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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.

Objectif: Interroger l’impact de l’utilisation d’une assistance robotisée dans le cadre d’une prostatectomie radicale chez des patients opérés d’un cancer de la prostate et sur la relation médecin–patient, en se focalisant particulièrement sur le vécu des patients.Méthode: Dans le cadre d’une recherche doctorale en cours, des entretiens semi-directifs de recherche en psychologie clinique explorant entre autres cette thématique sont proposés aux patients sur trois temps : en préopératoire, six semaines puis six mois après l’intervention, et s’accompagnent d’observations de consultations urologiques.Résultats: Le recours à une assistance robotisée est pour de nombreux patients assimilé à un geste anodin, à un simple outil qui vient prolonger le geste du chirurgien et apporter un meilleur confort. Néanmoins, pour certains, cela est source d’angoisse, notamment du fait des fantasmes construits autour du robot. En outre, certains patients associent l’utilisation de l’assistance robotisée à la gravité de leur maladie ou au fait de bénéficier ou non du meilleur traitement possible.Conclusion: Compte tenu du nombre croissant de prostatectomies radicales robot-assistées, il est essentiel de s’intéresser aux effets de cet outil non seulement sur le corps des patients, mais aussi sur les fantasmes et angoisses que son utilisation peut susciter, ainsi que sur la relation médecin–patient.

Le diagnostic précoce du cancer de la prostate permet à des patients de choisir de vivre avec un cancer peu menaçant, via une surveillance active (SA) qui mène souvent à une chirurgie, dont les effets secondaires s’inscrivent dans une forme de chronicité, impactant vie quotidienne, image de soi et sexualité. Qu’implique sur le plan psychique de vivre avec un cancer non traité, mais surveillé ? Comment vivre après une intervention chirurgicale aux conséquences mutilantes, handicapantes, portant atteinte au narcissisme ?Objectif: Interroger les remaniements psychiques à l’œuvre chez des patients diagnostiqués d’un cancer de la prostate, opérés soit après plus d’un an de SA, soit sans délai.Méthode: Dans le cadre d’une recherche doctorale en cours, des entretiens semi-directifs sont proposés en préopératoire, six semaines après, puis six mois. Ces entretiens sont appuyés par des autoquestionnaires ainsi que des tests projectifs : le Rorschach et le TAT (Thematic Apperception Test).Résultats: Les patients opérés après avoir vécu une SA ont bénéficié d’une temporalité particulière au cours de laquelle la plupart d’entre eux ont pu accepter l’inacceptable et tolérer l’idée d’avoir un cancer et vivre avec. Si cette période permet à certains de se préparer à l’évolution de leur cancer et à son traitement par ablation, souvent synonyme de guérison, les effets secondaires de la chirurgie restent parfois très difficiles à vivre, surtout lorsqu’ils s’installent dans la durée et impactent le quotidien, constituant alors une nouvelle forme de chronicité. Vivre avec un « corps cancéreux » en SA n’est pas ici une épreuve physique où le corps est le siège de douleurs physiques et de fatigue, mais essentiellement une épreuve psychique. De façon paradoxale, le « corps guéri » subit des transformations en période postopératoire, des bouleversements qui touchent et atteignent l’image que l’homme a de lui-même.Conclusion: Compte tenu des progrès de la médecine dans le dépistage et le traitement curatif du cancer de la prostate, quels sont les enjeux actuels du dépistage précoce ? Peut-on réellement parler de guérison lorsque le vécu subjectif des patients va à l’encontre de la définition habituelle de ce terme ? La « guérison chronique » succéderait-elle à la « maladie chronique » ?

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 whosePatients were prospectively included between April and December 2016. PET/CT was performed 60min after injection of 2MBq/kg of body mass ofThirty-three patients were included. The mean PSA serum level measured on the month of the PSMA-11 PET/CT was 2,8ng/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%).5.

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...

