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Resume Objectif Etudier l’influence du passage de la prostatectomie totale laparoscopique (PT-Lap) a la voie robot-assistee (PT-Rob) sur le taux d’interventions secondaires pour incontinence urinaire (IU) et dysfonction erectile (DE). Materiel Etude retrospective, evaluant chaque annee de 2008 a 2015, le nombre et le type d’interventions chirurgicales secondaires realisees pour IU et/ou DE post-PT, en fonction de la technique de PT (PT-Lap et PT-Rob). Resultats Entre 2008 et 2015, 2046 PT ont ete realisees dans notre service dont 372 PT-Lap et 1674 PT-Rob. Parmi ces patients, 84 (4 %) ont ete traites chirurgicalement pour IU (18 AMS800, 9 ballons Pro-Act, 57 bandelettes sous-uretrales) et 15 (0,7 %) ont eu une pose d’implant penien pour DE resistante au traitement medical ; 16 (0,7 %) ont ete operes a la fois d’IU et de DE. Le delai moyen de prise en charge de l’IU etait de 3,2 ans en 2008 et de 1 an en 2015 et est reste stable pour la DE (moyenne : 3,4 ans). Les taux globaux (PT-Lap et PT-Rob) d’interventions secondaires pour IU et DE par annee de PT sont restes stables et inferieurs a 5 % et 1,7 % respectivement, y compris pendant la phase de transition PT-Lap/PT Rob. Le taux d’intervention pour IU apres PT-Lap etait superieur a celui apres PT-Rob pour chaque annee de PT etudiee. Conclusion L’introduction de la robotique a des le depart un impact favorable sur le nombre d’interventions secondaires pour troubles fonctionnels genito-urinaires.

Çalışmada 21 yazar bulunmaktadır. Bu yazarlardan sadece Bursa Uludağ Üniversitesi mensuplarının girişleri yapılmıştır. Live surgery (LS) is considered a useful teaching opportunity. The benefits must be balanced with patient safety concerns. To evaluate the rate of complications of a series of urologic LS performed by experts during the Congress Challenge in Laparoscopy and Robotics (CILR). We present a large, multi-institution, multi-surgeon database that derives from 12 CILR events, from 2004 to 2015 with a total of 224 cases. Radical prostatectomy (RP) was the most common procedure and a selection of complex cases was noted. The primary measure was postoperative complications and use of a Postoperative Morbidity Index (PMI) to allow quantitative weighing of postoperative complications. From 12 events, the number of cases increased from 11 in 2004 to 27 in 2015 and a total of 27 surgeons. Of 224 cases (164 laparoscopic and 60 robotic), there were 26 (11.6%) complications: 5 grade I, 5 grade II, 3 grade IIIa, 12 grade IIIb and 1 grade V, the latter from laparoscopic cystectomy. Analysis of PMI was 23 times higher from cystectomy compared to RP. In the setting of live surgery, the overall rate of complications is low considering the complexity of surgeries. The PMI is not higher in more complex procedures, whereas RP seems very safe.

Objective To report long-term outcomes of laparoscopic radical cystectomy (LRC) in a multicentre European cohort, and explore feasibility and safety of LRC. Patients and Methods This study was coordinated by European Association of Urology (EAU)-section of Uro-technology (ESUT) with nine centres enrolling 503 patients undergoing LRC for bladder cancer prospectively between 2000 and 2013. Data were retrospectively analysed. Descriptive statistics were used to explore peri- and postoperative characteristics of th ecohort. Kaplan–Meier curves were constructed to evaluate recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). Outcomes were also stratified according to tumour stage, lymph node (LN) involvement and surgical margin status. Results Minor complications (Clavien I–II) occurred in 39% and major (IIIa–IVb) in 17%. In all, 10 (2%) postoperative deaths were recorded. The median (interquartile, IQR) LN retrieval was 14 (9–17) and positive surgical margins were detected in 29 (5.8%) patients. The median (mean, IQR) follow-up was 50 (60, 19–90), during which 134 (27%) recurrences were detected. Actuarial RFS, CSS and OS rates were 66%, 75% and 62% at 5 years and 62%, 55%, 38% at 10 years. Significant differences in RFS, CSS and OS were found according to tumour stage, LN involvement and margin status (log-rank P < 0.001). On multivariate Cox analysis, T stage and LN involvement (both P < 0.001) were significant predictors of RFS, CSS and OS. Positive margins were significant predictors of RFS (P = 0.016) and CSS (P = 0.043). Conclusions In this European LRC multicentre study, the largest to date, long-term RFS, CSS and OS rates after LRC appear comparable to those reported in current open RC series. Further randomised controlled trials are necessary to assess the global impact of LRC.

