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Background Confocal laser endomicroscopy (CLE) is an optical device that aims to image histological architecture and may be used to reduce positive surgical margins. The ability of CLE to describe prostatic and periprostatic tissues, and prostate cancer (PCa) is still an object of investigation. Objective To create an atlas of ex vivo CLE images of prostatic and periprostatic tissues, and PCa in order to recognise different prostatic structures. Design, setting, and participants From November 2017 to February 2018, 15 patients underwent radical prostatectomy for biopsy-proven PCa. Outcome measurements and statistical analysis Based on preoperative data and macroscopic examination, tumour location was assessed and confirmed on frozen sections. Prior to ex vivo CLE analysis, prostates were stained with fluorescein 10%. We used a GastroFlex probe to collect images of periprostatic tissue (adipose tissue, fibrous and connective tissues, vessels, nerve sheets, seminal vesicles, and urethra). Normal prostatic glands and tumour tissue according to the Gleason grade were analysed. Each PCa Gleason score was represented. Results and limitations A total of 139 video clips and 237 pictures of prostatic and periprostatic tissues were collected. Among them, we selected 16 highly representative images. Adipose tissue, fibrous tissue, and connective tissue were supposable in all 15 specimens. PCa glands captured fluorescein in their cytoplasm, normal prostatic glands did not capture fluorescein, and glandular structures were easily recognisable. The principal limitation of this study is its ex vivo nature of the study. Conclusions Each CLE image was correlated with the corresponding haematoxylin/eosin/saffron definitive pathology image, allowing building of an atlas as a necessary tool to assess the diagnostic performance of CLE during radical prostatectomy in achieving negative surgical margins. Patient summary In this study, we aim to provide an atlas of images illustrating prostatic, periprostatic, and PCa tissues obtained using Cellvizio confocal laser endomicroscopy as a tool for further interpretation of intraoperative surgical margins during radical prostatectomy.

International audience; Introduction: Since April 201, we have introduced PET/CT using a ligand of prostate-specific membrane antigen labeled with gallium-68 (PSMA-11). We aimed to evaluate its positivity rate and impact in patients presenting biochemical recurrence of prostate cancer whose 18F-fluorocholine (FCH) PET/CT was non-contributive.Patients and method: Patients were prospectively included between April and December 2016. PET/CT was performed 60 min after injection of 2 MBq/kg of body mass of 68Ga-PSMA-11. Three anatomical areas were considered: prostatic lodge, pelvic lymph nodes and distant locations. The impact of PSMA-11 PET/CT was assessed by comparing changes in therapeutic strategy decided during multidisciplinary meeting.Results: Thirty-three patients were included. The mean PSA serum level measured on the month of the PSMA-11 PET/CT was 2,8 ng/mL. Twenty-five (76%) PSMA-11 PET/CT were positive, 7 (21%) negative and 1 (3%) equivocal. Of 11 patients whose FCH PET/CT showed equivocal foci, PSMA-11 PET/CT confirmed those foci in 5 cases. Follow-up was available for 18 patients (55%). PSMA-11 PET/CT results led to a change in management in 12 patients (67%).Conclusion: 68Ga-PSMA-11 PET/CT is useful in detecting recurrence of prostate cancer, by identifying residual disease which was not detected on other imaging modalities and by changing management of 2 patients out of 3.Level of evidence: 5.; Introduction: Depuis avril 2016, nous avons introduit la TEP/TDM avec ligand de l’antigène membranaire spécifique de la prostate marqué au gallium-68 (PSMA-11). Nous avons évalué son taux de positivité et son impact chez les patients en récidive biologique de cancer de prostate, sans lésion affirmable en TEP/TDM à la 18F-fluorocholine (FCH).Patients et méthodes: Ces patients ont été prospectivement inclus d’avril à décembre 2016. La TEP/TDM a été effectuée 60 min après injection de 2 MBq/kg de 68Ga-PSMA-11. Trois sites anatomiques ont été considérés : loge prostatique, ganglions pelviens, et localisations à distance. L’impact des résultats de la TEP/TDM-PSMA-11 sur la prise en charge a été évalué en comparant les stratégies thérapeutiques proposées lors des réunions de concertation pluridisciplinaires.Résultats: Trente-trois patients ont été inclus. La concentration sérique moyenne du PSA mesurée au cours du mois de la TEP/TDM-PSMA-11 était de 2,8 ng/mL. Vingt-cinq TEP/TDM-PSMA-11 (76 %) étaient positives, 7 (21 %) négatives et 1 (3 %) douteuse. Sur 11 patients dont la TEP/TDM-FCH était douteuse, la TEP/TDM-PSMA-11 a confirmé les lésions douteuses dans 5 cas. Un suivi était disponible pour 18 patients (55 %). Les résultats des TEP/TDM-PSMA-11 ont conduit à un changement de la prise en charge chez 12 patients (67 %).Conclusion: La TEP/TDM au 68Ga-PSMA-11 est efficace dans la localisation de la récidive du cancer de la prostate, identifiant des cibles de maladie résiduelle non visualisées par les autres méthodes d’imagerie, changeant ainsi la prise en charge de 2 patients sur 3.Niveau de preuve: 5.

