J.-A. Long

Targeted MRI-guided Prostate Biopsies for the Detection of Prostate Cancer: Initial Clinical Experience With Real-time 3-Dimensional Transrectal Ultrasound Guidance and Magnetic Resonance/Transrectal Ultrasound Image Fusion

OBJECTIVE To prove the feasibility and evaluate the initial clinical results of targeted prostate biopsies using the Urostation novel platform using magnetic resonance imaging (MRI)/transrectal ultrasound (TRUS) registration to help steer the biopsy needle to suspicious areas. METHODS We prospectively included 30 patients for suspicion of prostate cancer from November 2011 to August 2012. All patients were previously evaluated by a multiparametric MRI, interpreted by a single radiologist who attributed a Prostate Imaging-Reporting and Data System (PI-RADS) score to each lesion. A conventional 12-core randomized biopsy protocol was performed and 2 additional targeted biopsies were performed on suspicious area(s). The results of randomized and targeted biopsies were compared. RESULTS Among the 30 patients, suspicious area(s) were found on MRI in 20 cases (67%). Median procedure time was 23 minutes. Targeting success rate (biopsy visualized inside the target) was 83%, with at least 1 biopsy reaching the target in all cases. Prostate cancer was detected in 14 cases (47%), including 11 cases with an abnormal MRI. Targeted biopsies detected cancer in all 11 cases and all but 1 were clinically significant. Randomized biopsies detected 10 of these 11 cases, and 3 more cases that MRI considered normal. Sensitivity to detect a significant cancer was 91% in both modalities. CONCLUSION This initial clinical study showed encouraging results for targeted MRI-guided prostate biopsies using MRI-TRUS fusion. Although further studies are needed to determine the role of prostate MRI before biopsy and the relevance of targeted biopsies, the Urostation is an MRI-TRUS fusion device that has good accuracy for targeting suspicious areas on MRI.

Recommandations en Onco-Urologie 2010 : Cancer du rein

Il s’agit d’une maladie a transmission autosomique dominante, a forte penetrance (95 % a 60 ans), pour laquelle un seul gene est en cause : le gene VHL situe sur le bras court du chromosome 3 (3p25-p26) (Tableau 1) [1]. La mutation causale du gene VHL est identifiable chez presque tous les patients atteints de cette affection. Il s’agit le plus souvent de mutations ponctuelles (75 % des cas) portant sur la sequence codante, mais des microdeletions, des micro-insertions, des deletions etendues ou une hypermethylation le plus souvent du promoteur ont egalement ete observees. Plus de 150 mutations differentes ont ete repertoriees sur l’ensemble des 3 exons [3-4]. Une consultation d’oncogenetique et un typage genetique du ou des sujets atteints puis des membres de la famille permet la mise en evidence de mutations du gene VHL et l’identification des sujets predisposes a cette maladie (Niveau de preuve 1). Il est recommande de depister les enfants a partir de 5 ans. Une imagerie abdominale annuelle est souhaitable car il existe un risque de 2,7 % de decouverte par an de nouvelle lesion renale (Niveau de preuve 4) [5-6].

External validation of the RENAL nephrometry score in renal tumours treated by partial nephrectomy

Using a standardized classification for renal tumours is a major step towards an objective comparison of the indications and expected outcomes of partial nephrectomy (PN). Several scores have been described, including the RENAL nephrectomy score (RNS), to evaluate the anatomical features of a renal tumour and predict the surgical challenges with particular regard to PN. Previous studies show discrepancies with regard to the effectiveness of using the RNS to predict postoperative outcomes. Although we showed that conversion to radical nephrectomy was predicted by the RNS, the occurence of complications was more difficult to predict.

A proportion of hereditary upper urinary tract urothelial carcinomas are misclassified as sporadic according to a multi-institutional database analysis: proposal of patient-specific risk identification tool.