Introduction and objectives BCG therapy deeply modified prognosis of high-risk non muscle invasive (NMI) urothelial carcinomas. However, these tumors remain potentially lethal. The objective of this study was to compare oncological outcome of radical cystectomy (RC) for BCG failure to primary invasive (PI) tumors. Material and methods RC performed between 2001 and 2011 were retrospectively reviewed. Clinicopathological and follow-up data were compared between RC performed for: NMI high-grade recurrence under BCG therapy (ReNMI); MI recurrence (≥ T2) under BCG therapy (ReMI); primary invasive tumors (PI). The three groups were defined according to tumor status on last TUR before RC. All NMI high-grade bladder tumors at diagnosis had maintenance BCG immunotherapy. Results Two hundred patients were included, 155 PI, 21 ReNMI et 24 ReMI. Median follow up was 42 months (1.74-135.9). Mean BCG instillations number was 8 ± 4.2 versus 9.5 ± 4.3 for ReNMI and ReMI respectively (P=0.24). Upstaging (≥ pT2) occurred in 33% of ReNMI. The rate of pN+ was 24%, 42% and 30% for the ReNMI, ReMI et PI respectively (P=0.39). No differences were observed between the groups for lymphovascular invasion, extracapsular extension if pN+, soft tissue surgical margins and adjuvant chemotherapy. 5-year cancer specific survival (CSS) was 48% for the ReNMI, 18% for the ReMI and 47% for the PI (P=0.02). Progression to muscle invasion under BCG therapy was an independent pejorative prognostic factor for CSS (P=0.05). Conclusion BCG failure led to poor prognosis, particularly when tumors progressed to muscle invasion. Recurrent NMI high-grade tumors seemed to have comparable prognosis than PI tumors because of the high amount of upstaging and nodal invasion. BCG failure is a therapeutic emergency.

Resume Objectif L’apex est une region particuliere de la prostate dans sa dissection chirurgicale et son analyse anatomopathologique. Nous avons voulu etudier la valeur pronostique de la localisation apicale des tumeurs de prostate. Methode De 1988 a 2010, les donnees pre- (âge, stade clinique, taux de PSA preoperatoires, score de Gleason des biopsies) et postoperatoires (poids de la prostate, stade pathologique TNM 2010, score de Gleason, statut des marges) de 2765 prostatectomies totales ont ete collectees prospectivement. Ces donnees ont ete comparees selon l’existence ou l’absence de tumeur a l’apex. L’impact pronostic des tumeurs a l’apex sur la survie sans recidive biologique (PSA > 0,2 ng/mL) a ete etudie dans des modeles uni- et multivaries. Resultats Mille huit cent dix-sept tumeurs avaient une localisation a l’apex (65,7 %). En analyse univariee, il y avait une difference significative pour le stade clinique, le score de Gleason biopsique et pathologique, le resultat du curage, le stade pathologique et le statut des marges entre les tumeurs de l’apex et les autres. Avec un recul median de 23,9 mois, 502 patients ont eu une recidive biologique (18,1 %). La survie sans recidive a dix ans etait de 60,7 % en cas de tumeur a l’apex versus 65,9 % dans les autres cas. La localisation a l’apex etait significativement associee a la recidive biologique en analyse univariee ( p = 0,01). Apres ajustement sur le stade clinique et pathologique, le taux de PSA, le score de Gleason et les marges chirurgicales, l’apex n’etait plus un facteur predictif pejoratif independant ( p = 0,0087). Conclusion L’existence de tumeur a l’apex prostatique etait associee a des criteres tumoraux plus agressifs et etait un facteur predictif pejoratif independant sur la survie sans recidive biologique a dix ans en analyse univariee. La localisation apicale pourrait etre un argument supplementaire dans la decision de traitement adjuvant apres prostatectomie.

