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Objectives: To compare the efficacy of 3 biologic hemostatic devices with that of conventional suture during laparoscopic partial nephrectomy (LPN) in a hypertensive porcine model. Improving hemostasis, urinary tract closure, and the warm ischemia (WI) time are important in the development of LPN., Methods: A total of 40 pigs were randomized prospectively into 4 groups before bilateral LPN. Right LPN involved 30% of the renal parenchyma without a urinary tract opening, and left LPN involved 40% of the renal parenchyma with a urinary tract opening. The renal section was treated with fibrin/thrombin sealant, fibrin glue, thrombin/gelatin granules, and conventional suture in groups 1, 2, 3, and 4, respectively. At 10 days postoperatively, left retrograde pyelography was performed. The pigs were then killed and the kidneys sent for pathologic analysis. The main criteria were the estimated blood loss, perioperative WI time, leaking pressure during retrograde pyelography, and parenchyma necrotic-induced lesions., Results: The estimated blood loss was lower in the pigs treated with either thrombin/gelatin granules or suture (P < .001). The use of thrombin/gelatin granules decreased the WI time compared with the use of suture (P < .001). However, the leaking pressure was greater in the pigs treated with suture (P < .01). The mean area of necrosis around the renal section was shorter when no suturing was performed (P < .01)., Conclusions: The use of thrombin/gelatin granules alone controlled hemostasis as effectively as suture and significantly decreased the WI time. However, conventional suture of the urinary tract, when opened, should be considered. Additional evaluation in humans is required before any clinical recommendation can be made.

Objectives: To evaluate prospectively a healthy parenchymal safety margin during conservative surgery for renal cell carcinoma., Methods: From 1997 to 2001, elective nephron-sparing surgery was performed through a flank incision in 61 consecutive patients (mean age 59.4 years, range 34.2 to 78.5). The mean tumor size was 32 mm (range 12 to 50). The tumor localization was juxtahilar in 10 and distant in 51. Prospective margin assessment used the following protocol. Margins were evaluated macroscopically by the surgeon, controlled by frozen section analysis, and subsequently measured during histologic examination. All patients were monitored with computed tomography scans, with a mean follow-up of 72.5 months (range 46 to 95)., Results: The histologic type was clear cell in 42 patients, papillary in 17, and chromophobic cell in 2. Of the 61 patients, 57 had 1997 TNM Stage pT1 and 4 had Stage pT2. The Furhman grade was grade 1 in 16, grade 2 in 35, and grade 3 in 10. No tumor margin was positive. Frozen section analysis and routine histologic examination yielded 53 complete and 8 incomplete margins compared with 51 and 10, respectively, as assessed by the surgeons. The mean peritumoral margin was 7 mm (range 4 to 10) for the cortex and 2 mm (range 0 to 5) for the deep part. No patient developed locoregional or metastatic relapse., Conclusions: No apparent relationship was observed between peritumoral margin width and the risk of disease progression, even for tumors abutting the hilum, rendering illusory a safety margin greater than 1 cm. Although the surgeons' macroscopic margin evaluations were accurate, frozen section analysis is mandatory when the margin status is in doubt. In all cases, margin negativity remains an oncologic imperative.

Objectives: To determine whether coloepiploic mobilization (CEM) is indicated to reduce the incidence of iatrogenic splenectomy during left radical nephrectomy for renal cell carcinoma. The incidence of iatrogenic splenectomy during a left nephrectomy is estimated to be between 1.4% and 24%. In a recent study, we reported that the incidence of iatrogenic splenectomy was 8% during a left nephrectomy performed for renal cell carcinoma through a transperitoneal anterior subcostal incision., Methods: A left radical nephrectomy was performed in 233 consecutive patients for renal cell carcinoma through a transperitoneal anterior subcostal incision with a CEM procedure in which the left colonic flexure was completely detached from the epiploa. Perioperative and postoperative complications, including splenic injury, were noted in a database. The mean patient age was 51.3 years (range 21.3 to 90.2). The mean tumor size was 58 mm (range 15 to 230)., Results: An iatrogenic splenectomy was required in 3 patients, and in 1 patient, a splenic injury was treated conservatively. The incidence of iatrogenic splenectomy accompanying left radical nephrectomy was 1.3%. The mean operative time was 120 minutes (range 80 to 240). The mean time to normal gut motility was 3.4 days (range 2 to 11) and to discharge from the hospital it was 9.3 days (range 6 to 19). Regarding CEM, we did not observe any significant abdominal complications., Conclusions: The incidence of iatrogenic splenectomy during a left radical nephrectomy through a transperitoneal anterior subcostal incision may be reduced by performing the technique of CEM.

