Pierre Conort

Résultats de la néphrectomie partielle pour les carcinomes à cellules rénales de plus de 4 cm

To date, radical nephrectomy (RN) remains the gold standard treatment for renal cell carcinoma (RCC) larger than 4 cm. However, from the early 1990s, improvements in surgical techniques have lead to the development of nephron-sparing surgery (NSS) for small renal tumours of less than 4 cm in diameter. This surgical procedure avoids nephronic waste with an acceptable morbidity and similar oncological outcomes compared to radical surgery. Recent large published series did not show any difference between NSS and RN in terms of oncological safety. Specific and disease-free five-year survival rates (82% to 97.3% and 81% to 97.3%, respectively) have confirmed the safety of NSS. Regarding laparoscopic NSS, the technique is still under evaluation and only mid-term outcomes are available so far. However, these studies are still limited and longer follow-up is needed before any definitive statement can be made. Current guidelines recommend NSS only in case of RCC of less than 4 cm in diameter in elective indications. In daily practice however, surgical teams are pushing back the limit above the threshold of 4 cm. More and more surgeons are either considering anatomical location or technical expected difficulties rather than just the tumour size. NSS leads to higher risk of bleeding, especially in case of tumours larger than 4 cm. Therefore, it is absolutely necessary to investigate thoroughly the vascularization of the tumour to avoid such complications with exhaustive and accurate preoperative imaging.

Article de revueRésultats de la néphrectomie partielle pour les carcinomes à cellules rénales de plus de 4 cmResults of nephron-sparing surgery for renal cell carcinoma of more than 4 cm in diameter

To date, radical nephrectomy (RN) remains the gold standard treatment for renal cell carcinoma (RCC) larger than 4 cm. However, from the early 1990s, improvements in surgical techniques have lead to the development of nephron-sparing surgery (NSS) for small renal tumours of less than 4 cm in diameter. This surgical procedure avoids nephronic waste with an acceptable morbidity and similar oncological outcomes compared to radical surgery. Recent large published series did not show any difference between NSS and RN in terms of oncological safety. Specific and disease-free five-year survival rates (82% to 97.3% and 81% to 97.3%, respectively) have confirmed the safety of NSS. Regarding laparoscopic NSS, the technique is still under evaluation and only mid-term outcomes are available so far. However, these studies are still limited and longer follow-up is needed before any definitive statement can be made. Current guidelines recommend NSS only in case of RCC of less than 4 cm in diameter in elective indications. In daily practice however, surgical teams are pushing back the limit above the threshold of 4 cm. More and more surgeons are either considering anatomical location or technical expected difficulties rather than just the tumour size. NSS leads to higher risk of bleeding, especially in case of tumours larger than 4 cm. Therefore, it is absolutely necessary to investigate thoroughly the vascularization of the tumour to avoid such complications with exhaustive and accurate preoperative imaging.

Diagnostic anatomopathologique et prise en charge clinique des lésions planes urothéliales détectées à l'aide de l'acide aminolevulinique (Hexvix®)

INTRODUCTIONnThe aim of the study was to review the most important flat lesions, to demonstrate the difficulty of classifying several lesions, to introduce to urologists the new problems linked to FD and to suggest new models for accurate analysis.nnnMATERIALS AND METHODSnData about urothelial carcinomas and flat lesions and fluorescence were searched on MEDLINE by using the following keywords: cystoscopy; fluorescence; flat lesion; carcinoma in situ; metaplasia; bladder carcinoma.nnnRESULTSnNo evidence 1 level data was available. Flat lesions are a new challenge in pathology and urology. As urologists have a better sight of bladder lesions with fluorescence diagnosis (Hexvix(®)), pathologists will be asked in the future to evaluate more frequently flat lesions, which are sometimes difficult to classify and for which interobserver agreement is not always evident.nnnCONCLUSIONnIt is essential to determine accurate histologic criteria, able to recognize flat lesions of the bladder and permitting adequate patients treatment. Further studies with larger cohort of patients are needed to validate preliminary results obtained with fluorescence and to improve our knowledge of the natural history of these tumours.

Dynamic contrast-enhanced imaging in localizing local recurrence of prostate cancer after radiotherapy: Limited added value for readers of varying level of experience: DCE in Localizing PCa Recurrence After RT

The incremental value of dynamic contrast‐enhanced (DCE) imaging in localizing radiorecurrent prostate cancer is uncertain.