Study Type – Diagnostic (exploratory cohort)

Recommandations en onco- urologie 2013 du CCAFU : Cancer du rein

Resume Introduction L’objectif de ce travail a ete d’etablir par le sous-comite rein du CCAFU des recommandations pour le diagnostic, le bilan, les traitements et la prise en charge des tumeurs du rein. Methodes Le sous-comite a remis a jour les recommandations de 2010 en s’appuyant sur une revue exhaustive de la litterature effectuee sur PubMed, en evaluant les references et leur niveau de preuve. Resultats Le scanner renal multiphasique est le standard diagnostique pour les tumeurs renales. Les biopsies renales sont d’importance croissante dans la mesure ou elles peuvent modifier la prise en charge. La nephrectomie partielle est a envisager systematiquement pour les tumeurs cT1. La voie incisionnelle reste le standard pour les cancers du rein localement avances. Le traitement des cancers du rein metastatiques inclut de nouvelles drogues. Le role de la nephrectomie en situation metastatique reste a demontrer dans le cadre de l’essai Carmena. Conclusions Les therapies mini-invasives et conservatrices prennent une part croissante dans les cancers du rein localises. L’arsenal therapeutique continue a s’enrichir pour les formes metastatiques.

High-grade renal injury: non-operative management of urinary extravasation and prediction of long-term outcomes.

Study Type – Therapy (outcomes)

Prostate Biopsies Guided by Three-Dimensional Real-Time (4-D) Transrectal Ultrasonography on a Phantom: Comparative Study versus Two-Dimensional Transrectal Ultrasound-Guided Biopsies

OBJECTIVE This study evaluated the accuracy in localisation and distribution of real-time three-dimensional (4-D) ultrasound-guided biopsies on a prostate phantom. METHODS A prostate phantom was created. A three-dimensional real-time ultrasound system with a 5.9MHz probe was used, making it possible to see several reconstructed orthogonal viewing planes in real time. Fourteen operators performed biopsies first under 2-D then 4-D transurethral ultrasound (TRUS) guidance (336 biopsies). The biopsy path was modelled using segmentation in a 3-D ultrasonographic volume. Special software was used to visualise the biopsy paths in a reference prostate and assess the sampled area. A comparative study was performed to examine the accuracy of the entry points and target of the needle. Distribution was assessed by measuring the volume sampled and a redundancy ratio of the sampled prostate. RESULTS A significant increase in accuracy in hitting the target zone was identified using 4-D ultrasonography as compared to 2-D. There was no increase in the sampled volume or improvement in the biopsy distribution with 4-D ultrasonography as compared to 2-D. CONCLUSION The 4-D TRUS guidance appears to show, on a synthetic model, an improvement in location accuracy and in the ability to reproduce a protocol. The biopsy distribution does not seem improved.

Development of a Novel Robot for Transperineal Needle Based Interventions: Focal Therapy, Brachytherapy and Prostate Biopsies

PURPOSE We report what is to our knowledge the initial experience with a new 3-dimensional ultrasound robotic system for prostate brachytherapy assistance, focal therapy and prostate biopsies. Its ability to track prostate motion intraoperatively allows it to manage motions and guide needles to predefined targets. MATERIALS AND METHODS A robotic system was created for transrectal ultrasound guided needle implantation combined with intraoperative prostate tracking. Experiments were done on 90 targets embedded in a total of 9 mobile, deformable, synthetic prostate phantoms. Experiments involved trying to insert glass beads as close as possible to targets in multimodal anthropomorphic imaging phantoms. Results were measured by segmenting the inserted beads in computerized tomography volumes of the phantoms. RESULTS The robot reached the chosen targets in phantoms with a median accuracy of 2.73 mm and a median prostate motion of 5.46 mm. Accuracy was better at the apex than at the base (2.28 vs 3.83 mm, p <0.001), and similar for horizontal and angled needle inclinations (2.7 vs 2.82 mm, p = 0.18). CONCLUSIONS To our knowledge this robot for prostate focal therapy, brachytherapy and targeted prostate biopsies is the first system to use intraoperative prostate motion tracking to guide needles into the prostate. Preliminary experiments show its ability to reach targets despite prostate motion.

