radical prostatectomy and lymphadenectomy for localized prostate cancer at our institution from 1993 to 1999. In 894 of these patients associations between margin status and location, Gleason score, pathological stage, preoperative prostate specific antigen, prostate weight and age with the risk of biochemical recurrence were examined. RESULTS Of these 894 patients 644 (72%) had negative margins and of these patients 100 (15.5%) had close surgical margins. In the group with prostate specific antigen failure, median time to recurrence was 3.5 years. In the group without recurrence median followup was 9.9 years. Cumulative recurrence-free survival differed significantly among positive, negative and close surgical margins (p <0.001). On multivariate analysis a close surgical margin constituted a significant, independent predictor of recurrence (HR 2.1, 95% CI 1.04-4.33). Gleason score and positive margins were the strongest prognostic factors. CONCLUSIONS In this cohort close surgical margins were independently associated with a twofold risk of postoperative biochemical recurrence. Further evaluation of the clinical significance of close surgical margins is indicated as they might be an indicator of local recurrence and of relevance when considering salvage therapy.

Validation of Preoperative Risk Grouping of the Selection of Patients Most Likely to Benefit From Neoadjuvant Chemotherapy Before Radical Cystectomy

Micro‐Abstract Neoadjuvant chemotherapy (NAC) has been demonstrated to be effective in prospective randomized trials for cT2‐cT4a N0 patients. However, this benefit was more evident in patients with clinical stage ≥ T3 disease. On the other hand, toxicity grade 3 and 4 were reported in 35% and 37% of patients who underwent NAC. Following these considerations, we validate here the preoperative risk model proposed by Culp et al as a fundamental tool in the preoperative prediction of patients who will benefit more from NAC administration. Introduction: The aim of this study was to validate the value of preoperative patient characteristics in prognosticating survival after radical cystectomy (RC) to guide treatment decisions regarding neoadjuvant systemic treatment. Methods: We evaluated a single cohort of 449 consecutive patients treated with RC for bladder cancer. Patients treated with neoadjuvant therapy were excluded from the study cohort (n = 24). Patients were stratified based on preoperative characteristics into 2 risk groups. The high‐risk group included patients harboring clinically non–organ‐confined disease (≥ cT3), hydroureteronephrosis, lymphovascular invasion, or variant histology (micropapillary, neuroendocrine, sarcomatoid, or plasmacytoid variants on transurethral resection). The low‐risk group included patients with cT2 disease without any of the aforementioned features. Survival expectancies after surgery were evaluated using competing risk and Kaplan‐Meier analyses. Results: We identified 153 (44.6%) low‐risk and 190 (55.4%) high‐risk patients. The majority of high‐risk patients had only 1 high‐risk feature (n = 111; 58.4%); the most common high‐risk feature was preoperative hydroureteronephrosis (n = 107; 56.3%). The majority of low‐risk patients were upstaged at time of RC (n = 118; 70.6%), whereas a pathologic downstage occurred only in 27 high‐risk patients (14.2%). Cancer‐specific mortality‐free rates at 5 years after RC were 77.4% versus 64.4% for low‐risk versus high‐risk patients, respectively. Conclusions: We confirm that preoperative risk features can stratify patients with muscle‐invasive bladder cancer into differential risk groups regarding survival. Decision‐making regarding neoadjuvant systemic therapy administration is likely to be improved by integrating clinical stage, lymphovascular invasion, variant histology, and hydroureteronephrosis.

Determinants and effects of positive surgical margins after prostatectomy on prostate cancer mortality: a population-based study

BackgroundThe objective of this population-based study was to assess patient, physician and tumour determinants associated with positive surgical margins after prostatectomy, and to assess the effects of positive surgical margins on prostate cancer-specific survival.MethodsWe included 1’254 prostate cancer patients recorded at the Geneva Cancer Registry who had radical prostatectomy during 1990–2008. To assess factors associated with positive margins, we used logistic regression. We assessed the effects of positive margins on prostate cancer-specific survival by Cox proportional hazard models accounting for numerous other prognostics factors including prostate and tumour volume, the total percentage of tumour, radiotherapy, surgical approach and surgeon’s caseload.ResultsAmong men undergoing prostatectomy, 479 (38%) had positive margins. In the multivariate logistic regression analysis, period, clinical- and pathological T stage, Prostate Specific Antigen (PSA) level, Gleason score and percentage of tumour in the prostate were significantly associated to positive margins. Ten-year prostate cancer-specific survival was 96.6% for the negative margins group and 92.0% for the positive margins group (log rank p = 0.008). In the Cox survival analysis adjusted for tumour characteristics, surgical margin status per se was not an independent prognostic factor while age, pathological T, PSA level and Gleason score remained associated with prostate cancer-specific survival.ConclusionsMore aggressive tumour characteristics were strong determinants for positive margins. Furthermore, surgical margin status per se was not an independent prognostic factor for prostate cancer-specific survival after adjusting by the gravity of the disease in the multivariate analysis.

