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Resume But Le traitement du cancer de la prostate par ultrasons focalises de haute intensite (HIFU) est un traitement dit mini-invasif qui a en principe une faible morbidite. L’objectif de cette etude etait d’evaluer la qualite de vie des patients traites par HIFU. Patients et methode Cinquante patients consecutifs traites de premiere intention par HIFU pour cancer localise de la prostate entre 2003 et 2005 ont recu le questionnaire de qualite de vie « UCLA/RAND PCI » en preoperatoire et un an apres traitement. Les scores de qualite de vie postoperatoires ont ete compares aux scores preoperatoires et a une population test sans cancer de prostate. Resultats Quatre-vingt pour cent des patients ont repondu aux deux questionnaires. 72,5 % des patients etaient « satisfaits » ou « tres satisfaits », 2,5 % etaient « tres mecontents » et 25 % etaient sans opinion. Les scores de qualite de vie generale (SF-36) n’ont pas mis en evidence de differences significatives avant et apres traitement. Une alteration de la fonction et de la gene ressentie etait statistiquement significative sur le plan sexuel et urinaire. Pour la fonction digestive, il n’y avait pas de difference avant et apres traitement ; en revanche, il y avait une degradation statistiquement significative de la gene ressentie. Conclusion Le traitement HIFU du cancer de prostate est bien accepte par le patient, la qualite de vie est preservee a un an. Il y a une degradation significative de la fonction sexuelle et plus moderee de la fonction urinaire.

Resume Un cancer chez un sujet en etat de mort encephalique est une contre-indication au prelevement d’organe. Il n’existe aucune donnee sur l’evaluation prostatique des sujets en etat de mort encephalique avant prelevement d’organes. L’objectif de travail a ete d’evaluer le depistage du cancer de prostate par dosage du taux de PSA serique chez les donneurs d’organe de plus de 50 ans. Methodes De fevrier a mai 2006, des dosages du taux de PSA serique ont ete realises chez tous les donneurs de sexe masculin dans 5 centres de prelevement differents. Ont ete egalement releves l’âge du donneur et la duree de sondage vesical. Resultats Sur les 85 prelevements realises, 30 (35,3%) concernaient des hommes âges de plus de 50 ans (moyeune : 60,4 ans, extremes 50-82 ans). La duree de sondage etait en moyenne de 3,l jours (extremes 0,522 jours). Le taux de PSA moyen etait de 8,7 nglml (extremes : 0,03 - 52,7) avec un rapport PSA libre/total de 31% (extremes 14-47). Douze donneurs avaient un taux de PSA superieur a 4 ng/ml (de 4,7 a 52 ngrlml), deux autres avaient un taux de PSA superieur a 2,s ngrlml (respectivement 2,77 et 3,3 a 72 et 57 ans). Il n’y avait pas de correlation entre l’âge des donneurs, leur taux de PSA et la duree de sondage. Conclusion L’âge des donneurs en etat de mort encephalique augmente et atteint les seuils d’âge ou l’Association Francaise d’urologie recommande le depistage du cancer de prostate par le toucher rectal et le dosage du taux de PSA. Si le risque de transmission d’un cancer de prostate apres transplantation est actuellement inconnu, il ce stade ou la majorite des cancers de prostate est decouverte devant une augmentation du taux de PSA avec un toucher rectal normal, le risque de transmission d’un cancer de prostate du donneur au receveur est minime voire inexistant. Il existe une grande variabilite des taux de PSA chez les donneurs en etat de mort encephalique de plus de 50 ans, ce qui ne permet pas d’identifier les donneurs a risque de cancer de prostate. Plus que le taux de PSA, ce sont les donnees du toucher rectal qui peuvent contre-indiquer un prelevement d’organe.

OBJECTIVE To evaluate the experimental feasibility of laparoscopic computer-assisted pyeloplasty for pelvi-ureteric junction obstruction. MATERIALS AND METHODS Fourteen pyeloplasties were undertaken in pigs using a laparoscopic transperitoneal approach and the robotic surgical system (da Vinci, Intuitive Surgical Inc., Sunnyvale, CA, USA). RESULTS The robotic surgical system provides real-time three-dimensional stereoscopic vision. Manipulating the intracorporeal endo-wristed instruments from a remote console allows laparoscopic manoeuvres that are as easy as those during open surgery. Surgeons with no particular experience in laparoscopic surgery could learn complex surgery easily and quickly. CONCLUSION This technique provides faster training and the possibility of undertaking complex laparoscopic procedures, especially reconstructive, with less fatigue for the surgeon.