Introduction. Radical prostatectomy (RP) can lead to erectile dysfunction due to surgical injury of the cavernous nerves. However, there is no simple, objective test to evaluate cavernous nerve damage caused by RP in clinical practice. Aim. To assess the value of the measurement of penile thermal and vibratory sensory thresholds to reflect cavernous nerve damage caused by RP. Methods. We included 42 consecutive patients who underwent RP with cavernous nerve sparing (laparoscopic approach, N = 12) or without cavernous nerve sparing (laparoscopic, N = 13; retropubic, N = 11; or transperineal, N = 6). Penile thermal (warm and cold) and vibratory sensory thresholds were measured twice, together with the Erectile Dysfunction Symptom Score (EDSS), 1 month before and 2 months after RP. Main Outcome Measures. Penile sensory thresholds for warm, cold, and vibration sensations. Results. Penile sensory thresholds for warm (P < 0.0001) and cold (P < 0.0001) sensations significantly increased after non-nerve-sparing RP, but not after nerve-sparing RP. Vibration threshold only increased after transperineal non-nerve-sparing RP (P = 0.031). EDSS values were significantly increased in all groups of patients 2 months after surgery. Conclusions. Sensory nerve fibers carrying penile skin sensations travel with the cavernous nerves in the pelvis. Therefore, testing these sensations may help to evaluate the extent of cavernous nerve damage caused by RP. In this series, post-operative changes in penile sensory thresholds differed with the surgical technique of RP, as the cavernous nerves were preserved or not. The present results support the value of quantitative penile sensory threshold measurement to indicate RP-induced cavernous nerve injury. Yiou R, De Laet K, Hisano M, Salomon L, Abbou C-C, and Lefaucheur J-P. Neurophysiological testing to assess penile sensory nerve damage after radical prostatectomy. J Sex Med 2012;9:24572466.

Zwar konnte inzwischen die technische Machbarkeit der laparoskopischen radikalen Zystektomie belegt werden und das Verfahren wird in den EAU-Guidelines 2011 („Eurpean Association of Urology“) als Alternative angegeben. Der endgultige Stellenwert ist gegenwartig jedoch noch unklar. Einserseits konnten inzwischen die Vorteile des laparoskopischen Vorgehens fur die Zystektomie (geringerer Blutverlust, niedrigere Transfusionsrate, kurzerer Analgesiebedarf) in retrospektiven Vergleichsstudien belegt werden, andererseits fuhren die technischen Schwierigkeiten bei rein laparoskopisch durchgefuhrter Harnableitung zu langen Operationszeiten und beim laparoskopisch assistierten Vorgehen ist der Nutzens der Laparoskopie zweifelhaft. Hier fehlen auch suffiziente funktionelle Langzeitergebnisse (Strikturrate, Kontinenz, Potenz). Trotz Kasuistiken von Portmetastasen und Peritonealkarzinose nach laparoskopischen oder roboterassistierten Vorgehen unterscheiden sich die onkologischen Langzeitdaten von erfahrenen Zentren (≤10 Jahren) bei vergleichbaren Beobachtungszeitraumen nicht von denen der offenen Zystektomie. Hier fallt auf, dass sich die kurative Chance der Patienten kaum von der eingesetzten operativen Technik (offen vs. minimal-invasiv), sondern von der Effektivitat adjuvanter Therapien (Polychemotherapie) abhangt. Gegenwartig sollte das Verfahren nur bei niedrigem Tumorstadium (pT1–2) mit entsprechend niedrigem Metastasenrisiko eingesetzt werden. Der endgultige Stellenwert der laparoskopischen radikalen Zystektomie kann nur im Rahmen einer prospektiv randomisierten multizentrischen Studie geklart werden.

