Y. Neuzillet

Comparison of oncological outcomes after segmental ureterectomy or radical nephroureterectomy in urothelial carcinomas of the upper urinary tract: results from a large French multicentre study.

Study Type – Therapy (multi‐centre retrospective cohort)

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].

The role of American Society of Anesthesiologists scores in predicting urothelial carcinoma of the upper urinary tract outcome after radical nephroureterectomy: results from a national multi-institutional collaborative study

Study Type – Prognosis (cohort)

Kystes atypiques et tumeurs kystiques du rein : considérations anatomopathologiques, radiologiques et chirurgicales. Conclusions du forum AFU 2007

Malignant tumours may have a cystic appearance. They are dominated by multilocular cystic renal cell carcinoma, usually low-grade, which rarely metastasize. The Bosniak classification distinguishes non suspicious lesions (type I and II) from suspicious lesions (type III and IV) requiring resection and lesions requiring follow-up (type IIF). The main feature suggestive of malignancy is the enhancement of the septa and the walls of the cyst. Renal cysts classified as IIF require surveillance by contrast-enhanced imaging (CT, MRI or ultrasound). The treatment of cystic tumours is based on surgery. Partial nephrectomy is recommended in this type of tumour regardless of the size. Laparoscopy is a validated technique in experienced hands. Aspiration is not very effective for the treatment of benign cysts, but may be useful for diagnosis. Surgical resection of the roof of the cyst is the most effective technique.

Les traitements ablatifs modifient-ils la prise en charge des tumeurs du rein chez la personne âgée ?

The development of ablative techniques in renal oncology has profoundly changed treatment of small renal tumors. The objective of this review of the literature was to assess the arguments for treating localized kidney tumors with these techniques in the elderly patient. The two techniques retained because of their recognized use, for all approaches, are radiofrequency and cryotherapy. The data in the literature report more frequent local recurrence with these techniques than with surgical excision and an advantage to cryotherapy over radiofrequency. There seems to be no difference in terms of metastatic progression. Morbidity is not insignificant, with major complications in slightly less than 10% of cases. Given the need to consider small tumors (<4 cm), the advantage in terms of life expectancy is challenged by series studying active monitoring of the oldest patients who present co-morbidities. At present, the indications should therefore be measured and based on a general assessment of the patient, with particular consideration of the existing co-morbidities so as not to treat a patient while imposing undue complications.

Le carcinome urothélial des patients de moins de 40 ans. Revue du comité de cancérologie de l’Association française d’urologie

INTRODUCTION Urothelial carcinoma in young patients (<40 years) is rare. The only known risk factor is exposure to tobacco smoking and/or early active tobacco intoxication. No genetic predisposing factor seems to exist. MATERIAL AND METHODS A review of the literature was performed using PubMed database with a combination of the following keywords: urothelial carcinoma, young patients/adults, children, pediatrics, urothelium and neoplasm prognosis. DISCUSSION Urothelial carcinomas before the age of 20 years are non-invasive papillary lesions (papillary urothelial neoplasm of low malignant potential and non-invasive papillary urothelial carcinoma low grade or high grade) of excellent prognosis. Rare cases of infiltrating carcinomas have been described between 20 to 40 years; their histological and clinical aspects are close to those observed in usual urothelial carcinomas. CONCLUSION The management of urothelial carcinomas of patients under 40 years relies on the tumor grade and stage. Treatment of aggressive cases has to be curative from a clinical point of view, nevertheless conserving vital and reproducing functions.

Modalités de clampage au cours de la néphrectomie partielle: aspects techniques et conséquences fonctionnelles. Revue du sous-comité rein du Comité de cancérologie de l'Association française d'urologie (CCAFU)

Partial nephrectomy requires control of renal blood flow by using renal vessels clamping. Multiple clamping techniques are available. The clamping procedure can be parenchymal or vascular, involving enbloc arterial and veinous clamping or arterial onlone, being continuous or intermittent, associated or not with renal cooling. The purpose of this present review was to analyze technical aspects of clamping methods during partial nephrectomy and their functional consequences in terms of blood loss, surgical margins status and changes in renal function.

Intérêt et modalités pratiques de la cystoscopie de fluorescence en 2011 pour la prise en charge des carcinomes urothéliaux de la vessie : une revue du Comité de cancérologie de l’Association française d’urologie

AIM Fluorescence-guided cystoscopy is a useful tool for bladder tumour detection in association with white-light cystoscopy and decreases the residual tumour rate. The aim of the study was to provide an overview of the pertinent literature on this subject. MATERIALS AND METHODS The data were provide from a Medline(®) research by using the follow keywords: urinary bladder neoplasms; cystoscopy; fluorescence; prognosis; intraepithelial neoplasm. RESULTS No evidence 1 level data was available. The fluorescence-guided cystoscopy improves the bladder cancer detection rate, especially the flat lesions, and improve the recurrence-free survival by decreasing the residual tumour rate. The specific indications for fluorescence-guided cystoscopy in the diagnosis and management of non-muscle invasive bladder cancer (NMIBC) should benefit the patients. CONCLUSION The fluorescence-guided cystoscopy is a benefical tool in association with white-light cystoscopy in NMIBC diagnosis. It has been shown to have a positive impact on recurrence-free survival but not on progression-free survival. More investigations with significant follow-up should be lead in the future to accurately assess its therapeutic impact on patients.