Resumen La cirugia endoscopica se convierte en muchos casos en el tratamiento de primera eleccion de la litiasis ureteral, sea cual sea su localizacion. Se trata de una tecnica delicada que debe seguir un protocolo quirurgico riguroso. Debe informarse al paciente de las complicaciones posibles como son el fracaso de la ureteroscopia y la necesidad de una cirugia convencional urgente. La calidad del material quirurgico (mesa de operaciones, amplificador de brillo, ureteroscopio, camara, fuente luminica, etc.) es un elemento fundamental para el exito de la tecnica endourologica. Los instrumentos de litotricia utilizan diferentes fuentes de energia: acustica (choques piezoelectricos), electrica (choques hidroelectricos), mecanica (choques balisticos) o luminosa (laser pulsado). Si los fragmentos son de pequeno tamano la extraccion es innecesaria y debe restringirse el uso de la sonda de cestilla. La colocacion de un drenaje ureteral postoperatorio debe ser sistematica. En caso de complicacion (lesion ureteral) o fracaso de la laparoscopia, el cateterismo ureteral con una sonda es la maniobra mas adecuada. La ureterolitotomia esta indicada en aproximadamente el 5% de los casos (calculos de gran tamano, calculos impactados, fracaso de las tecnicas endourologicas). Aunque la via de acceso sea convencional o laparoscopica, las maniobras son las mismas: acceso directo para evitar la migracion del calculo, ureterotomia longitudinal sobre el calculo, extraccion atraumatica del calculo en un solo fragmento y ureterorrafia perfecta con o sin drenaje ureteral.

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...

The objective of the cavernous nerve preservation is to avoid injury of the unmyelinated nerve fibers and arteries destined to the corpora cavernosa. Dissection anatomical plans could be inter or extra fascial allowing complete or partial neurovascular bundle preservation. The technique is chosen according to the carcinological evaluated risk and anatomical characteristics. Accessory pudendal arteries preservation must be performed when such an artery is identified in order to improve the chance of recovery of spontaneous erections.

We outline the structure of the clinical and training program of laparoscopic urologic oncology at Memorial Sloan-Kettering Cancer Center. We discuss the steps and key elements necessary in acquiring lapa roscopic proficiency.The program lasts 2 years and trains fellows and faculty. For fellows, the program consists of a 6 months high volume laparoscopic oncology rotation, during which dry lab, animal lab, vide review and operating room experience are required. For faculty, the program consists of 1 accredited continuin medical education course, 20 hours of dry lab, 1 session animal lab, observation of laparoscopic cases, first assistant in a minimum of 15 laparoscopic cases, performing laparoscopic cases under mentoring.8 fellows have completed the training, 4 of whom have completed their fellowship and are in academic centers, performing advanced laparoscopy. The laparoscopic approach represents on average 80% of their urologic practice. Three attendings are performing laparoscopic surgery with mentoring.The goals of a surgical education program should be the standardization of the acquisition o surgical skills and assessment of the performance in a uniform setting to ensure the maintenance of the acquisition of skills and to develop programs to teach new skills.

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.

The late 1990s witnessed an unprecedented evolution in the surgical approaches to the prostate thru the eye of the laparoscope. Initially taken with doubt, laparoscopic radical prostatectomy (LRP) has gained tremendous popularity and widespread implementation at specialized centers worldwide becoming the standard in many of them. LRP represents a technically demanding laparoscopic procedure but it can be performed systematically with standard techniques. Obvious advantages are shorter convalescence and markedly lower operative blood loss without compromise of cancer control. Long-term functional and oncological results are maturing but early reports of positive surgical margin rates and freedom from prostate-specific antigen (PSA) recurrence rates after LRP are encouraging. Early quality of life results of postoperative urinary and sexual function appear similar to those in open surgical series. The real challenge for laparoscopic surgeons entails a paradigm swift, one that breaks off from the traditional and bias impetus, and tests the instruments, procedures, techniques differences and evaluates outcomes in a prospective controlled and randomized manner. If achieved, the laparoscopic movement may give rise to a generation of forward thinking surgeons generating a wealth of clinical evidence for their patients.

We performed a nonrandomized retrospective comparison of 2 techniques for laparoscopic partial nephrectomy, that is without and with clamping the renal vessels.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.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 minutes (range 90 to 390) in group 1 compared with 121.5 +/- 37 minutes (range 60 to 210) in group 2 (p = 0.004). Mean intraoperative blood loss was significantly higher in group 1 than in group 2 (708.3 +/- 569 versus 270.3 +/- 281 ml., p = 0.014). Three patients in group 1 and 2 in group 2 required blood transfusions. Immediately postoperatively mean creatinine was 1.26 +/- 0.36 and 1.45 +/- 0.61 mg./dl. in groups 1 and 2, respectively (p = 0.075). Surgical margins were negative in all specimens. Pathological examination revealed renal cell cancer in 18 cases (stages pT1 in 17 and pT3a in 1), oncocytoma in 4, angiomyolipoma in 5 and renal adenoma in 1.Laparoscopic partial nephrectomy represents a feasible option for patients with small renal masses. Clamping the renal vessels during tumor resection and suturing the kidney mimics the open technique and seems to be associated with less blood loss and shorter laparoscopic operative time.