Loss of heterozygosity (LOH) is the most consistent genetic alteration in prostate cancer (CaP), frequently associated with advanced cancer and metastasis. We performed LOH analysis on 6 chromosomal regions of interest in localized CaP to obtain an overview of allelic losses in organ confined tumors and test the association with the usual prognostic factors.Tumoral and normal DNA were extracted from 48 radical prostatectomy specimens (all organ confined) with a Gleason score of 5 to 7. Biological and pathological data, such as prostate specific antigen (PSA), Gleason score and perineural invasion (PNI), were correlated with allelic losses at 7q31, 8p22, 12p13, 13q14, 16q23.2 and 18q21. Analysis was done by genotyping using highly informative microsatellites markers.The rate of LOH was 25% for chromosomes 13 and 18, and between 40% and 47% for chromosomes 7, 8, 12 and 16. The mean frequency of overall LOH events was less than 34%. Except for the 12p13 and 16q23.2 loci no significant correlation was found between LOH and PSA or Gleason score. PNI was significantly associated with LOH on 8p22 (p = 0.003) and with a high frequency of LOH events (greater than 34%) (p = 0.02).The frequency of allelic losses in localized and differentiated CaP is associated with PNI but not with the usual prognostic markers, such as PSA and Gleason score. The relationship between LOH on 8p22 and PNI suggests the presence on this region of a gene involved in epithelium/nerve interaction.

We performed a prospective oncological evaluation of laparoscopic radical prostatectomy in regard to local tumor control and biochemical recurrence.Between January 1998 and March 2002, 1,000 consecutive patients with a mean age +/- SD of 63 +/- 6.2 years and clinically localized prostate cancer underwent laparoscopic radical prostatectomy at 1 institution. Preoperative 1997 TNM clinical stage was T1a in 6 patients (0.6%), T1b in 3 (0.3%), T1c in 660 (66.5%), T2a in 304 (30.4%) and T2b in 27 (2.7%). Mean preoperative prostate specific antigen (PSA) +/- SD was 10 +/- 6.1 ng./ml. (range 1.5 to 55). Postoperatively, surgical specimens were assessed and positive surgical margins recorded. Factors that could influence the surgical margins status were evaluated. Irrespective of pathological stage or surgical margin status, no adjuvant treatment was proposed before an increasing PSA. PSA recurrence was defined as PSA greater than 0.1 ng./ml. and was confirmed by a second increase. Recurrence time was defined as the time of the first increase in PSA.Postoperative pathological stage was pT2aN0/Nx in 203 patients (20.3%), pT2bN0/Nx in 572 (57.2%), pT3aN0/Nx in 142 (14.2%), pT3bN0/Nx in 77 (7.7%) and pT1-3 N1 in 6 (0.6%). Positive surgical margin rate was 6.9%, 18.6%, 30% and 34% for pathological stages pT2a, pT2b, pT3a and pT3b, respectively (p0.001). The main predictors of a positive surgical margin were preoperative PSA (p0.001), clinical stage (p = 0.001), pathological stage (p0.001) and Gleason score (p = 0.003). The overall actuarial biochemical progression-free survival rate was 90.5% at 3 years. According to the pathological stage, the progression-free survival rate was 91.8% for pT2aN0/Nx, 88% for pT2bN0/Nx, 77% for pT3aN0/Nx, 44% for pT3bN0/Nx and 50% for pT1-3N1 (p0.001). Of the patients 94% with negative surgical margins and 80% with positive margins had progression-free survival (p0.001). Preservation of the neurovascular bundles in patients with localized tumors had no significant effect on the subsequent risk of positive surgical margins or progression-free survival.Based on followup, our evaluation confirms that laparoscopic radical prostatectomy provides satisfactory results in regard to local tumor control and biochemical recurrence.