International audience; BACKGROUND: Patients with end-stage renal disease (ESRD) are at risk of developing renal tumours. OBJECTIVE: Compare clinical, pathologic, and outcome features of renal cell carcinomas (RCCs) in ESRD patients and in patients from the general population. DESIGN, SETTING, AND PARTICIPANTS: Twenty-four French university departments of urology participated in this retrospective study. INTERVENTION: All patients were treated according to current European Association of Urology guidelines. MEASUREMENTS: Age, sex, symptoms, tumour staging and grading, histologic subtype, and outcome were recorded in a unique database. Categoric and continuous variables were compared by using chi-square and student statistical analyses. Cancer-specific survival (CSS) was assessed by Kaplan-Meier and Cox methods. RESULTS AND LIMITATIONS: The study included 1250 RCC patients: 303 with ESRD and 947 from the general population. In the ESRD patients, age at diagnosis was younger (55 ± 12 yr vs 62 ± 12 yr); mean tumour size was smaller (3.7 ± 2.6 cm vs 7.3 ± 3.8 cm); asymptomatic (87% vs 44%), low-grade (68% vs 42%), and papillary tumours were more frequent (37% vs 7%); and poor performance status (PS; 24% vs 37%) and advanced T categories (≥ 3) were more rare (10% vs 42%). Consistently, nodal invasion (3% vs 12%) and distant metastases (2% vs 15%) occurred less frequently in ESRD patients. After a median follow-up of 33 mo (range: 1-299 mo), 13 ESRD patients (4.3%), and 261 general population patients (27.6%) had died from cancer. In univariate analysis, histologic subtype, symptoms at diagnosis, poor PS, advanced TNM stage, high Fuhrman grade, large tumour size, and non-ESRD diagnosis context were adverse predictors for survival. However, only PS, TNM stage, and Fuhrman grade remained independent CSS predictors in multivariate analysis. The limitation of this study is related to the retrospective design. CONCLUSIONS: RCC arising in native kidneys of ESRD patients seems to exhibit many favourable clinical, pathologic, and outcome features compared with those diagnosed in patients from the general population.

De novo tumors in renal allografts are rare and their prevalence is underestimated. We therefore analyzed renal cell carcinomas arising in renal allografts through a retrospective French renal transplant cohort. We performed a retrospective, multicentric survey by sending questionnaires to all French kidney transplantation centers. All graft tumors diagnosed after transplantation were considered as de novo tumors. Thirty-two centers participated in this study. Seventy-nine tumors were identified among 41 806 recipients (Incidence 0.19%). Patients were 54 men and 25 women with a mean age of 47 years old at the time of diagnosis. Mean tumor size was 27.8 mm. Seventy-four (93.6%), 53 (67%) and 44 tumors (55.6%) were organ confined (T1-2), low grade (G1-2) and papillary carcinomas, respectively. Four patients died of renal cell carcinomas (5%). The mean time lapse between transplantation and RCC diagnosis was 131.7 months. Thirty-five patients underwent conservative surgery by partial nephrectomy (n = 35, 44.3%) or radiofrequency (n = 5; 6.3%). The estimated 5 years cancer specific survival rate was 94%. Most of these tumors were small and incidental. Most tumors were papillary carcinoma, low stage and low grade carcinomas. Conservative treatment has been preferred each time it was feasible in order to avoid a return to dialysis.

Cancer in a brain-dead subject constitutes a contraindication to organ harvesting. However no data are available on prostatic assessment of brain-dead subjects prior to organ harvesting. The objective of this study was to evaluate prostate cancer screening by serum PSA assay in potential organ donors over the age of 50.From February to May 2006, serum PSA assays were performed in all male donors in 5 different organ harvesting centres. The donor's age and the duration of bladder catheterization were also recorded.Of the 85 organ harvests performed, 30 (35.3%) concerned men over the age of 50 years (mean: 60.4 years, range: 50-82 years). The mean duration of catheterization was 3.1 days (range: 0.5-22 days). The mean PSA level was 8.7 ng/ml (range: 0.03-52.7) with a free PSA/total PSA ratio of 31% (range: 14-47). Twelve donors had a PSA level greater than 4 ng/ml (4.7 to 52 ng/ml), two others had a PSA level greater than 2.5 ng/ml (2.77 and 3.3 in subjects aged 72 and 57 years, respectively). There was no correlation between the donor's age, their PSA level and the duration of catheterization.The age of brain-dead donors is increasing and is reaching the age limit recommended by the Association Francaise d'Urologie for prostate cancer screening by digital rectal examination and PSA assay. Although the risk of transmission of prostate cancer after transplantation is currently unknown, at this stage when the majority of prostate cancers are discovered in a context of elevated PSA with normal digital rectal examination, the risk of transmission of a prostate cancer from the donor to the recipient is minimal or even non-existent. Digital rectal examination findings may be more relevant than PSA to contraindicate organ harvesting.