To propose a scoring system of difficulties for the most currently performed laparoscopic procedures in urology.Each current laparoscopic procedure has been evaluated according to three different criteria: technical difficulty, operative risk and the attention required. Each criterion is scored from 1 (minimal impact of the criteria) to 7 (maximal impact of the criteria). The sum of the 3 criteria is used to classify each operation according to an increasing level of global difficulty, classified into 6 levels: easy (E: sum of criteria between 3 and 5), slightly difficult (SD: sum of criteria between 6 and 8), fairly difficult (FD: sum of criteria between 9 and 11), difficult (D: sum of criteria between 12 and 14), very difficult (VD: sum of criteria between 15 and 17), extremely difficult (ED: sum of criteria greater than 18).Procedures currently performed by laparoscopy have been selected for evaluation according to the above criteria, and retrospectively validated by European experts in laparoscopic urology according to their experience and the international literature.This proposal of a scoring scale system is a basis for discussion, teaching and learning of urological laparoscopy. By necessity, this scale is evolving and will be regularly reconsidered and updated every 5 years.

To retrospectively evaluate the morbidity of radical prostatectomy, with the exception of sexual complications, based on a recent single-centre series.From January 1996 to January 1998, the morbidity of 100 consecutive patients undergoing radical retropubic prostatectomy was compared to the morbidity of the first 150 patients operated by the same technique in our department for the period 1983-1993. The perioperative morbidity was studied retrospectively on case files, while continence was evaluated in the last 50 patients by a self-administered questionnaire. Sexual complications could not be evaluated objectively for methodological reasons and were not addressed in this study.The single operative complication was a rectal injury (1%). The transfusion rate was 31%. The early complication rate was 23% with a major complication rate of 5% (four thromboembolic complications and one gastrointestinal haemorrhage). The most frequent minor complications (18%) were wound abscess (5%). The reoperation rate was 3%. The mean duration of vesical catheterization was 7 days (range: 4-30) and the mean hospital stay was 8 days (range: 5-30). With a mean follow-up of 14 months, 73% of patients are perfectly continent, with no incontinence pads, while 15% of the patients required incontinence pads "as a precaution". Incontinence required implantation of an artificial sphincter in 2 patients (2%). Only one patient developed stenosis of the anastomosis requiring internal urethrotomy. The reduction of morbidity in these 100 recently operated patients compared to the first 150 operated patients concerned the transfusion rate (31% versus 65%), the reoperation rate (3% versus 8%) and the minor complication rate (18% versus 32%). The reduction of operative morbidity partly explains the reduction of mean duration of vesical catheterization (7 days versus 15 days), and hospital stay (8 days versus 18 days); the anastomotic stenosis rate was also decreased from 17.3% to 1%.This study confirms the reduction of overall morbidity of retropubic radical prostatectomy. This improvement is probably multifactorial: increased operative experience and better postoperative management. These retrospective data must be taken into account in the diagnostic and therapeutic decisions concerning localized prostate cancer.

Evaluate the technical feasibility of laparoscopic radical prostatectomy, its carcinological efficacy and per- and post-operative morbidity.We performed radical prostatectomy using a new laparoscopic technique in 28 patients between February 1 and August 31, 1998.Radical prostatectomy was achieved totally by a laparoscopic approach in 24 patients (86%). No conversion was required in the last 14 patients. In 9 patients (32%) ilio-obturator node resection was also performed as indicated by preoperative extension work-up. Mean operative time was 270 minutes. The only major complication was one rectal wound (patient n degree 8) which had a benign course after suturing under laparoscopy. The bladder catheter was removed a mean 7.7 days after the procedure. Five patients (18%) required transfusions (mean 2.7 units, range 2-3). Rapid discharge on day 3 was possible due to rapid pain relief postoperatively. Tumor classes were pT2 in 26 patients, NO in 9, NX in 17. The surgical border was doubtful at the apex in one case. The last prostate specific antigen assay was below detectable levels (0.1 ng/ml) in 16 patients (89%) among the 18 with levels know prior to the procedure. Continence was assessable in 20 patients after a 1 to 6 month follow-up. Continence was perfect in 18 patients and becoming so in 12. Sexual activity was not assessed in this series due to the short follow-up.Radical prostatectomy can be reasonably performed as a routine laparoscopic procedure by a well-trained team. The cancerological results in this series were equivalent to those with conventional retropubic surgery and morbidity was very low. Improved operative vision was considerable, allowing much more precise dissection. The laparoscopic technique appears to be an important improvement for radical prostatectomy and should help improve functional outcome.