Objective To describe a standardized and easily reproducible method for fluoroscopy-guided renal access during supine percutaneous nephrolithotomy (sPCNL). Patients and Methods From January 2009 to January 2010, 35 patients underwent sPCNL. In 10 patients, ultrasound-guided puncture was unsuccessful. In these patients, we completed percutaneous access with a method based on fluoroscopy. We used a simple technique, adapted to sPCNL, consisting of cephalad tilting of the C-arm during puncture of the targeted calyx. We prospectively recorded the time necessary for the puncture, the success, and the complication rate of the puncture. Results Among the 10 study patients, the mean operative time for the puncture was 50 seconds (range 35–180). The puncture was successful after 1 attempt in 7 patients and in the remaining patients after a second or a third attempt. There were no complications related to the puncture technique. Conclusions This technique is easy and reproducible for creating a fluoroscopy-guided renal access adjunctive to ultrasound during sPCNL. It may also be useful for urologists not familiar with ultrasound-guided access.

Resume But Evaluer la prise en charge par une infirmiere des injections intra-caverneuses d’alprostadil (IIA) apres prostatectomie radicale (PR). Patients Cent patients consecutifs ont ete formes aux IIA un mois apres PR par une infirmiere (j0). Ils realisaient eux-memes la premiere injection (2,5 μg) puis avaient la consigne d’augmenter les doses a domicile jusqu’a obtenir des erections satisfaisantes. En cas de probleme, ils pouvaient demander a etre contactes par telephone par l’infirmiere. Nous avons evalue a j0, j15 et a six mois : la capacite a realiser l’IIA, la survenue de priapisme, les doses injectees, la reprise de la fonction sexuelle (questionnaires EHS et GAQ) et la douleur a l’erection (EVA). Resultats Quatre-vingt-un pour cent des patients etaient tres satisfaits de la formation. A J15, 93 % des patients reussissaient l’IIA (dose moyenne injectee : 5,2 μg). Aucun priapisme n’a ete note. Le traitement avait ameliore les erections dans 80 % des cas (GAQ) ; 47 % des patients avaient des erections suffisantes pour permettre une penetration (EHS >2) et 39 % avaient des rapports sexuels. La douleur a l’erection (3,9/10 en moyenne) constituait le principal motif de demande de rappel. A six mois, 69 patients poursuivaient le traitement ; la douleur, le score EHS et la dose injectee etaient respectivement de 3,2/10, 2,9/4 et 8,8 μg. Conclusions L’initiation des patients aux IIA par une infirmiere permettait d’obtenir des taux satisfaisants d’accomplissement du geste d’injection et d’adhesion au traitement. Cependant, un suivi rapproche et prolonge etait necessaire en raison des douleurs peniennes post-IIA.

To describe the surgical technique of robot-assisted sacral colpopexy (RASCP) and to assess its feasibility and safety in a high-volume laparoscopic center.12 women with symptomatic urogenital prolapse with or without concomitant urinary stress incontinence were treated with RASCP by one surgeon at our institution. The preoperative workup involved a detailed urologica and gynecologic history and physical examination to determine the type, the degree of the prolapse and the presence of concomitant stress urinary incontinence.Mean operative time was 144 minutes (range 120-180 min). No conversion to a laparoscopic or open procedure was necessary. The mean patient age was 57.1 years old (range 44-79). The mean estimated blood loss was 60 mL (range 20-200 mL). The mean catheterization time was 2 days, and the mean hospital stay was 3.4 days (range 3-4 d). At a mean follow-up of 19.1 months (range 8-28 mos), no recurrence of the prolapse occurred.RASCP for treatment of patients with urogenital prolapse is a feasible alternative to open and laparoscopic procedures. It procures an anatomic repositioning of the pelvic organs. The short-term results and the complication rates are similar with gold standard techniques.