Outcome of patients with nonmetastatic muscle‐invasive bladder cancer not undergoing cystectomy after treatment with noncisplatin‐based chemotherapy and/or radiotherapy: a retrospective analysis

Transurethral resection of bladder tumor (TURBT), radiotherapy, chemotherapy, or combinations can be used in patients with muscle‐invasive bladder cancer (MIBC) not undergoing cystectomy. Nevertheless, unfitness for cystectomy is frequently associated with unfitness for other therapeutic modalities. We report the outcome of patients with MIBC who did not undergo cystectomy and did not receive cisplatin‐based chemotherapy. Selection criteria for the study were nonmetastatic MIBC, no cystectomy, no cisplatin‐based chemotherapy. Chemotherapy and/or radiotherapy should have been used aside from TURBT. Forty‐nine patients (median age 79), managed between April 2001 and January 2012, were included in this analysis. Median Charlson Comorbidity Index was 5, while 76% were unfit for cisplatin. Treatment included radiotherapy (n = 7), carboplatin‐based chemotherapy (n = 25), carboplatin‐based chemotherapy followed by radiotherapy (n = 10), and radiochemotherapy (n = 7). Five‐year event‐free rate was 26% (standard error [SE] = 7) for overall survival, 23% (SE = 7) for progression‐free survival, and 30 (SE = 8) for cancer‐specific survival (CSS). Patients who were treated with combination of radiotherapy and chemotherapy had significantly longer CSS compared to those treated with radiotherapy or chemotherapy only (5‐year CSS rate: 16% [SE 8] vs. 63% [SE 15], P = 0.053). Unfit‐for‐cystectomy patients frequently receive suboptimal nonsurgical treatment. Their outcome was poor. Combining chemotherapy with radiotherapy produced better outcomes and should be prospectively evaluated.

Prospective evaluation of early postoperative male and female sexual function after radical prostatectomy with erectile nerves preservation

Prostate cancer screening has led to the diagnosis of localized prostate cancer in increasingly young and sexually active men. Accordingly, the impact of cancer treatment on sexual function is gaining more attention. To prospectively evaluate the impact of radical prostatectomy (RP) on male, female and conjugal sexual function. Patients were prospectively assessed by an urologist and a sexologist before and 6 months after robot-assisted laparoscopic RP (RALP). RALP was performed with uni- or bilateral neurovascular bundle preservation by a single surgeon. Postoperatively, all patients were prescribed tadalafil 20 mg, 3 times a week during 6 months. Male and female sexual functions were evaluated by using the International Index of Erectile Function (IIEF-5), the Female Sexual Function Index (FSFI) and the Lock-Wallace Marital Adjustment Test (MAT). Continuous variables were analyzed with rank-sum and t-tests, as needed, and categorical variables with chi-squared tests. All tests were two-sided, with a P-value⩽0.05 considered significant. Twenty-one couples were included. Mean patient male and female age was 62.4 and 60.7 years, respectively. Bilateral nerve sparing was performed in 12/21 (57%) patients. Median preoperative IIEF-5 was 20/25, corresponding to mild erectile dysfunction (ED). Median preoperative FSFI and MAT were both within normal range (28/36 and 114/158, respectively). Six months following surgery, both IIEF-5 (11/25) and FSFI (25/36) had significantly dropped (P=0.007 and 0.003, respectively). Postoperative decreases in IIEF-5 and FSFI scores were associated within couples. MAT scores (115/158), however, remained unaffected by RALP, showing an unmodified relationship satisfaction postoperatively. Finally, bilateral nerve sparing surgery preserved not only male but also female sexual function. This study shows that the expected short-term post-RALP ED is associated with a worsening of female sexual function, whereas nerve sparing surgery has a protective effect on both the patient’s and his partner’s sexual function with a significant effect of bilateral over unilateral neurovascular bundle preservation. Furthermore, we found that conjugal complicity remains stable throughout the first semestrial postoperative period despite the decrease in sexual function.

Midterm oncological outcomes of laparoscopic vs open radical prostatectomy (RP)

To compare the midterm risks of biochemical recurrence (BCR) and salvage radiation therapy (SRT) after laparoscopic (LRP) and open retropubic radical prostatectomy (RRP). Strong evidence that these techniques are comparable to the ‘gold standard’ of open RRP is lacking, as most comparative studies are limited by short follow‐up or rely on historical controls.

