R. Boissier

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.

The prognostic value of the neutrophil-lymphocyte ratio in renal oncology: A review

BACKGROUND The neutrophil-lymphocyte ratio (NLR) is a biological marker of inflammation with a significant prognostic value in the field of oncology. AIM In this review, we discuss the prognostic value of the NLR in renal cell carcinoma (RCC). MATERIAL AND METHOD We conducted a literature review of the PubMed database in August 2016. Initial research identified 31 publications. Following full-text screening, 15 studies were finally included: 7 studies concerning metastatic or locally advanced renal cancer, 6 studies dealing with localized renal cancer, 2 articles evaluating the NLR in renal cancer whatever the status of the disease (metastatic or localized). RESULTS For localized RCC, an NLR o 3 was predictive of a reduced risk of recurrence (hazard ratio ¼ 1.63 [1.15, 2.29]). The prognostic value of the NLR was stronger for metastatic or locally advanced RCC. An NLR o 3 predicted increased overall survival (hazard ratio ¼ 1.55 [1.36, 1.76]), progression-free survivals (hazard ratio ¼ 3.19 [2.23, 4.57]), and a response to systemic treatment. CONCLUSION In current practice, the NLR is a simple and inexpensive prognostic factor with potential improvement in the prognostic performance of nomograms used in renal oncology.

The Risk of Tumour Recurrence in Patients Undergoing Renal Transplantation for End-stage Renal Disease after Previous Treatment for a Urological Cancer: A Systematic Review

CONTEXT Renal transplantation is the gold standard renal replacement therapy in end-stage renal disease owing to its superior survival and quality of life compared with dialysis. When the potential recipient has a history of cancer, the waiting period before renal transplantation is usually based on the Cincinnati Registry. OBJECTIVE To systematically review all available evidence on the risk of cancer recurrence in end-stage renal disease patients with a history of urological cancer. EVIDENCE ACQUISITION Medline, Embase, and the Cochrane Library were searched up to March 2017 for all relevant publications reporting oncologic outcomes of urological cancer in patients who subsequently received a transplantation or remained on dialysis. The primary outcome was time to tumour recurrence. Secondary outcomes included cancer-specific and overall survival. Data were narratively synthesised in light of methodological and clinical heterogeneity. The risk of bias of each included study was assessed. EVIDENCE SYNTHESIS Thirty-two retrospective studies enrolling 2519 patients (1733 dialysed, 786 renal transplantation) were included. For renal cell carcinomas, the risks of recurrence, cancer-specific, and overall survival were similar between transplantation and dialysis. For prostate cancer, most of the tumours had favourable prognoses consistent with nomograms. Studies dealing with urothelial carcinomas (UCs) mainly included upper urinary tract UC in the context of aristolochic acid nephropathy, for which the risks of synchronous bilateral tumour and recurrence were high. Data on testicular cancer were scarce. CONCLUSIONS Immunosuppression after renal transplantation does not affect the outcomes and natural history of low-risk renal cell carcinomas and prostate cancer. Therefore, the waiting time from successful treatment for these cancers to transplantation could be reduced. Except in the particular situation of aristolochic acid nephropathy, more studies are needed to standardise the waiting period after UC owing to the paucity of data. PATIENT SUMMARY Renal transplantation does not appear to increase the risk of recurrence of renal carcinoma or the recurrence of low-risk prostate cancer compared with dialysis. More reliable evidence is required to recommend a standard waiting period especially for urothelial and testicular carcinomas.