Resume Nous rapportons une observation d’un carcinome medullaire du rein concernant une patiente de 38 ans drepanocytaire heterozygote. La tomodensitometrie a mis en evidence une masse renale de 48 mm × 20 mm, hypovascularisee, siegeant au niveau du pole inferieur du rein gauche, empietant sur le sinus renal. Il existait une coulee ganglionnaire latero-aortique et inter-aorticocave. Une nephrectomie elargie avec curage ganglionnaire lomboaortique a ete realisee. L’examen anatomopathologique de la piece operatoire associe a une analyse immuno-histochimique a permis de conclure a un carcinome medullaire du rein classe T1N2R0 (TNM 2002). Une chimiotherapie a base de gemcitabine-cisplatine a ete instituee. La masse ganglionnaire residuelle a regresse apres six cycles de chimiotherapie. La tomographie par emissions de positons (TEP) a montre que la masse residuelle ne fixait pas le traceur radioactif. L’exerese de la masse ganglionnaire residuelle a revele que les ganglions etaient indemnes de tout processus tumoral. La patiente n’avait aucun signe clinique ou radiologique de progression a huit mois de la nephrectomie. Nous discutons des criteres diagnostiques et analysons les perspectives therapeutiques.

Study Type – Diagnosis (exploratory cohort) Level of Evidence 2b OBJECTIVE To determine the performance characteristics of the prostate cancer gene 3 (PCA3) score on the outcome of biopsy relative to different ranges of free-to-total prostate-specific antigen (PSA) ratio (f/tPSA) in men with a previous negative biopsy and a PSA level of 2.5–10 ng/mL, as urine tests like PCA3 are currently under investigation in order to improve prostate cancer diagnosis and to decrease the rate of unnecessary rebiopsies. PATIENTS AND METHODS Data from the previous prospective European multicentre study were reviewed. Only patients with a PSA level of 2.5–10 ng/mL were included in the present study. In all, 301 patients had complete data. The diagnostic accuracy of the PCA3 score for predicting a positive biopsy outcome was studied using sensitivity, specificity, negative and positive predictive values. The PCA3 performance was evaluated relative to three different subgroups of f/tPSA, as follows: >20% (group 1), 10–20% (group 2) and 30, vs 10.3%, 15.5% and 28.6% when the PCA3 score was 30 was a significant independent predictor of positive biopsies (odds ratio 3.01; 95% confidence interval 1.74–5.23; P < 0.001). CONCLUSIONS PCA3 remained a better predictor of prostate cancer than f/tPSA. In men with a f/tPSA of >10%, the use of the PCA3 score was highly correlated with the risk of having cancer on re-biopsy, and could prevent unnecessary prostate biopsies if the value is low.

Resume Objectif L’incidence du cancer de la prostate est en forte augmentation du fait, d’une part, du vieillissement de la population et, d’autre part, de l’utilisation du taux de PSA. Apres 75 ans, il n’y a pas de regle absolue mais la morbidite competitive augmente et rend le benefice de la chirurgie plus discutable par rapport aux autres alternatives therapeutiques. En realite, la plupart des urologues ne proposent pas la prostatectomie radicale (PR) aux patients de plus de 70 ans. Nous presentons les resultats carcinologiques et fonctionnels de notre serie de patients âges de plus de 75 ans et ayant eu une PR laparoscopique. Methode De 2000 a 2007, 22 patients âges de 75 ans et plus ont ete traites par PR pour un cancer de la prostate localise selon la classification TNM 2002. Les survies, globale, specifique et sans recidive biologique, ont ete analysees selon la methode de Kaplan-Meier. La recidive biologique etait definie par une seule valeur postoperatoire du PSA superieur a 0,2 ng/ml. Une valeur de p Resultats L’âge moyen des patients au moment de la chirurgie etait de 76,5 ans (75–81). Le PSA moyen etait de 10,77 ng/ml (5–30). Le score American Society of Anesthesiologists (ASA) moyen etait de 2 (2–3). Cinq patients (23 %) presentaient une tumeur localement avancee sur l’analyse anatomopathologique. Les marges chirurgicales etaient positives sur trois pieces operatoires (14 %). Avec un suivi moyen de 42 mois, aucun patient n’est decede, cinq ont eu une recidive biologique et sont traites de maniere adjuvante. A 12 mois postoperatoires, 82 % des patients etaient continents (zero protection), 36 % des patients avait une erection permettant un rapport sexuel avec ou sans prise de IPDE-5. Conclusion La PR par voie laparoscopique peut etre proposee chez les patients de plus de 75 ans selectionnes. Les complications postoperatoires semblaient minimes et les resultats fonctionnels et carcinologiques satisfaisants.