Influence of previous or synchronous bladder cancer on oncologic outcomes after radical nephroureterectomy for upper urinary tract urothelial carcinoma

OBJECTIVE The objective of the study was to evaluate the effect of a history of bladder cancer (BC) or synchronous BC on the prognosis and survival of patients who have undergone radical nephroureterectomy (RNU). METHODS AND MATERIALS Using a multi-institutional, retrospective database, we identified 662 patients with upper urinary tract urothelial carcinoma (UUT-UC) treated by radical nephroureterectomy, between 1995 and 2010. We analyzed clinicopathologic characteristics and outcomes according to the history of BC or concomitant BC or both, at the time of diagnosis. BC was evaluated as a prognostic factor for bladder recurrence and survival. RESULTS Overall, 83 (12.5%) patients had previous BC, 62 (9.4%) exhibited concomitant BC, and 75 (11.3%) presented with both previous and current BC. A history of BC was less seen in women and nonsmokers (P<0.0001 and P = 0.013, respectively). The patients with associated BC had more tumors located in the ureter (P<0.0001), as well as more multiple locations in the upper tract (P<0.0001). The tumors without concomitant BC were more likely to be associated with locally advanced stages (P = 0.024). At a median follow-up time of 37.3 months, 31.4% of patients experienced BC recurrence and 2.9% developed contralateral upper tract tumor. Using multivariate analyses, the previous or synchronous BC (P = 0.01) and positive surgical margins (P = 0.03) are independent prognostic factors for BC recurrence. The metastasis-free survival and cancer-specific survival rates did not significantly differ according to the associated BC status. CONCLUSIONS In patients without previous or concomitant BC, the upper tract tumors are more frequently localized in the renal pelvis and are associated with a more invasive status at the time of diagnosis. Nevertheless, the presence of UUT-UC without previous or synchronous BC did not significantly affect the survival rates after nephroureterectomy.

High Grade Blunt Renal Trauma: Predictors of Surgery and Long-Term Outcomes of Conservative Management. A Prospective Single Center Study

PURPOSE The management of major renal trauma has shifted in the last decade in favor of a nonoperative approach. Our level 1 trauma center promotes this approach with the objective of renal function preservation. However, certain situations still require surgery. In this study we analyze predictors of surgery and long-term outcomes after conservative management. MATERIALS AND METHODS From January 2004 to March 2015 we prospectively collected data from all patients admitted to our institution for high grade blunt renal trauma (grades IV and V). Nonoperative management was considered successful when patients did not undergo surgical exploration, regardless of angioembolization or endoscopic treatment. RESULTS Of 306 patients with renal trauma 151 presented with major injuries, including 124 grade IV and 27 grade V. Nonoperative management was successful in 110 (89%) cases of grade IV and 14 (52%) cases of grade V lesions. Deceleration mechanism (p=0.03), associated lesions (p=0.001), percentage of devitalized parenchyma (p=0.012), angioembolization (p <0.001), hemodynamic instability (p <0.001) and low hemoglobin (p=0.001) were more frequent in patients treated surgically. On multivariate analysis grade (OR 7.36, p=0.01) and hemodynamic instability (OR 4.18, p=0.04) were the only independent predictors of surgical treatment. Long-term followup of preserved kidneys revealed a remaining 40% and 0% relative renal function after grade IV and V injuries, respectively. Only devascularized parenchyma greater than 25% predicted the decline of long-term renal function. CONCLUSIONS Nonoperative management can and should be performed safely in cases of grade IV injuries whenever possible, with valuable long-term renal function. It can also be initiated in grade V cases. However, surgeons should consider nephrectomy with the onset of any suspicious symptoms.