Place de la néphrectomie laparoscopique chez le sujet âgé.

The concomitant increase in life expectancy and the incidence of kidney cancers will result in an increase in kidney cancers in subjects over 75 years of age in the coming years. A wait-and-see attitude in cases of voluminous tumors, particularly symptomatic tumors, may well alter the quality of life of these patients through chronic abdominal pain, macroscopic hematuria, or alteration of the general condition due to metastatic progression. Curative or palliative surgical management can be envisioned and should be discussed in the multidisciplinary consensus meeting. Before validating the indication for nephrectomy in the elderly patient, a preoperative geriatric assessment should be made. Moreover, preoperative renal function should be carefully evaluated to measure the risk of terminal renal failure. The reduction in the mean duration of the hospital stay provided by laparoscopic surgery allows patients to return home or to their institution more quickly, an important consideration in the rehabilitation of these patients, who are very sensitive to such changes. Laparoscopic nephrectomy, with evidence in the literature of reduced morbidity and satisfactory oncological results, could therefore be superior to open surgery when indicated and technically feasible.Resume L’augmentation concomitante de l’esperance de vie et de l’incidence des cancers du rein va conduire dans les prochaines annees a une augmentation des cancers du rein chez les sujets de plus de 75 ans. Une attitude attentiste en cas de volumineuses tumeurs, en particulier symptomatiques, risque d’alterer la qualite de vie des patients par des douleurs abdominales chroniques, des hematuries macroscopiques ou une alteration de l’etat general par evolution metastatique. Une prise en charge chirurgicale curative ou palliative peut etre envisagee et doit etre discutee en reunion de concertation pluridisciplinaire. Avant de valider l’indication d’une nephrectomie chez le sujet âge, une evaluation geriatrique preoperatoire rigoureuse doit etre realisee. De meme, la fonction renale pre-operatoire doit etre soigneusement evaluee afin de mesurer les risques d’insuffisance renale terminale. La diminution de la duree moyenne de sejour grâce a la voie d’abord laparoscopique permet aux patients un retour plus rapide a leur domicile ou leur institution, element important dans la rehabilitation de ces patients tres sensibles aux changements temporo-spatiaux. La nephrectomie laparoscopique dont la litterature suggere qu’elle est associee a une morbidite reduite et des resultats carcinologiques satisfaisants pourrait donc etre preferee a la voie ouverte quand indiquee et techniquement faisable.

Prise en charge du cancer du rein en 2007 : actualités et recommandations

In case of a single renal cell carcinoma strictly located in the kidney, the radical nephrectomy remains the treatment of choice. However, it has been estimated that nearly 30 to 40 % of renal cell carcinoma are about to recur after primitive surgery. In certain cases, conservative surgery can be discussed as an alternative to radical treatment, especially in case of exophytic renal tumour or less than 4 cm in diameter. New ablative techniques (radiofrequency and cryoablation) have shown promising results but the follow-up is still very limited. French national recommendation regarding kidney cancer have been updated in 2007 and following the development of clinical trials using antiangiogenic agents. Regarding the use of antiangiogenic agents, several points have to be taken into account: existence of renal cell carcinoma, presence of metastasis, number of metastasis, location and risk factor prognosis determination.Resume En cas de cancer limite au rein, la nephrectomie partielle et la nephrectomie radicale sont les traitements de choix pour les tumeurs respectivement inferieures a 4 cm et superieures a 7 cm. Entre 4 et 7 cm, la nephrectomie partielle peut se discuter en fonction de la localisation. Trente a 40 % des tumeurs du rein non metastatiques progresseront ensuite, a distance de la chirurgie. Dans certains cas, une chirurgie conservatrice peut etre discutee plutot qu’une chirurgie radicale; notamment en cas de tumeur de moins de 4 cm de diametre et/ou exophytique. Les techniques ablatives (radiofrequence et cryoablation) sont porteuses de resultats interessants, mais encore limites. Les recommandations de l’AFU concernant le traitement des tumeurs du rein ont ete remises a jour en 2007 et refletent le developpement des essais therapeutiques toujours plus nombreux concernant la place des molecules antiangiogeniques. Concernant l’initiation des traitements anti-angiogeniques, les elements a prendre en compte pour debuter un traitement sont la preuve d’un carcinome renal a cellules claires, la presence de metastases, leur nombre, leur site et l’appartenance a un groupe pronostic.