Transrectal Ultrasound-Guided Prostate Biopsy for Cancer Detection: Performance of 2D-, 3D- and 3D-MRI Fusion Targeted Techniques.

Introduction: The study aimed to evaluate 3 different modalities of transrectal ultrasound (TRUS)-guided prostate biopsies (PBs; 2D-, 3D- and targeted 3D-TRUS with fusion to MRI - T3D). Primary end point was the detection rate of prostate cancer (PC). Secondary end point was the detection rate of insignificant PC according to the Epstein criteria. Patients and Methods: Inclusion of 284 subsequent patients who underwent 2D-, 3D- or T3D PB from 2011 to 2015. All patients having PB for initial PC detection with a serum prostate-specific antigen value ≤20 ng/ml were included. Patients with T4 and/or clinical and/or radiological metastatic disease, so as these under active surveillance were excluded. Results: Patients with T3D PB had a significantly higher detection rate of PC (58 vs. 19% for 2D and 38% for 3D biopsies; p = 0.001), with no difference in Gleason score distribution (p = 0.644), as well as detection rate of low-risk cancers (p = 0.914). Main predictive factor for positive biopsies was the technique used, with respectively a 3- and 8-fold higher detection rate in the 3D- and T3D group. For T3D-PB, there was a significant correlation between radiological cancer suspicion (Prostate Imaging Reporting and Data System Score) and cancer detection rate (p = 0.02). Conclusions: T3D PB should be preferred over 2D PB and 3D PB in patients with suspected PC as it improves the cancer detection rate.

Post-kidney Transplant Robot-assisted Laparoscopic Ureteral (Donor-receiver) Anastomosis for Kidney Graft Reflux or Stricture Disease

OBJECTIVE To report our experience with robot-assisted ureteral anastomosis for kidney graft. Kidney graft complex ureteral strictures or symptomatic vesicoureteral reflux may require complex reconstruction. This is classically done through an open surgical access, which adds to the morbidity of kidney transplantation. The da Vinci robot enables performance of complex laparoscopic procedures and may hence be used for such reconstructions. PATIENTS AND METHODS We retrospectively reviewed all patients undergoing robotic surgical revision for stricture or reflux disease over a 3-year period. Contemporary patients who underwent open surgery were used as a control group. RESULTS Ten patients underwent a robotic attempt, of whom 4 needed conversion to open surgery. Seven patients underwent an open surgery. Preoperative demographics were similar in both groups. The median operative time was 293 minutes, with a shorter operative time in the open group. The group of patients who could be completed robotically had a significantly lower postoperative length of stay (5 vs 9 days), quicker return to normal food intake (postoperative day 1 vs 3), and quicker control of pain without opiates (postoperative day 1 vs 4) than the converted or open group. Morbidity was comparable with 1 late Clavien IIIb complication in each subgroup (open, converted, and robotic group). After a median follow-up of 43 months, renal function was stable and there were no recurrent graft infections. CONCLUSION Robotic ureteral reconstruction for kidney graft patients is feasible and efficient, and offers the classical advantages of minimally invasive surgery with outcomes comparable with open series.

Bulbomembranous anastomotic urethroplasty for strictures of the proximal bulbar urethra unassociated with pelvic trauma

1 Urabe F, Kimura T, Miki J, Shimizu K, Kishimoto K, Egawa S. Estimated glomerular filtration rate on postoperative day 1 is associated with renal functional outcome after percutaneous renal cryoablation for renal tumors. Int. J. Urol. 2017; 24: 553–4. 2 Altunrende F, Autorino R, Hillyer S et al. Image guided percutaneous probe ablation for renal tumors in 65 solitary kidneys: functional and oncological outcomes. J. Urol. 2011; 186: 35–41. 3 Zargar H, Atwell TD, Cadeddu JA et al. Cryoablation for small renal masses: selection criteria, complications, and functional and oncologic results. Eur. Urol. 2016; 69: 116–28. 4 Motzer RJ, Jonasch E, Agarwal N et al. NCCN clinical practice guidelines in oncology kidney cancer version 2.5-9. [Cited 20 Dec 2016.] Available from URL: http://www.nccn.org/professionals/physician_gls/pdf/kidney.pdf 5 Ljungberg B, Bensalah K, Bex A et al. Guidelines on renal cell carcinoma. EAU 22–3. [Cited 20 Dec 2016.] Available from URL: http://www.euro peanurology.com/eau-guidelines 6 Escudier B, Porta C, Schmidinger M et al.; ESMO Guidelines Working Group. Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann. Oncol. 2014; 25 (Suppl 3): iii49–56.