Objective: To evaluate the efficacy of tunica albuginea plication without excision in patients with congenital and acquired penile curvature., Methods: Results were retrospectively analyzed in 60 consecutive patients treated from 1982 to 1996. Mean age was 42.8 years (range 16-77). 25 patients had congenital curvature and 35 patients had acquired curvature (29 Peyronie's disease, 5 postoperative and 1 posttrauma). All patients had penile curvature with angulation over 30 degrees and major intercourse difficulties., Results: Postoperatively, 52 patients (87%) had satisfactory cosmetic results and 49 (82%) had satisfactory functional results. All patients (100%) with congenital or postoperative curvature had satisfactory cosmetic results and satisfactory functional results. Patients with Peyronie's disease had a lower success rate with 81% satisfactory cosmetic results and 62% satisfactory functional results., Conclusion: Tunica albuginea plication is a more simple procedure than tunica albuginea resection (Nesbit procedure) with a comparable success rate and minimal morbidity.

Objective: We report on central nervous system metastases from urothelial bladder carcinoma in patients treated with M-VAC chemotherapy., Methods: 50 patients with advanced transitional cell carcinoma of the bladder were treated with the M-VAC regimen at the Hôpital Cochin (Paris, France) between December 1989 and February 1995. Brain relapses were diagnosed by CT scanning., Results: We observed a surprising increase in the number of central nervous system relapses (8/50) in patients treated consecutively at the same institution. The mean time to metastatic recurrence in the brain from the initiation of first chemotherapy was 21 months (range 7-38). Six patients had single and 2 patients had multiple central nervous system metastases. Treatment consisted of radiotherapy alone (n = 5) or both surgery and radiotherapy (n = 3). Median survival time from the appearance of cerebral metastases was 3 months (range 1-10)., Conclusion: The prolonged duration of remissions which are achieved following M-VAC chemotherapy may explain the greater likelihood of the detection of cerebral involvement.

Objectives: Detection of circulating tumor cells may improve the preoperative local staging of prostate cancers. The aim of this study was to perform enhanced reverse transcriptase-polymerase chain reaction (RT-PCR) of prostate-specific antigen (PSA) mRNA to define the predictive value of PSA-positive circulating cells in a large series of patients., Methods: The study included 46 patients with Stage T1 to T2 prostate cancer, 94 with benign prostatic hyperplasia (BPH), and 51 (including 9 women) with nonprostatic disease. PSA-positive cells from peripheral blood samples were detected by Southern blot analysis of the RT-PCR products. Original oligonucleotide primers were defined to exclusively detect the three PSA mRNA splices., Results: Circulating PSA-positive cells were observed in 8 (8.5%) of 94 patients with BPH, 10 (22%) of 46 with Stage T1 to T2 prostate cancer, and 9 (17.6%) of 51 with nonprostatic disease. The detection rate of PSA-positive circulating cells was significantly increased in patients with prostate cancer versus patients with BPH (P = 0.03). Among clinically localized prostate cancers with a Gleason score less than 8, a correlation was observed between PSA-positive circulating cells and Stage pT3 cancer (P = 0.038), capsular penetration (P = 0.04), and a positive margin (P = 0.038). The specificity of the assay for Stage pT3 cancer detection was 84.6%, with a positive predictive value of 60%., Conclusions: Although RT-PCR assay may have a role in preoperative local staging, this study demonstrated the absence of tissue and tumor specificity of PSA-positive circulating cells, accounting for the weak positive predictive value of this technique.