La prostatectomia radicale laparoscopica come trattamento del cancro della prostata conosce una nuova rivoluzione con l’apporto tecnologico della robotica. Inizialmente considerata un’impresa e rimasta a lungo unica, questa tecnica conosce da 3 anni una vera espansione. Uno dei vantaggi proposti e il risultato funzionale legato a una dissezione piu fine dei fasci neurovascolari e dell’apice. Questo articolo ha lo scopo di presentare la tecnica chirurgica e di analizzarne i risultati oncologici e funzionali.

Resume Objectif Decrire la pratique de la nephrectomie partielle (NP) en France et evaluer ses resultats en terme de morbidite et de controle carcinologique. Materiel et methode Sept centres universitaires francais dont la chirurgie renale conservatrice representait au minimum 30 % des indications de nephrectomie pour tumeur ont participe a cette etude en incluant de facon la plus exhaustive possible toutes les observations de NP. Pour chaque patient, 70 variables ont ete recueillies, visant a caracteriser la population interessee, l’indication et la technique operatoires, la tumeur, les complications per- et postoperatoires, le suivi carcinologique et de la fonction renale. Resultats Sept cent quarante et une NP, dont 579 pour tumeurs malignes, ont ete analysees. La taille tumorale moyenne etait de 3,4 ± 2,1 cm (0,1–18) et 20,8 % des tumeurs operees mesuraient plus de 4 cm. Il s’agissait dans 30,1 % des cas d’une indication de necessite. Dans 12,2 % des cas la NP etait realisee sous cœlioscopie. La duree operatoire moyenne etait de 152 ± 54,2 minutes (55–420). Les taux de complications medicales et chirurgicales etaient respectivement de 15,2 et 14,7 %. Avec un recul moyen de 38 mois, les taux de recidive locale et de deces specifique etaient respectivement de 3,5 et 4,5 %. Conclusion La NP a connu ces 20 dernieres annees un essor progressif dans la pratique chirurgicale francaise. Les resultats le justifient et doivent conduire l’ensemble de la communaute urologique a la considerer desormais comme le traitement de reference des tumeurs renales de moins de 4 cm.

Resume Objectif Evaluer la morbidite de la nephrectomie partielle (NP) en fonction de la taille tumorale et du type d’indication a travers une etude multicentrique retrospective. Materiels et methodes Sept centres universitaires francais ont participe a l’etude. Les donnees concernant la taille tumorale, l’indication de la NP (elective ou de necessite), l’âge, le sexe, le stade TNM, le type histologique, le grade de Fuhrman, le score ASA et le performance status (ECOG) ont ete analysees. Les complications medicochirurgicales, les pertes sanguines peroperatoires, le taux de transfusion sanguine et la duree d’hospitalisation ont egalement ete etudies. L’analyse statistique des variables qualitatives et quantitatives a ete faite a l’aide du test de χ 2 (test de Fischer) et du test- t de Student. Resultats Six cent quatre-vingt onze patients ont ete inclus. La taille tumorale mediane etait de 3 cm [0,4–18]. Les tumeurs inferieures ou egales a 4 cm et incidentales representaient 77,7 et 80,7 % des cas, respectivement. Les carcinomes a cellules claires representaient 75,1 % des tumeurs malignes. Parmi, 89,1 % de tumeurs etaient T1, 1,6 % N+ et 2,3% M+. Dans les 486 indications electives, la duree operatoire ( p = 0,03), les pertes sanguines moyennes ( p = 0,04), le taux de fistules urinaires ( p = 0,01) etaient significativement augmentes dans les tumeurs superieures a 4 cm. Ces differences ne se traduisaient pas par une augmentation du taux de complications medicales ( p = 0,7) ou chirurgicales ( p = 0,2) ni de la duree d’hospitalisation ( p = 0,4). Conclusion Elargir les indications des NP electives implique une morbidite accrue, mais qui est acceptable. Cette donnee est importante pour l’information des patients et pour choisir la strategie chirurgicale en particulier chez les sujets âges, fragiles ou avec des comorbidites notables.