Purpose: We performed a nonrandomized retrospective comparison of 2 techniques for laparoscopic partial nephrectomy, that is without and with clamping the renal vessels.Materials and Methods: Between December 1997 and February 2002, 28 consecutive patients underwent transperitoneal laparoscopic partial nephrectomy for renal tumor. In group 1 (12 patients) partial nephrectomy was performed with ultrasonic shears and bipolar cautery without clamping the renal vessels, while in group 2 (16 patients) the renal pedicle was clamped before tumor excision. In group 2 patients intracorporeal kidney cooling was achieved by a ureteral catheter connected to 4C solution. Intracorporeal freehand suturing techniques were used to close the collecting system when opened and approximate the renal parenchyma.Results: All procedures were successfully completed laparoscopically. Mean renal ischemia time ± SD was 27.3 ± 7 minutes (range 15 to 47) in group 2 patients. Mean laparoscopic operating time was 179.1 ± 86 minu...

Purpose: To propose a scoring system of difficulties for the most currently performed laparoscopic procedures in urology. Materials and Methods: Each current lapa

Resume L’objectif de la preservation nerveuse est de traumatiser le moins possible les fibres non myelinisees et les arteres qui se destinent aux corps caverneux. Le plan anatomique de la dissection peut etre inter ou extra fascial et il est possible de preserver toute ou partie des pedicules neurovasculaires. La technique depend du risque carcinologique evalue et des caracteristiques anatomiques locales. La preservation des arteres pudendales accessoires doit egalement etre tentee, lorsqu’elles sont identifiees afin d’ameliorer les chances de recuperer des erections naturelles.

Objectives : The aim of this study is to compare the initial experience at two different urologic centers of the 20 first laparoscopic nephrectomies performed either by transperitoneal laparoscopy (10 cases) in one center or by retroperitoneal laparoscopy (lumboscopy, 10 cases) in the other center. Methods: 5 males and 15 females with a mean age of 36 years (range 3-74) were operated on the right side in 8 cases and on the left side in 12 cases. Nephrectomies were indicated in 18 cases for benign renal disease, and in 2 cases for ureteric tumor (1 patient in each group). The techniques of these two approaches are described. Results : The mean operating time was shorter with lumboscopy (173 min) than with laparoscopy (210 min), probably due to the direct approach to the renal compartment without intraperitoneal dissection with lumboscopy. There were no severe intraoperative or postoperative complications, but one hematoma of the renal area in the laparoscopic group. The mean postoperative hospital stay was identical following lumboscopy and laparoscopy (4.3 and 4.2 days, respectively). Conclusion : These two approaches can be used to perform nephrectomy. In this initial experience, the results appear to be equivalent in terms of morbidity and postoperative hospital stay, but the operating time appears to be shorter with lumboscopy. Larger studies comparing respective nephrectomy conversion rates would provide other arguments in favor of one or other of these techniques.

Purpose: Rectal injury is a potential complication of radical prostatectomy. Because laparoscopic radical prostatectomy is still a challenging procedure, we review the incidence and management of rectal injury in 1,000 cases of consecutive laparoscopic radical prostatectomy performed at our institution.Materials and Methods: Of the first 1,000 laparoscopic transperitoneal radical prostatectomies performed between January 1998 and April 2002, 13 (1.3%) were complicated by rectal injury. Mean patient age was 66.5 years (range 58 to 76) and mean prostate specific antigen was 12.9 ng./ml. (range 2.9 to 26). Clinical stage was T1c, T2a and T2b in 5, 7 and 1 patient, respectively. Mean preoperative Gleason score was 5.8 (range 3 to 8). Once recognized the rectal defect was closed laparoscopically in 2 layers and tested for the absence of leakage. Broad-spectrum intravenous antibiotics were given for 7 days. Oral liquids were started the day after surgery with a low residue diet, and a regular diet was s...