The prognostic significance of seminal vesicle invasion on the radical prostatectomy specimen was evaluated according to the proximal or distal site of this invasion.52 consecutive patients undergoing radical prostatectomy for stage pT3b N0 M0 prostatic cancer were classified into two groups: group A (18 patients): patients with invasion limited to the proximal part of the seminal vesicles (stage T3b limited); group B (34 patients): patients with invasion extending to the free part of the seminal vesicles (stage T3b extensive). The PSA progression-free curves were compared between the two groups. A multivariable regression model was performed to determine independent prognostic factors.Overall, the 5-year PSA progression free rate of the 52 patients was 14.4%. The 5-year PSA progression-free rate of the patients in group A was 45.4 vs. 4.2% at 4 years in group B (p = 0.0004). The stage of seminal vesicle invasion and the Gleason score were the only independent predictive factors of PSA progression (p = 0.02 and p = 0.04, respectively).The prognostic significance of seminal vesicle invasion is not constant and depends on the site of invasion. Preoperative seminal vesicles biopsies can select patients with invasion extending to the free part of seminal vesicles and who have a poor prognosis in terms of PSA progression after radical prostatectomy.

To allow the diagnosis of pathological stage C prostatic cancer before deciding on treatment.Seminal vesicle biopsy was performed as an outpatient procedure without anaesthesia. An identical antibiotic prophylaxis to that used for prostatic biopsy was performed. Biopsies were performed by longitudinal vision using a transrectal probe. A seminal vesicle needle biopsy was performed lateral to the prostate in the medial third of the seminal vesicle.When seminal vesicle biopsies are positive, the final pathology report after radical prostatectomy confirmed the diagnosis in 100% of cases. When seminal vesicle biopsies were negative, seminal vesicle invasion was detected on the final pathology examination in one third of cases, mostly corresponding to exclusively intraprostatic involvement of the seminal vesicle. Biopsies are useful when at least one of the two prostatic bases is involved. In the series of the last 42 radical prostatectomies performed because of negative seminal vesicle biopsies, we detected only 11% of capsular lesions, almost always less than 1 mm, and 0% of ilio-obturator lymph node invasion.Although the digital rectal examination findings, the PSA level, the Gleason score, and the number of positive biopsies and their length, allow an approach to preoperative staging, only seminal vesicle biopsies can provide a better preoperative staging of prostatic cancer for a given patient and no longer just statistically.

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).

The advent of extra-corporal shock-wave lithotripsy in the eighties totally changed management strategies for renal and ureteral lithiasis of the upper urinary tract. Currently, approximately 80% of all patients can benefit from lithotripsy with an overall success rate of about 75%. Although classical surgery has a higher success rate of about 90%, extra-corporal shock-wave lithotripsy has many advantages. First there is a very low risk of morbidity (pain, immobilization, complications) for this outpatient treatment. Second, the overall cost, including that of preventive treatment, is low as illustrated by the major reduction in the number of cases of pyonephritis on stones and of corraliform lithiasis. The apparent safety of shock-wave therapy should not mask the risk of unacceptable indications: small stones which may resolve spontaneously or inversely very large stones carrying the risk of residual fragments and renal damage. Long-term morbidity remains to be evaluated, but the management of upper urinary tract lithiasis now relies heavily on shock-wave therapy alongside conventional surgery and percutaneous or endoscopic methods.