To evaluate the feasibility and safety of totally robotic laparoscopic cystoprostatectomy for neurogenic bladder, with intracorporeal ileal-conduit urinary diversion in tetraplegic patients with severe neurogenic bladder complications.Two men, 41 and 38 years old, with complete post-traumatic C7-C8 quadriplegia and poor lower urinary-tract condition underwent totally transperitoneally performed cystoprostatectomy and ileal-conduit urinary diversion with robotic assistance (Da Vinci).The procedures were completed without open conversion. The total surgical time was 9.25 and 6.75 hours, respectively. There were no intraoperative complications. In the postoperative period, both patients had mild complications (pulmonary and urinary infections) that were treated successfully medically. The postoperative hospital stay was 13 days in both cases.Our results demonstrate the safety and feasibility of robot-assisted laparoscopic cystoprostatectomy with ileal-conduit urinary diversion in two tetraplegic patients.

Background. Robot-assisted laparoscopic donor (RALD) nephrectomy, a new procedure for the removal of a kidney from a living donor, was performed on 13 subjects at our centre. Methods. The immediate post-operative courses for these donors, and their respective recipients, were compared with those of 13 previous open live-donor nephrectomies (OPEN), performed in our facility. Results. We found no significant differences between these two donor groups with respect to age, gender, body mass index or renal vasculature. The average operative times and the warm ischaemia times were greater in the RALD group, 185.5 00 vs 113.4 00 (P ¼ 0.0001) and 7 0 15 00 vs 1 0 41 00 (P ¼ 0.0001), respectively. There was no conversion to the open procedure in the RALD group. The estimated blood loss was slight in both groups. Following nephrectomy, deep venous thrombosis occurred in one RALD patient and acute pyelonephritis in one OPEN patient. The average duration of hospitalization was shorter after the RALD procedure (5.84±1.8 days vs 9.69± 2.2 days, P ¼ 0.0001). The estimated creatinine clearance rate (eClcreat) was equivalent for all donors, at 5 days and 1 month after nephrectomy. All kidneys started functioning immediately after the transplantation. The mean recipient eClcreat (ml/min) was 58.16±26.7 for OPEN group kidneys and 62.23±17.59 for RALD group kidneys (P ¼ 0.65), 5 days after transplantation. Conclusions. RALD nephrectomies were associated with very low morbidity among donors, in which both the operative and warm ischaemia times were of longer duration, but had no observable adverse effects upon short-term graft function.

The objective of the present study was to describe kidney temperature variations during transplantation and to identify the factors responsible for kidney warming. Kidney temperature was recorded steadily during transplantation. Kidney weight, body mass index (BMI), second warm ischemia time (t), and kidney temperature at the time of being placed in the recipient were analyzed so that we could evaluate their influence on kidney temperature and on kidney warming during transplantation. Kidney temperature at the time of removal from the container was 1.6 degrees C and 6. 3 degrees C when the kidney was placed in the recipient. Kidney temperature in the recipient depended on kidney temperature after serum washing (P0.0001), but was independent of kidney preparation time (P=0.94). Then, kidney temperature (T) increased according to the logarithmic curve given in the following equation: T=7.2 ln(t)-0.6. Kidney temperature at the end of anastomosis was 26.7 degrees C. Kidney warming speed was 0.48 degrees/min and was dependent on the length of time of vascular anastomosis (P0.0001). Kidney weight decreased the kidney warming speed (P=0.02). In conclusion, kidney warming increases slowly during ex vivo preparation. Kidney temperature stays below the damaging ischemic temperature of 18 degrees C. Because of its major impact on kidney warming, it is desirable that vascular anastomosis time be reduced, and, consequently, ex vivo kidney preparation needs to be meticulous.

