J. Branchereau

18F‐fluorodeoxyglucose positron emission tomography–computed tomography for preoperative lymph node staging in patients undergoing radical cystectomy for bladder cancer: A prospective study

The objective of our study was to analyze the diagnostic performance of 18F‐fluorodeoxyglucose positron emission tomography–computed tomography for lymph node staging in patients with bladder cancer before radical cystectomy and to compare it with that of computed tomography.

Renal cell carcinoma (RCC) arising in native kidneys of dialyzed and transplant patients: are they different entities?

Study Type – Prognosis (case series)

Prognostic value of the lymphovascular invasion in high-grade stage pT1 bladder cancer.

PURPOSE High-grade (HG) stage pT1 bladder cancers have the highest recurrence and progression rates of all non-muscle-invasive bladder cancers. Some prognostic factors for recurrence and progression have been identified: multifocal HG pT1, concomitant carcinome in situ, tumor diameter >3 cm, infiltration of the deep lamina propria, and persistence of pT1 tumor on a second transurethral resection of the bladder. The objective of this study was to determine whether the presence of lymphovascular invasion (LVI) is also a prognostic factor that must be taken into account. MATERIALS AND METHODS This retrospective study was performed with 108 patients with HG stage pT1 bladder cancer: 89 patients were treated conservatively (transurethral resection of the bladder plus bacille Calmette-Guérin therapy), and 19 patients underwent early cystectomy. The mean (SD) follow-up was 47.8 ± 41.2 months. Classic prognostic factors and LVI were analyzed in terms of overall survival, specific survival, recurrence-free survival, and progression-free survival. RESULTS Thirty-six percent of patients had LVI on the chips of the first transurethral resection of the bladder. Five-year overall survival and specific survival were 40% and 75%, respectively. Multivariate analysis of risk factors showed a significant reduction of overall survival in the presence of LVI (P = .007). The presence of LVI was also a factor of poor prognosis in the case of delayed cystectomy (P = .010) but not in the case of early cystectomy. CONCLUSIONS Identification of LVI on the first resection of a HG stage pT1 bladder cancer is a significant prognostic factor for overall survival.

Technical feasibility of robot-assisted laparoscopic radical prostatectomy in renal transplant recipients: Results of a series of 12 consecutive cases

INTRODUCTION We evaluate the technical feasibility of robotic prostatectomy in renal transplant recipients. METHODS We retrospectively analyzed preoperative and perioperative settings, as well as functional and oncologic results of 12 patients operated on between 2009 and 2013. Prostatectomy was performed via a transperitoneal approach without any changing in the ports position. The average age was 61.92 ± 2.98 years. The period between transplant and the diagnosis of adenocarcinoma was 79.7 months. The mean PSA was 7.34 ng/mL (range: 4.9-11). RESULTS The operative time was 241.3 ± 35.6 minutes with only one conversion and one transfusion. The intervention was difficult due to adhesions on the side of the graft in 50% of cases. There was a case of obstructive acute renal failure resulting from a hematoma of the Retzius treated by percutaneous nephrostomy at D20. There was a majority of pT2c (72.7%), including 3 positive margins (27.3%) and 2 biochemical relapses treated with radiotherapy and hormonotherapy, respectively. The end point prostate-specific antigen was undetectable. There was no significant difference between preoperative and J7 creatinine (p = 0. 22). CONCLUSIONS Robotic prostatectomy in renal transplant recipients is a safe technique with no serious effects on the allograft.

Résultats et complications chirurgicales de la néphrectomie donneur vivant: lombotomie vs laparoscopie manuellement assistée