The treatment of veslcoureteric reflux by submucosal advancement is effective in human clinical practice on nondilated refluxing ureters, with a low morbidity. In contrast, the results of this technique in the presence of concomitant disease such as megaureter appear to be less favourable and could be due to obstruction induced by the reflux surgery. The objective of this study was to evaluate the urodynamic modifications of ureterovesical reimplantation in 10 female Beagle dogs. Left ureterovesical reimplantation by submucosal ureteric advancement was performed in each animal which constituted its own control. The morphological results were assessed by intravenous urography and retrograde cystography. The urodynamic study was conducted during another surgical operation performed, on average, around the 18th postoperative week. A 6F two-channel probe was inserted on each ureter: while a pump delivered a constant infusion (2 then 5 ml/min) into one channel, the ureteric pressure was measured by the other channel. The bladder pressure was recorded by a bladder catheter. For each infusion rate, the increased pressure in the reimplanted ureter was compared to that measured in the control ureter, as a function of the bladder pressure. The subsequent morphological evaluation demonstrated the absence of any repercussions on the upper urinary tract and the absence of vesicoureteric reflux and paraureteric diverticulum. An initial increase in the basal ureteric pressure was observed at the beginning of the infusion and was significantly higher in the operated ureter than in the control ureter (for an infusion rate of 2 then 5 ml/min, p = 0.0008 and 0.00029, respectively). The mean ureteric pressures increased in parallel, but those recorded in the reimplanted ureter were significantly higher than those recorded in the control ureter (p0.01). Ureteric pressure peaks were only recorded on the reimplanted left ureter at an infusion rate of 2 ml/min. These results suggest that, in this experimental model, the resistance to passive flow was higher in the reimplanted ureterovesical junction than in the control ureterovesical junction.

The authors report their experience of the first 10 patients operated by upper urinary tract lumboscopic surgery. Lumboscopy is performed in the lateral supine position and a simple technique for creation of retropneumoritoneum is described. In 4 patients, the planned nephrectomy could be performed because of poor anatomical conditions (peripyelitis and/or perinephritis). Lumboscopy allowed complete renal exploration, two nephrectomies, two resections of the roofs of compressive parapelvic cysts and one lumbar ureterolithotomy. The ease and rapidity of lumboscopic dissection makes it a valuable alternative to laparoscopy.

45 patients were included in a retrospective study designed to assess the long-term efficacy and tolerance of immunotherapy by intravesical BCG instillation in the treatment of stage pTa bladder tumours (mean follow-up 52.7 months, range: 12-87 months). 41 patients (91% responded to immunotherapy: 24 (53%) did not develop anu recurrences with a mean follow-up of 49.4 months (range: 19-87 months) and 17 (37.7%) were improved by treatment as the interval between recurrences was significantly increased. 4 patients (8.8%) failed to respond to BCG therapy with progression to stage pTa G3 vesical papillomatosis in one patient. The local tolerance was poor for twelve patients (26.6%), requiring discontinuation or spacing of the instillations. Other complications such as prostatitis and intense fever were observed. Three patients had persistent disturbances of micturition following treatment in the form of urinary frequency due to the decreased bladder volume. Neither the grade, nor the frequency of recurrences prior to treatment, nor the solitary or multifocal nature, nor the site of the initial tumour appeared to influence the response to BCG therapy and did not constitute independent individual prognostic indicators.

Eight patients with interstitial cystitis were treated by supratrigonal cystectomy and enterocystoplasty. The indications for this procedure are functionally disabling interstitial cystitis refractory to conservative treatment and associated with severely altered cystomanometric parameters. 6 patients obtained an excellent functional result and 2 patients obtained a poor result, due to sphincter hypotonia responsible for total incontinence in one case.

The curative cell carcinoma is surgery and consists of a radical nephrectomy. Pre-operative assessment must be complete. Indications are extensive because nephrectomy allow, even in evaluated forms, a long and comfortable survival. The incidental discovery of renal cell carcinoma is more and more frequent. It allows limited surgery and should be followed by higher survival rates.

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.

Secondary urethral stricture is the most serious complication of traumatic rupture of the membranous urethra, directly related to the treatment of the rupture. In a series of 45 patients treated for urethral rupture with a minimal follow-up of 5 years, 30 developed stricture (66%). An urethral guide, inserted in 31 cases, was responsible for the stricture in 26 of these cases (84%). This stricture developed rapidly (average of 7.4 months), whether the initial rupture was complete or incomplete and was longer (average of 35 mm) in the case of complete rupture. End-to-end urethrorraphy performed between the 15th and 35th day in 14 patients was complicated by 4 secondary strictures (28%). The treatment of the stricture depended on the initial treatment of the rupture and the radiological length of the stricture. In the case of stricture secondary to an urethral guide, end-to-end urethrorraphy for a stricture less than or equal to 40 mm (12 cases) and 2 stage urethroplasty for a stricture greater than 40 mm (4 cases) achieved a good result in 68.8% of cases. The strictures secondary to end-to-end urethrorraphy (4 cases) were treated by direct vision urethrotomy (3 cases) with 100% of immediate good results and by urethral telescoping (1 case) complicated stress urinary incontinence.