Traitement palliatif de l'hyperplasie bénigne prostatique symptomatique par prothèse endo-uréthrale permanente (Ultraflex ® , Boston Scientific) chez les patients à haut risque chirurgical

Resume Objet Evaluer les resultats a moyen et long terme du traitement de l’hyperplasie benigne prostatique (HBP) symptomatique par la mise en place d’une prothese endo-urethrale permanente trans-prostatique chez des patients a haut risque chirurgical. Materiels et methodes Etude retrospective monocentrique portant sur 19 patients consecutifs d’âge moyen 79.5 ans (61-96) ayant eu la mise en place d’une prothese urethrale permanente en nitinol (Boston Scientific Corp.) de decembre 1995 a juillet 2006 pour obstacle prostatique. Les patients avaient tous une contre-indication majeure (ASA III ou IV) a une prise en charge chirurgicale conventionnelle immediate. La pose se faisait sous anesthesie locale par gel de xylocaine ® endo-urethral. Quatorze patients presentaient une retention aigue d’urine et 4 une insuffisance renale chronique obstructive. Un patient ayant une sonde a demeure, avait des prostatites aigues a repetition. L’evaluation fonctionnelle etait jugee sur la reprise d’une miction, la mesure du residu vesical post mictionnel, le taux de creatininemie et la recherche d’infection urinaire symptomatique. L’evaluation anatomique etait realisee par une urethro-cystographie retrograde et mictionnelle et une endoscopie urethrale. Resultats Ces 19 patients ont ete suivis 20 mois en moyenne (1-62). Aucun incident per-operatoire n’etait note. La reprise de la miction avait lieu chez 18 patients en post operatoire immediat. Un patient necessitait un drainage plus prolonge des urines avant une reprise de miction. Aucun cas de migration de prothese n’etait releve. La creatininemie post operatoire etait stable. Quinze patients avaient un residu vesical post mictionnel inferieur a 100 ml et chez quatre il etait inferieur a 200 ml. Un patient etait expiante. Conclusion Le traitement de l’obstruction cervicoprostatique par mise en place d’une prothese permanente urethrale est une alternative a la chirurgie, pour les patients juges temporairement ou definitivement in operables. L’indication reste exceptionnelle, mais a connaitre, compte tenu des resultats a moyen terme qui sont satisfaisants avec une morbidite faible pour un geste realise sous anesthesie locale pure.OBJECTIVEnTo evaluate the medium-term and long-term results of treatment of symptomatic benign prostatic hyperplasia (BPH) by permanent transprostatic urethral stenting in high surgical risk patients.nnnMATERIALS AND METHODSnSingle-centre retrospective study on 19 consecutive patients with a mean age of 79.5 years (range: 61-96) treated by nitinol permanent urethral stent (Boston Scientific Corp.) from December 1995 to July 2006 for bladder neck obstruction. All patients presented a major contraindication (ASA III or IV) to immediate conventional surgical management. Stenting was performed under endourethral Xylocaine gel local anaesthesia. Fourteen patients presented acute urinary retention and 4 had chronic obstructive renal failure. One patient with an indwelling catheter had a history of recurrent acute prostatitis. The functional results were assessed by resumption of voiding, determination of post-voiding residual volume, serum creatinine and presence or absence of symptomatic urinary tract infection. The anatomical assessment was performed by voiding and retrograde cystourethrography and urethral endoscopy.nnnRESULTSnThis series of 19 patients had a mean follow-up of 20 months (1-62). No intraoperative complication was observed. Resumption of voiding was achieved immediately postoperatively in 18 patients. One patient required more prolonged urinary drainage before voiding was restored. No cases of stent migration were observed. Postoperative serum creatinine was stable. Post-voiding residual volume was less than 100 ml in fifteen patients and less than 200 ml in four patients. One patient was explanted.nnnCONCLUSIONnThe treatment of bladder neck obstruction by permanent urethral stenting is an alternative to surgery for patients considered to be temporarily or permanently inoperable. This indication remains exceptional, but should be kept in mind in view of the satisfactory medium-term results to associated with a low morbidity for a procedure performed exclusively under local anaesthesia.

Multiparametric MRI for Suspected Recurrent Prostate Cancer after HIFU:Is DCE still needed?

PurposeTo assess the added value of the dynamic contrast-enhanced sequence (DCE) to combination T2-weighted imaging (T2w) + diffusion-weighted imaging (DWI) in detecting prostate cancer (PCa) recurrence after HIFU (high-intensity focused ultrasound).MethodsForty-five males with clinical and biological suspected PCa recurrence were retrospectively selected. All underwent multi-parametric MRI (mpMRI) before biopsies. Two readers independently assigned a Likert score of cancer likelihood on T2w + DWI + DCE and T2w + DWI images. Prostatic biopsies were taken as the gold standard.ResultsRecurrent PCa was identified at biopsy for 37 patients (82%). Areas under the receiver-operating curve of T2w + DWI and T2w + DWI + DCE imaging were not significantly different for both readers. Using a Likert score ≥ 3 for the PCa diagnosis threshold, sensitivity at the lobe level for the (1) senior and (2) junior reader for T2w +DWI +DCE sensitivity was (1) 0.97 and (2) 0.94 vs. (1) 0.94 and (2) 0.97 for T2w + DWI.ConclusionAccuracy of mpMRI was not significantly improved by adding DCE to T2w + DWI. Sensitivity was high for T2w + DWI + DCE and T2w + DWI with no significant difference for either the junior or senior reader.Key Points• MpMRI has the capability to detect PCa recurrence in post-HIFU monitoring.• The sensitivity of T2w and DWI for detecting PCa recurrence was not improved by DCE.• Readers with different degrees of experience did not improve their performance with DCE.