Objetivo: Presentar un breve esquema de la estructura del programa clínico y de formación en oncología urológica laparoscópica en el Memorial Sloan-Kettering Cancer Center. Describir las fases y los elementos claves necesarios para adquirir la capacitación en laparoscopia. Material y métodos: El programa dura 2 años y forma a residentes en formación y a urólogos. En el caso de los residentes, el programa consiste en una rotación en oncología con un gran volumen de procedimientos laparoscópicos, de 6 meses de duración, en el cual se adquiere experiencia en laboratorio de simulación, laboratorio animal, revisión de vídeos y experiencia en quirófano. Para los urólogos, el programa consiste en 1 curso de formación médica continuada acreditada, 20 horas de laboratorio de simulación, 1 sesión de laboratorio animal, observación de casos laparoscópicos, ejercer como primer ayudante en un mínimo de 15 procedimientos laparoscópicos y ejecución de procedimientos laparoscópicos bajo supervisión. Resultados: 8 residentes han completado el programa de formación laparoscópica, 4 de los cuales han completado su ciclo de especialización y están en centros académicos, realizando laparoscopia avanzada. El abordaje supone un promedio del 80% de su práctica urológica. Tres de los participantes están realizando cirugía laparoscópica bajo supervisión. Conclusión: Los objetivos de un programa de formación quirúrgica deberían ser la normalización de la adquisición de experiencia quirúrgica y la evaluación de los resultados en un marco uniforme para garantizar la conservación de la experiencia adquirida y desarrollar programas para enseñar nuevas técnicas.

Objectifs.— Evaluer les caracteristiques de deux «definitions » de cancer de la prostate localise a haut risque de recidive dans une serie francaise contemporaine de prostatectomies radicales. Methodes.— De janvier 2011 a mars 2013, 167 patients ont ete operes d’une PR. Le stade clinique etait T1c chez 77, T2 chez 87, T3a/b chez 3 patients. Le PSA median = 8,41 (2,06—85,87), score de Gleason median preoperatoire = 7 (6—10). L’IRM prostatique a toujours confirme une tumeur localisee. Une lymphadenectomie pelvienne a ete realisee si le risque d’envahissement ganglionnaire etait superieur a 2 % (nomogramme MSKCC). Le nombre moyen de ganglions etait de 10,8 (2—30). Le resultat pathologique etait : 82 tumeurs pT2 (N0 : 44, Nx : 34, N1 : 0) ; 85 tumeurs pT3 (68pT3a/17pT3b ; N0 : 58 ; N1 : 18 ; Nx : 9). Trente-neuf patients avait un score de Gleason superieur ou egal a 8. Nous avons applique les definitions preoperatoires de cancer prostatique a haut risque en utilisant les definitions de d‘Amico et du nomogramme (MSKCC) avec un seuil a 75 % de survie sans recidive biologique (SSRB) a 10 ans (correspondant a la survie mediane sans recidive d’une population de patients traites par prostatectectomie radicale) et compare les resultats. Resultats.— En utilisant d’Amico, 38 patients etaient consideres a haut risque correspondant finalement a 8 tumeurs stade pT2 (10 %), 19 pT3a (28 %), 11 pT3b (64,7 %). Vingt-quatre patients avaient un score de Gleason superieur ou egal a 8 (61,5 %). Le statut ganglionnaire etait Nx chez 4 (10 %), N0 chez 23 (21,1 %) et N1 chez 11 patients (61,1 %). En utilisant le nomogramme, 34 patients avaient une SSRB a 10 ans inferieure a 75% correspondant a 5 tumeurs stade pT2 (6 %), 16 pT3a (23,5 %) et 13 pT3b (76,5 %). Vingt-huit patients avaient un score de Gleason superieur ou egal a 8 (71,8 %). Le statut ganglionnaire etait Nx chez 2 (5 %), N0 chez 19 (17,4 %) et N1 chez 13 patients (72,2 %). Conclusion.— Le nomogramme avec un seuil a 75 % de SSRB a 10 ans semble superieur a la definition des patients a « haut risque » de d’Amico, incluant moins de patients dont le stade anatomopathologique apparait favorable (pT2 N0/Nx) et plus de patients dont le stade anatomopathologique apparait defavorable (pT3b et/ou N1).

estimate -2.99, 95%CI -3.45,-2.53) but more anastomotic strictures (OR 1.40, 95%CI 1.04,1.87) and higher rates of salvage therapy (OR 3.67, 95%CI 2.81,4.81). Patients of high-volume MIRP experienced fewer anastomotic strictures (OR 0.93, 95%CI 0.87,0.99) and less salvage therapy (OR 0.92, 95%CI 0.88,0.98). CONCLUSIONS: Men undergoing MIRP vs. open radical prostatectomy have lower risk for perioperative complications and shorter lengths of stay, but are at higher risk for salvage therapy and anastomotic strictures. However, risk for these unfavorable outcomes decreases with increasing MIRP surgical volume.