PURPOSE Hand-assisted laparoscopic nephrectomy in living donors is a minimally invasive surgical modality. Laparoscopic nephrectomy is now a routine procedure. This study compares an initial group of patients undergoing laparoscopic live donor nephrectomy to a group of patients undergoing open donor. Donor morbidity and graft function in the laparoscopic group were compared with those in the open group. MATERIALS AND METHODS We retrospectively reviewed the medical records of 53 consecutive laparoscopic nephrectomy and compared them with 60 consecutive open donor nephrectomies. RESULTS Demographic data of donors and recipients were similar in the two groups. No conversion to open surgery was necessary. Laparoscopic group patients had a shorter hospital stay compared to those undergoing open surgery. Long-term follow-up of serum creatinine levels revealed no significant differences among the two groups: at 3.6 and 12 months: 112 (+/-27) versus 122 (+/-11), 111 (+/-25) versus 119 (+/-19), 114 (+/-23) versus 122 (+/-25). There was no difference between hand-assisted laparoscopic nephrectomy (two vesico ureteral leak, three hematoma (one needed a surgical revision) and lombotomy (one vesico ureteral leak, one hematoma needed a surgical revision, two arteries stenosis). The rate of recipient ureteral stenosis in the laparoscopic and open nephrectomy groups was 0 of 39 cases and two of 60, respectively. Two vesico ureteral leak versus none appear in the lapararoscopic group. CONCLUSION Hand-assisted laparoscopic nephrectomy in living donors is a safe procedure which presented low morbidity after surgery. This provides equal graft function equal urological complications compared to open live donor nephrectomy. This is our reference method.

Tumeur stromale prostatique à potentiel malin incertain (STUMP) : définition, anatomopathologie, pronostic et prise en charge

Prostatic Stromal Tumors of Uncertain Malignant Potential (STUMP) are rare tumor of the prostate of mesenchymal origin, accounting, with sarcoma for 0.1-0.2% of all malignant prostatic tumours. They however require to be individualized, to differentiate it from a benign prostatic hyperplasia or a sarcoma of the prostate. The therapeutic management should be made keeping in mind the risk of degeneration towards a malignant shape. Although the appropriate treatment is unknown, radical prostatectomy seem to be the treatment of reference, especially for young patient or for extensive lesion.

Evaluation of FR104, a Treg sparing antagonist anti-CD28 monovalent Fab’ antibody in kidney transplantation in non-human primates

Methods and results Here we evaluated in a non-human primates this “Treg sparing strategy” with FR104, a novel monovalent humanized and pegylated Fab’ anti-CD28 antibody fragment. PK/PD studies in monkeys revealed that FR104 presented an elimination half-life of 8 days and 100% target saturation over at least a month after a single iv injection of 5 mg/kg. FR104 was next evaluated in a baboon kidney allograft model at the dose of 5 mg/kg at day 0, 4, 14 and then every two-week until 3 months. Monotherapy modestly but significantly prolonged allograft survival (MST: 18.5 days for monotherapy vs 6 days for untreated recipients). FR104 synergized with low doses tacrolimus (lowTac, trough: 5-10 ng/ml; MST >100 days for FR104/ lowTac vs. 15 days for lowTac alone) as well as with calcineurin-free regimens: therapeutic doses of MMF or rapamycin (day 0-90) with 1 mg/kg of corticosteroids from day 0-14 (MST >100 days for FR104 + MMF/Rapa vs. 18/15 days for MMF/Rapa alone). Flow cytometry analyses indicated that blood Treg cells of the natural and inducible types were preserved in FR104/MMF or FR104/lowTAC bitherapies and accumulated in FR104 monotherapy and in FR104/Rapa bitherapy, whereas Treg cells were lowered by MMF and lowTac monotherapies. Histology also revealed that CTLA4+ and Foxp3+ T lymphocytes were accumulated into the graft of FR104 treated recipients.

One-Year Blood Glucose Level is the Best Metabolic Marker for the Prediction of Late Pancreas Graft Failure

