Jacques Hubert

Characterization of Human Renal Stones with MDCT: Advantage of Dual Energy and Limitations Due to Respiratory Motion

OBJECTIVE Our aim was to determine, using CT attenuation values, the chemical composition of 241 human renal stones placed in a jelly phantom and to analyze the influence of respiratory motion on the classification. MATERIALS AND METHODS The stones were placed in a jelly simulating the X-ray attenuation of the kidneys. A dynamic platform was used to apply to the phantom free-breathing motion (sinusoidal motion in z-axis) and motion due to lack of maintenance of a breath-hold (5 mm x s(-1) in z-axis). Determination of the chemical composition was performed with mean CT attenuation values obtained at 80 and 120 kV and with dual-energy CT attenuation values. RESULTS Two hundred forty-one human urinary stones were classified into six groups: uric acid, cystine, struvite, weddellite (calcium oxalate dihydrate), whewellite (calcium oxalate monohydrate), and brushite. With no motion, the use of dual energy enabled differentiation of all of the types of stones with statistically significant differences. Uric acid (-20 +/- 22 H), cystine (106 +/- 19 H), struvite (271 +/- 16 H), weddellite (323 +/- 5 H), brushite (415 +/- 30 H), and whewellite (510 +/- 17 H) were identified as distinct groups. Motion-induced mean CT attenuation values were significantly different from those obtained with no motion. With motion, dual-energy CT attenuation values did not allow differentiation of all stone types. CONCLUSION Dual-energy CT attenuation values can be used to predict the chemical composition of stones in vitro. However, when slight motion is applied to renal stones during image acquisition, the values become significantly different from those obtained with no motion. Consequently, confusion arises in differentiating stone types. A perfect breath-hold has to be performed for in vivo use of attenuation value to discern stone type.

Robotic-assisted pelvic organ prolapse surgery

BackgroundThis study describes technical aspect and short-term results of pelvic organ prolapse surgery using the da Vinci robotic system.MethodsDuring a 1-year period, 18 consecutive patients with pelvic organ prolapse were operated on using the da-Vinci system. Clinical data were prospectively collected and analyzed.ResultsAll but one procedure was successfully completed robotically (95%). Performed procedures were colpohysteropexy (n = 12), mesh rectopexy (n = 2), or sutured rectopexy combined with sigmoid resection (n = 4). Average setup time was 21 min and significantly decreased with experience. Mean operative time was 172 min (range, 45–280). There were no mortality and no specific morbidity due to the robotic approach. Mean hospital stay was 7 days. At 6 months, all patients were free of pelvic organ prolapse and stated that they were satisfied with anatomical and functional results.ConclusionOur experience indicates that using the da-Vinci robotic system is feasible, safe, and effective for the treatment of pelvic organ prolapse.

Renal Cell Carcinoma (RCC) in Patients With End-Stage Renal Disease Exhibits Many Favourable Clinical, Pathologic, and Outcome Features Compared With RCC in the General Population

BACKGROUND Patients with end-stage renal disease (ESRD) are at risk of developing renal tumours. OBJECTIVE Compare clinical, pathologic, and outcome features of renal cell carcinomas (RCCs) in ESRD patients and in patients from the general population. DESIGN, SETTING, AND PARTICIPANTS Twenty-four French university departments of urology participated in this retrospective study. INTERVENTION All patients were treated according to current European Association of Urology guidelines. MEASUREMENTS Age, sex, symptoms, tumour staging and grading, histologic subtype, and outcome were recorded in a unique database. Categoric and continuous variables were compared by using chi-square and student statistical analyses. Cancer-specific survival (CSS) was assessed by Kaplan-Meier and Cox methods. RESULTS AND LIMITATIONS The study included 1250 RCC patients: 303 with ESRD and 947 from the general population. In the ESRD patients, age at diagnosis was younger (55 ± 12 yr vs 62 ± 12 yr); mean tumour size was smaller (3.7 ± 2.6 cm vs 7.3 ± 3.8 cm); asymptomatic (87% vs 44%), low-grade (68% vs 42%), and papillary tumours were more frequent (37% vs 7%); and poor performance status (PS; 24% vs 37%) and advanced T categories (≥ 3) were more rare (10% vs 42%). Consistently, nodal invasion (3% vs 12%) and distant metastases (2% vs 15%) occurred less frequently in ESRD patients. After a median follow-up of 33 mo (range: 1-299 mo), 13 ESRD patients (4.3%), and 261 general population patients (27.6%) had died from cancer. In univariate analysis, histologic subtype, symptoms at diagnosis, poor PS, advanced TNM stage, high Fuhrman grade, large tumour size, and non-ESRD diagnosis context were adverse predictors for survival. However, only PS, TNM stage, and Fuhrman grade remained independent CSS predictors in multivariate analysis. The limitation of this study is related to the retrospective design. CONCLUSIONS RCC arising in native kidneys of ESRD patients seems to exhibit many favourable clinical, pathologic, and outcome features compared with those diagnosed in patients from the general population.