Objectives: To compare results of color Doppler-guided ultrasonography (CDUS) versus those of systematic biopsies in 591 patients with an elevated serum PSA level and to correlate them with digital rectal examination (DRE) findings., Methods: Biopsies were directed into hypervascularized (CDUS+) or hypovascularized (CDUS-) hypoechoic peripheral zone nodules (443 cases). When transrectal ultrasound (TRUS) was normal (148 cases), biopsies were directed into hypervascular area. Six additional posterior biopsies were also performed in every patient, together with four anterior biopsies in 117 patients with normal DRE and prostate weight above 40 g., Results: Biopsies were positive in 339 patients (57%). Positive biopsy rate (PBR) of directed biopsies was 84% in hypervascular abnormalities (264 of 316) and 17% in hypovascular nodules (23 of 134) (P < 0.001). PBR of combined biopsies was 84% in CDUS+ patients (266 of 316) and 26% in CDUS- patients (73 of 275) (P < 0.001). Comparison of TRUS and CDUS showed a sensitivity of 0.9 and 0.78, respectively, and a specificity of 0.46 and 0.8, respectively. Of the 131 patients with a PSA level between 4 and 10 ng/mL and a normal DRE, PBR was 59% (22 of 37) when CDUS was positive and 11% (10 of 94) when it was negative, regardless of TRUS abnormalities (P < 0.001). Nonpalpable cancers with a negative CDUS showed a significantly (P < 0.001) lower Gleason score (5.5 +/- 0.9) than that of CDUS+ cancer (6.5 +/- 1.1). Eleven cancers were diagnosed by only anterior positive biopsies. All of them had a negative CDUS and a PSA level above 10 ng/mL., Conclusions: CDUS does not modify prostate biopsy policy except in patients with negative CDUS, normal DRE, and PSA level between 4 and 10 ng/mL, where deferment of biopsy can be advocated. Anterior biopsies are only useful in patients with a PSA level above 10 ng/mL and a negative CDUS.

Objective: To assess the value of the detection of circulating prostate cells [prostate-specific antigen (PSA) positive] by reverse-transcriptase nested polymerase chain reaction (nested RT-PCR) to improve the staging of clinically localized prostate cancer., Methods: Nested PCR was performed on blood samples of 29 patients submitted to radical prostatectomy for clinically localized (T1-T2) prostate cancer. Nine patients with various benign urologic diseases comprised the negative control group. Incubation was for 25 cycles for each PCR, using beta 2-microglobulin to test the integrity of RNA samples. Each sample was tested in quadruplicate and analyzed by agarose gel electrophoresis, blotted and hybridized with specific internal primers. Nested PCR results were compared with the pT stage of the prostate specimen, processed according to the Stanford method., Results: In 6 out of 29 patients (20.7%) with clinically localized prostate cancer, circulating prostate cells were detected by nested PCR. There was no relationship between pathologic stage and RT-PCR results. Eleven out of 14 pT2 patients (78.6%) were PCR negative and only 3 out of 15 pT3 patients (20%) were PCR positive. All control samples were PCR negative., Conclusions: In selected patients with T1-T2 prostate cancer, there was no relationship between pathologic stage and the presence of circulating PSA-positive cells detected by nested PCR. However, in 20.7% of patients with clinically localized prostate cancer, circulating prostate cancer cells were detected. A further follow-up based on PSA is necessary to clarify the clinical relevance of this biologic anomaly.

Twenty renal cell carcinomas were cultured in the presence of 200 IU/ml of recombinant interleukin-2; tumour-infiltrating lymphocytes (TIL) developed in 70% of cases; the phenotypic profile was heterogeneous in 11 TIL tested on day 30: 4 were mostly CD8 positive, 4 mostly CD4 and 3 showed CD4-CD8-CD56 mixed phenotypes. The cytotoxic activity was also heterogeneous, and no TIL developed a tumour-specific cytotoxic activity. The phenotypic profile and cytotoxic activity were also tested after thawing, and this study demonstrated that TIL can be frozen at the time of the nephrectomy, then thawed and cultured for the purposes of therapeutic trials when metastases appear. The differences between TIL derived from renal cell carcinoma and TI1 derived from melanoma are discussed.