The impact of drugs on male fertility: a review

Beside cytotoxic drugs, other drugs can impact mens fertility through various mechanisms. Via the modification of the hypothalamic–pituitary–gonadal axis hormones or by non‐hormonal mechanisms, drugs may directly and indirectly induce sexual dysfunction and spermatogenesis impairment and alteration of epididymal maturation. This systematic literature review summarizes existing data about the negative impact and associations of pharmacological treatments on male fertility (excluding cytotoxic drugs), with a view to making these data more readily available for medical staff. In most cases, these effects on spermatogenesis/sperm maturation/sexual function are reversible after the discontinuation of the drug. When a reprotoxic treatment cannot be stopped and/or when the impact on semen parameters/sperm DNA is potentially irreversible (Sulfasalazine Azathioprine, Mycophenolate mofetil and Methotrexate), the cryopreservation of spermatozoa before treatment must be proposed. Deleterious impacts on fertility of drugs with very good or good level of evidence (Testosterone, Sulfasalazine, Anabolic steroids, Cyproterone acetate, Opioids, Tramadol, GhRH analogues and Sartan) are developed.

Endoscopic Treatment of Symptomatic Vesicoureteral Reflux after Renal Transplantation

PURPOSE We evaluated the success of endoscopic treatment of symptomatic vesicoureteral reflux after renal transplantation and identified factors predicting success. MATERIALS AND METHODS Endoscopy was performed for symptomatic vesicoureteral reflux after renal transplantation in 38 women and 20 men between January 2000 and December 2010. Reflux was documented by retrograde cystography and its symptomatic character was determined by at least 1 episode of acute graft pyelonephritis. The results of endoscopic treatment were evaluated clinically at 1 and 3 months, and annually, and by cystography at 3 months. Clinical success was defined as absent acute graft pyelonephritis during followup. Radiological success was defined as absent reflux on followup cystography at 3 months. RESULTS Endoscopic treatment was clinically successful in 32 patients (56.1%), including 26 (65%) who received dextranomer-hyaluronic acid and 5 (33.3%) who received polydimethylsiloxane. Treatment was radiologically successful in 14 patients (26.4%) at a mean ± SD followup of 38 ± 33 months. On multivariate analysis male gender and dextranomer-hyaluronic acid were factors predictive of clinical success. Reflux grade did not predict success or failure. No high grade complication was reported. CONCLUSIONS Endoscopic treatment of symptomatic vesicoureteral reflux of a transplanted kidney was effective in half of the cases regardless of the bulking agent used. However, dextranomer-hyaluronic acid appeared to be more effective than polydimethylsiloxane. Due to its minimally invasive nature and low morbidity endoscopic treatment with dextranomer-hyaluronic acid could be proposed as preoperative first line treatment for symptomatic vesicoureteral reflux of a transplanted kidney regardless of reflux grade.

A Quality Assessment of Patient-Reported Outcome Measures for Sexual Function in Neurologic Patients Using the Consensus-based Standards for the Selection of Health Measurement Instruments Checklist: A Systematic Review

CONTEXT Impaired sexual function has a significant effect on quality of life. Various patient-reported outcome measures (PROMs) are available to evaluate sexual function. The quality of the PROMs to be used for neurologic patients remains unknown. OBJECTIVE To systematically review which validated PROMs are available to evaluate sexual function in neurologic patients and to critically assess the quality of the validation studies and measurement properties for each identified PROM. EVIDENCE ACQUISITION A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. The included publications were assessed according to the Consensus-Based Standards for the Selection of Health Measurement Instruments checklist. EVIDENCE SYNTHESIS Twenty-one studies for PROMs regarding sexual function were identified for the following patient groups: spinal cord injury (11 studies), multiple sclerosis (MS; 6 studies), Parkinsons disease (2 studies), traumatic brain injury (1 study), and epilepsy (1 study). The evidence for the quality of PROMs was found to be variable, and overall evaluation of measurement properties was lacking in 71% of the studies. The measurement error and responsiveness were not studied in any of the publications. CONCLUSIONS Several PROMs have been identified to evaluate sexual function in neurologic patients. Strong evidence was found only for the Multiple Sclerosis Intimacy and Sexuality Questionnaire-15 and Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 for patients with MS, although evidence was lacking for certain measurement properties as well. Future research should focus on identifying relevant PROMs and establishing adequate quality for all measurement properties in studies with high methodological quality. PATIENT SUMMARY A quality assessment of patient-reported outcome measures (PROMs) for sexual function in neurologic patients was made. The evidence found for good PROMs was limited. Studies with high methodological quality are needed to improve the quality of PROMs to evaluate sexual function in neurologic patients.