Aim The goal of this study was to explore whether donor and recipient’s characteristics, and one-year biological parameters could have a predictive value for the diagnosis of late pancreas graft failure. Methods 354 type 1 diabetic patients underwent pancreas transplantation between 2000 and 2015. Pancreas graft failure was defined as return to oral antidiabetics, permanent insulin-dependence. Recipient and donor characteristics were analyzed at the time of transplantation to determine potential risk factors for late graft dysfunction (after one year). Biological parameters such as HbA1c, fasting blood glucose, C-peptide, insulin, amylase, lipase, OGTT, Matsuda index, Beta score, HOMA IR and HOMA B, were analyzed one year after transplantation. Results 280 SPK, 38 PTA and 36 PAK were performed in 139 men and 215 women, with a mean age of 40 years. Median follow-up was 6 years. Patient survival was 96% at 1 year, 93% at 3 years and 87.5% at 5 years, whithout any significant difference between the three pancreas categories. Cardio-vascular diseases were the first cause of late recipient death. 111 patients experienced graft failure, 50 of them after the first year of transplantation. Pancreas survival was 80.5%, 70.7% and 67.5%, respectively at 1, 3 and 5 years, without any difference between the three categories. After the first year post-transplantation, death with a functioning graft occurred in 35.5% of patients with graft dysfunction. Donor death from cardiovascular cause was the only risk factor for late graft failure (OR 1,82 [1.05; 3.75], p=0,0345). One-year fasting blood glucose was the best predictive marker for a future graft dysfunction, especially when this value was over 5,4 mmol/l (OR 3.44 [1.80; 6.58] p=0.0002). 2-hour OGTT glucose level was also a risk factor for graft failure (OR 1.19 [1.04; 1.37] p=0,0109) while high Beta score (OR 0.62 [0.41; 0.94] p=0.0231) and high values of HOMA-B (OR 0.996 [0.992; 0.999] p=0,0483) were protective factors. Multivariate analysis identified a value of fasting blood glucose over 5.4 mmol/l (OR 4.24 [1.28; 14.04] p=0.0180) as the only significant risk factor. Graft survival was significantly different between patients with one-year blood glucose over or below 5.5 mmol/l: 85.2 vs 94.5% at 3 years and 72.3% vs 91.5% at 5 years (p<0,05), respectively. Conclusion Donor death from cardiovascular cause was the single risk factor for late graft failure among all donor and recipient’s base-line data. One-year fasting blood glucose level was the most significant biochemical parameter among patients at risk for graft failure, especially when the value was over 5,4 mmol/l. Two-hour OGTT glucose level, Beta score and HOMA B performed one year after transplantation are additional useful tools for identification of patients at risk. Whether medical intervention (i.e. GLP-1 analogue) among patients with still “normal glucose metabolism” could improve long-term graft survival requires prospective evaluation.

Transplant nephrectomy after graft failure: is it so risky? Impact on morbidity, mortality and alloimmunization

PurposeTo determine the impact of transplant nephrectomy on morbidity and mortality and HLA immunization.MethodsAll patients who underwent transplant nephrectomy in our centre between 2000 and 2016 were included in this study. A total of 2822 renal transplantations and 180 transplant nephrectomies were performed during this period.ResultsThe indications for transplant nephrectomy were graft intolerance syndrome: 47.2%, sepsis: 22.2%, vascular thrombosis: 15.5%, tumour: 8.3% and other 6.8%. Transplant nephrectomies were performed via an intracapsular approach in 61.7% of cases. The blood transfusion rate was 50%, the morbidity rate was 38% and the mortality rate was 3%. Transplant nephrectomies more than 12 months after renal transplant failure were associated with more complications (p = 0.006). Transfusions in the context of transplant nephrectomy had no significant impact on alloimmunization.ConclusionThe risk of bleeding, and therefore of transfusion, constitutes the major challenge of this surgery in patients eligible for retransplantation. Even if transfusions in this context of transplant nephrectomy had no significant impact on alloimmunization, this high-risk surgery, whenever possible, must be performed electively in a well-prepared patient.

Hypothermic pulsatile perfusion of human pancreas: Preliminary technical feasibility study based on histology

BACKGROUND There are currently two approaches to hypothermic preservation for most solid organs: static or dynamic. Cold storage is the main method used for static storage (SS), while hypothermic pulsatile perfusion (HPP) and other machine perfusion-based methods, such as normothermic machine perfusion and oxygen persufflation, are the methods used for dynamic preservation. HPP is currently approved for kidney transplantation. METHODS We evaluated, for the first time, the feasibility of HPP on 11 human pancreases contraindicated for clinical transplantation because of advanced age and/or history of severe alcoholism and/or abnormal laboratory tests. Two pancreases were used as SS controls, pancreas splitting was performed on 2 other pancreases for SS and HPP and 7 pancreases were tested for HPP. HPP preservation lasted 24 h at 25 mmHg. Resistance index was continuously monitored and pancreas and duodenum histology was evaluated every 6 h. RESULTS The main finding was the complete absence of edema of the pancreas and duodenum at all time-points during HPP. Insulin, glucagon and somatostatin staining was normal. Resistance index decreased during the first 12 h and remained stable thereafter. CONCLUSION 24 h hypothermic pulsatile perfusion of marginal human pancreas-duodenum organs was feasible with no deleterious parenchymal effect. These observations encourage us to further develop this technique and evaluate the safety of HPP after clinical transplantation.