Aparte de las atrofias parenquimatosas segmentarias, la indicacion de la nefrectomia parcial se establece cada vez con mas frecuencia para tratar los tumores renales aislados de pequeno tamano. En los ultimos anos, esta tecnica se ha adoptado para la exeresis de los tumores menores de 4 cm. Con el fin de disminuir la morbilidad de la intervencion, se ha recomendado la via de acceso laparoscopica. En la ultima decada, la nefrectomia parcial laparoscopica ha alcanzado su madurez y, en la actualidad, esta tecnica ha logrado una estandarizacion adecuada. El conocimiento y el dominio de las vias trans y retroperitoneal son indispensables. La via extraperitoneal se adapta mejor a las lesiones posteriores o del polo inferior. La via preferente en caso de tumor cercano al hilio o anterior es la transperitoneal. Se han desarrollado distintos metodos de pinzamiento y de refrigeracion. La seccion del parenquima se realiza cada vez mas sin emplear energia termica, lo que permite identificar mejor las lesiones. En la actualidad, las vias excretoras, los vasos y la zona de seccion del parenquima se suturan de forma sistematica. Aunque es una tecnica compleja, se ha convertido en reproducible y fiable en los centros especializados en laparoscopia.

The objective of the study was to evaluate the long-term results of retroperitoneal laparoscopic radical prostatectomy (LRP). From 2001 to 2005, 550 consecutive patients underwent a laparoscopic extraperitoneal prostatectomy in our department. Continence and erectile function were analysed prospectively by a self-administrated questionnaire. Mean operating time was 188 min, mean bladder catheterisation time 5.9 days, mean hospital stay 4.6 days Pathological stage was pT2 in 55.8%, pT3a in 29.6%, pT3b in 9.1% and pT4a in 5.4% tumours. Positive surgical margins were 17.9% for pT2, 44.8% for pT3 tumours and 71.4% for pT4a tumours. Five years survival without biochemical progression was 78.8%. After 24 months of follow-up, diurnal continence rate was 91%, and potency rate was 64% when both neurovascular bundles were preserved, 78.6% when the patients were younger than 60 years. LRP is now a standardised procedure. An extraperitoneal approach combines the advantages of a laparoscopic procedure with those of an extraperitoneal approach.

Radical cystectomy remains one of the most invasive surgical procedures in urology, which can be associated with a high rate of complications, even in expert hands. These risks, together with the rapid advances in minimally invasive surgery stimulated the development of laparoscopic radical cystectomy. This is, however an evolving, relatively new procedure and to date, experience is limited to centers with established laparoscopic skills and established programmes. The main merit of the laparoscopic technique lies in the potential to reduce morbidity of the procedure. Although experience with laparoscopic radical cystectomy is limited in all reported series, especially when compared to open radical cystectomy, statistically significant advantages are emerging such as reduced blood loss, return to full diet, analgesic requirement and hospital stay. Long term oncologic data are awaited. So far, only short term results based on margin status and lymph node involvement are available with limited follow-up. These results do not seem to differ significantly from open surgery and there is no evidence that laparoscopic access compromises oncologic safety. Before this innovative technique will be considered as routine or standard, many technical innovations will be necessary to achieve acceptable operative times. Most importantly, long-term oncologic efficacy remains to be proven in large series of patients to establish laparoscopic radical cystectomy as a viable alternative to open radical cystectomy.