Review of the Different Treatments and Management for Prostate Cancer and Fertility

OBJECTIVE To compare the options available for prostate cancer management and their consequences on fertility for men, in order to best advise these men to choose their treatment, especially if they are young, with no child with their current partner. METHODS A literature review on prostate cancer and fertility over the last 26 years was carried out on PubMed database. The literature was based on evidence and practical considerations. Twenty-nine articles were selected according to their relevance. RESULTS After prostatectomy, there is an obstructive infertility in 100% of the cases. In external radiotherapy, doses more than 15 cGy induced reduction in sperm count. Direct irradiation between 15 and 35 cGy caused oligozoospermia and doses between 35 and 50 cGy caused reversible azoospermia. The calculated projected doses on testicles were 196 cGy (± 145 cGy). The brachytherapy effects on fertility seems to be less harmful. The irradiation dose received by testicles is less important (less than 20 cGy) after brachytherapy than after external radiotherapy. Infertility induced by hormonal therapy alone should be reversible. Fertility and focal therapy have not been well evaluated yet. Active surveillance is the management of prostate cancer which allows to keep at best mens fertility. CONCLUSION Urologists should consider approaching the topic of infertility when discussing the pros and cons of various prostate cancer management with their younger patients. If a patient with prostate cancer expresses interest in future fertility, a semen analysis should be performed. Cryopreservation represents the only preemptive accompanying possibility to preserve fertility in young cancer patients.

Résultats à moyen terme du traitement de la dyssynergie vésicosphinctérienne par sphinctérotomie prothétique permanente

OBJECTIVES The aim of this study was to assess the outcomes of nitinol permanent urethral stents used in detrusor-striated sphincter dyssynergia (DSD) treatment on male patients with a spinal cord injury. MATERIALS We investigated retrospectively all patients treated from 2004 to 2012. A total of 22 patients were included, with an age ranging from 22 to 76 years old. The DSD syndrome was due to spinal cord injury (18) or various spinal cord diseases (four) and treated with a nitinol urethral stent (11 Ultraflex(®) and 11 Mémotherm(®)). Every patient had an urodynamical study. The follow-up reached at least 2 years. RESULTS The mean follow-up was 56 months (± 14). Complementary procedures after stenting included: five stent prolongation or displacement (mean interval 7.6 months), six bladder neck incisions (12.2 months), three urethrotomy (42 months), ten obstruction treated by laser (47.3 months). Eight patients had a change of their urinary pattern: four underwent ileal conduit diversion, one had a continent urinary diversion, one chose self intermittent catheterization, two were under indwelling catheterization waiting for another treatment. Stent retrieval was either harmful or impossible for four of them. Three patients were free of complementary procedures. CONCLUSIONS Nitinol urethral stent was an effective treatment initially. However, by the third year, urethral stenosis and hypertrophic growth of the urethral mucosa usually require iterative endoscopic procedures (0.31 per patient per year). Patients treated with permanent uretral stent deserve a yearly endoscopic follow-up. Safety and effectiveness of permanent uretral stent compared to surgical sphincterotomy to treat DSD are discussed.

Switch to Abobotulinum toxin A may be useful in the treatment of neurogenic detrusor overactivity when intradetrusor injections of Onabotulinum toxin A failed

To assess the outcomes of switching to a different brand of botulinum toxin A (BTA, from Botox® to Dysport®) in case of failure of intradetrusor injections (IDI) of Botox® in the treatment of neurogenic detrusor overactivity (NDO).

Continent catheterizable tubes/stomas in adult neuro‐urological patients: A systematic review

To systematically review all available evidence on the effectiveness and complications of continent cutaneous stoma or tube (CCS/T) to treat bladder‐emptying difficulties in adult neuro‐urological patients.