Complete robotic‐assistance during laparoscopic living donor nephrectomies: An evaluation of 38 procedures at a single site

Objective:  To evaluate our initial experience with entirely robot‐assisted laparoscopic live donor (RALD) nephrectomies.

Laparoscopic robotic-assisted management of pelvi-ureteric junction obstruction in patients with horseshoe kidneys: technique and 1-year follow-up

Authors from France describe their experience, in a small series of patients with pelvi‐ureteric junction obstruction, of laparoscopic robotic‐assisted pyeloplasty, and present their operative results with a 1‐year follow‐up.

Three-dimensional CT-scan reconstruction of renal calculi. A new tool for mapping-out staghorn calculi and follow-up of radiolucent stones.

OBJECTIVES The development of CT scanners (CT scan) with continuous rapid spiral acquisition now allows three-dimensional reconstructions of mobile organs such as kidneys. The aim of this study was to appreciate the merits of this new technique in the field of renal lithiasis. METHOD This non-invasive technique was applied in 27 renal calculi (23 staghorn and 4 radiolucent stones). The acquisition does not require any injection of contrast material. Reconstruction was carried out by three-dimensional (3D) shaded surface display. RESULTS 3D reconstruction of calculi permits a precise study of the shape of the stone, and of the number, size and direction of its branches. Therefore, it allows for better planning of the PCNL (number of ports, per-operative pelvi-caliceal exploration ...). Large radiolucent calculi are clearly defined with 3DS, facilitating the follow-up under medical treatment. CONCLUSION 3D CT scan reconstruction is a noninvasive, cost-effective method which offers high quality 3D images of renal calculi. These results should spur the more widespread use of this technique.

Continuous versus six months a year maximal androgen blockade in the management of prostate cancer: a randomised study.

OBJECTIVE To evaluate systematically interrupted androgen suppression (SIAS) 6 mo a year compared with continuous androgen suppression (CAS) in prostate cancer treatment. PATIENTS AND METHODS All patients underwent maximal androgen blockade for 6 mo. Then, depending on the randomisation arm, they continued (CAS) or stopped their treatment for 6 mo before they resumed it a year later and so on (SIAS). Primary end points were patients health-related quality of life (HQOL) and time to progression. Secondary end points were cancer-specific and overall survival. Progression was defined by a clinical event or PSA value exceeding double the value obtained at the end of the first 6 mo of therapy. RESULTS Sixty-two patients were randomised to CAS and 67 to SIAS. There were no significant differences between groups at baseline. Androgen suppression was associated with HQOL deterioration except for an improvement in urinary symptoms. The 6-mo off-therapy period was not long enough to regain normal testosterone values. There was no difference in HQOL scores between CAS and SIAS except that men in the latter group reported a greater need for painkillers but a better ability to have an erection. Progression occurred in 62 patients (48.1%) with no significant difference between CAS and SIAS with a mean follow-up of 44.8 mo. Death occurred in 41 patients and specific death in 19 patients (10% and 19% of the CAS and SIAS groups, respectively). CONCLUSIONS Although patients in the SIAS group were maintained off-therapy 50% of the time, insufficient testosterone recovery in this group likely explains why differences between the two groups were moderate or absent with regards to HQOL and survival, respectively.