Introduction: High Intensity Focused Ultrasound (HIFU) is a minimally invasive therapy which can produce tissues necrosis in depth by a local thermal effect. Objectives: Evaluate the effect of extracorporeal HIFU with electronic scanning in the treatment of pig kidney. Material and method: The kidney of 12 pigs were treated in vivo under general anaesthesia by extracorporeal HIFU. The HIFU machine was a Pyrotech (Edap-Technomed ; France) modified with a fast electronic scanning of the focal point. Each ultrasonic pulse thus scans a square area of adjustable dimensions from 3x3 mm to 5x5 mm. An ultrasound probe inserted in the treatment head, allowed the localization of the target into the kidney. The volume treated in the kidney was 1.4 to 2.6 cm 3 . The delay between the ultrasound pulses were 40 to 60 s. The treatments duration varied between 9 to 16 min. The kidneys were removed 3 days after the HIFU treatment and analyzed in histology. Results: 7 kidneys had homogeneous necrotic lesions. The volume of the lesions corresponded to the treated volume. 3 kidneys had partial necrotic lesions, with non treated inclusions. In 2 kidneys, no lesions were found. Skin burns were observed on 2 pigs. Conclusion: Extracorporeal HIFU with electronic scanning can produce tissue necrosis into pig's kidneys. This treatment could be used in human as a non invasive therapy of small kidney's tumors less than 30 cm 3 of volume.

Objectives: Compare the muscular parietal heating during high intensity focused ultrasound (HIFU) at different acoustic power levels. Methods: 3 series of 100 acoustic pulses of same energy but variable power were applied in vivo on the muscular lumbar and abdominal walls in 4 pigs. The target volume was located 47 to 94 mm behind the skin. Two thermocouples were inserted into the muscular wall facing the focal point 10-15 mm and 25-30 mm from the skin. The position of the treatment head was the same for the 3 series of acoustic pulses. The temperatures in the muscular wall were recorded during the HIFU treatment. Results: The lumbar muscular wall heating were: at low acoustic power (53 to 67W) 1.5 to 4.0°C, at medium acoustic power (532 to 654W) 2.3 to 6.5°C and at high acoustic power (1895 to 2372W) 1.2 to 5.0°C. The abdominal muscular wall heating were: at low acoustic power (128 to 163W) 0.5 to 6.5°C, at medium acoustic power (451 to 574W) 2.7 to 8.4°C and at high acoustic power (1213 and 1545W) 3.3 to 8.5°C. Conclusion: During extracorporeal HIFU treatments, the muscular parietal heating is variable among individuals and increases with the acoustic power.

Introduction: The efficacy of extracorporeal High Intensity Focused Ultrasound (HIFU) on bladder wall has been demonstrated. However, the treatment is still slow, needing about 15 min to treat 1 cm . Objectives: Demonstrate the feasibility of HIFU with electronic scanning and reduce the duration of HIFU treatments. Methods: The HIFU machine was a modified Pyrotech (Edap-Technomed; France) allowing fast electrdnic scanning of the focal point. Each ultrasonic pulse could scan an adjustable square area ranging from 4x4 mm to 7×7 mm. On 16 anaesthetized pigs, 26 areas of the posterior bladder wall were treated with this technique. Target areas were 1.4 to 4.4 cm 2 large. Delays between ultrasonic pulses were ranging from 30 to 65 sec. The treatment durations were 5 to 10 min. Focal intensity between 7000 and 11000 W/cm 2 . The bladder, the rectal wall and the abdominal wall were removed 3 days after HIFU treatments and histology was performed. Results: 22 lesions were obtained on posterior bladder walls. Necrotic areas were surrounded by a 2 mm edematous rim. The sizes of necrotic areas were equal to the target sizes. Depth of lesions extended either over mucosa alone or mucosa and deep muscle. 7 superficial rectal lesions were noticed but none in the abdominal walls or on the skin. Conclusions: Necrotic lesions on bladder posterior wall can be obtained with HIFU treatments using electronic scanning of the focal point. Average treatment duration with electronic scanning is reduced to 3 min 30 sec / cm.

Urinary diversion is a therapeutic option in quadriplegic patients with poor lower urinary tract conditions, but it is an invasive procedure. Laparoscopic techniques are less invasive, but are technically demanding, and only a few surgical teams are able to complete such a complex procedure endoscopically. Robotics bring an unprecedented control of surgical instruments, shorten the learning curve, and allow open surgeons to apply more easily their technical skill to the laparoscopic approach. This complex case of laparoscopic ileal conduit in a quadriplegic woman was completed by our team with the Da Vinci system after 6 months of clinical experience in robotic surgery.