Laparoscopic computer-assisted pyeloplasty: the results of experimental surgery in pigs

The attraction of using the Da VinciTM robotic system is considerable, despite the great costs involved. The three‐dimensional view and the wide degree of freedom of movement allows, as we are told, a procedure which can be learned more quickly than standard laparoscopic surgery. The authors from France describe their early experience with the technique and provide an overview of other robotic methods.

Is an Extended 20-Core Prostate Biopsy Protocol More Efficient than the Standard 12-Core? A Randomized Multicenter Trial

PURPOSE We determined the impact of increasing the number of cores from 12 to 20 at initial prostate biopsy in men suspicious of prostate cancer. MATERIALS AND METHODS From December 2009 to November 2011, patients in 7 centers scheduled for a first prostate biopsy, with a prostate specific antigen less than 20 ng/ml and no nodule on digital rectal examination, were invited to participate in this superiority trial. Patients were randomized to a 12-core (PB12 group) or a 20-core (PB20 group) protocol. The primary end point was cancer detection rate. Secondary end points were cancer characteristics, rate of complications and patient tolerance assessed by a self-completed booklet before prostate biopsy and at day 5 and day 15. RESULTS A total of 339 patients were randomized. Preoperative variables were similar in both groups. Cancer was detected in 71 patients (42.0%) in PB12 group and in 81 patients (48.8%) in PB20 group, and the difference was not significant (p >0.2). Gleason score and cancer length measured on prostate biopsy cores were not significantly different between groups. Although the cancer detection rate was linked to prostate volume, this was not affected by the number of extracted cores (p >0.4). Complications number and seriousness were comparable in both arms. No significant difference was noted regarding side effects and tolerance as self-assessed by the patient at day 5 and day 15 after prostate biopsy. CONCLUSIONS Our findings suggest that there is no significant advantage in using a 20-core biopsy protocol vs 12-core protocol during an initial prostate biopsy.

Sunitinib Alone or after Nephrectomy in Metastatic Renal-Cell Carcinoma

BACKGROUND Cytoreductive nephrectomy has been the standard of care in metastatic renal‐cell carcinoma for 20 years, supported by randomized trials and large, retrospective studies. However, the efficacy of targeted therapies has challenged this standard. We assessed the role of nephrectomy in patients with metastatic renal‐cell carcinoma who were receiving targeted therapies. METHODS In this phase 3 trial, we randomly assigned, in a 1:1 ratio, patients with confirmed metastatic clear‐cell renal‐cell carcinoma at presentation who were suitable candidates for nephrectomy to undergo nephrectomy and then receive sunitinib (standard therapy) or to receive sunitinib alone. Randomization was stratified according to prognostic risk (intermediate or poor) in the Memorial Sloan Kettering Cancer Center prognostic model. Patients received sunitinib at a dose of 50 mg daily in cycles of 28 days on and 14 days off every 6 weeks. The primary end point was overall survival. RESULTS A total of 450 patients were enrolled from September 2009 to September 2017. At this planned interim analysis, the median follow‐up was 50.9 months, with 326 deaths observed. The results in the sunitinib‐alone group were noninferior to those in the nephrectomy–sunitinib group with regard to overall survival (stratified hazard ratio for death, 0.89; 95% confidence interval, 0.71 to 1.10; upper boundary of the 95% confidence interval for noninferiority, ≤1.20). The median overall survival was 18.4 months in the sunitinib‐alone group and 13.9 months in the nephrectomy–sunitinib group. No significant differences in response rate or progression‐free survival were observed. Adverse events were as anticipated in each group. CONCLUSIONS Sunitinib alone was not inferior to nephrectomy followed by sunitinib in patients with metastatic renal‐cell carcinoma who were classified as having intermediate‐risk or poor‐risk disease. (Funded by Assistance Publique–Hôpitaux de Paris and others; CARMENA ClinicalTrials.gov number, NCT00930033.)