Purpose of review Laparoscopic and robotic-assisted prostatectomy have been proposed as alternatives to traditional open retropubic prostatectomy. In this review, we update the more recent data concerning the results, technical trends and controversies regarding these novel, minimally invasive procedures. Recent findings As a result of improved patient selection, a better understanding of surgical anatomy, and refinements in surgical techniques, traditional retropubic prostatectomy set the standards very high, leaving little room for improvement. In this review, the results of laparoscopic prostatectomy are compared with contemporary in addition to historical series. Besides the transperitoneal laparoscopic approach, which was almost exclusively used in the initial series, the introduction and development of the extraperitoneal laparoscopic approach meant a significant change in the surgical strategy of a number of teams worldwide. The relative merits of the transperitoneal and extraperitoneal approaches are discussed. Robotic radical prostatectomy is a promising technical innovation that allows us to overcome many of the inherent limitations of laparoscopic surgery. As a result of financial constraints, the experience has been limited to a few centres worldwide. Summary Although long-term results are still lacking, novel minimally invasive techniques seem to fulfil the highest standards of radical prostatectomy in terms of early oncological cure, functional results and morbidity. A standardization of data collection and evaluation methodology will be indispensable for a better comparison of the different series.

Robotic technology is an expansion of laparoscopic surgery. Robots can be conceived of as specialized laparoscopic tools; their aim is to improve dexterity of the operating surgeon, and therefore they correspond to computer-enhanced telemanipulator devices. For the patient, the advantage of robotic surgery is essentially the advantage of the laparoscopic approach. It gives surgeons tremendous benefits, however, with its intuitive Endowrist and dexterity. From the patient perspective, the biggest difference is between an open operation and one that uses minimally invasive techniques. The contribution of robotics to the evolution of surgery will be obvious if these new systems increase the number of conventionally trained surgeons performing more complex operations using minimally invasive surgical techniques, or if the outcome data from different centers worldwide suggest that the use of advanced technology permits surgeons to have augmented technical performance.

The INK4a/ARF locus encodes 2 cell cycle regulatory proteins: p16 and p14 ARF . P16 inhibits the activities of cdks, which maintain the retinoblastoma protein (pRb) in its active hypophosphorylated state. P14 ARF blocks MDM2-induced p53 degradation and transactivational silencing. In this study, we investigated the expression of p16 and p14 ARF in reference human urothelium and in 51 urothelial carcinomas (UCs) of all stages and grades, by reverse transcription-polymerase chain reaction (RT-PCR). Patterns of p14 ARF and p16 expression were compared with each other and then with patterns of p53 and pRb protein expression, respectively, as determined by immunohistochemistry. P14 ARF and p16 mRNAs were present at low levels or were undetectable in reference urothelia and in most superficial tumors, whereas they were present at high levels in a subset of tumors of advanced stage and high grade. The expression profiles of these 2 mRNAs were correlated in all but 4 cases, indicating that the 2 INK4a products may have nonredundant functions. Forty-six of the 51 tumors (90%) presented changes to or a lack of activation of the p14 ARF -p53 pathway and were p53 positive (n = 10), p14 ARF negative (n = 23), or both p53 positive and p14 ARF negative (n = 13), suggesting that these 2 components of the pathway may be altered or nonactivated. Markedly high levels of p16 mRNA (n = 5) were associated with the absence of pRb expression, with the exception of 1 case in which the p16 gene contained a deletion mutation. A lack of p16 mRNA or low levels of this mRNA were associated with pRb detection in all but 1 case. In invasive UCs, the p16-pRb pathway, the p14 ARF -p53 pathway, or in many cases both pathways were altered or not activated, demonstrating the involvement of these pathways in invasive bladder tumorigenesis.

Objective(s): The aim of our retrospective study was to determine if systematic placement of a posterior mesh, in addition to an anterior vesico-vaginal mesh, is necessary for laparoscopic treatment of pelvic organ prolapse. Methods: A laparoscopic promontory sacral colpopexy was performed in 108 patients, including 55 patients with a concurrent laparoscopic Burch procedure (50.9%). We compared 33 patients treated with a single anterior mesh (SAM) and 71 treated with a double, anterior and posterior, mesh (DM). Results: The difference between the SAM and DM groups was statistically significant in terms of posterior compartment failure (rectocele and/or enterocele): 31.3% and 5.9%, respectively ( p =0.0006). This significant difference persisted in the Burch (B) group ( p =0.001), but not in the non-Burch (NB) group ( p =0.98). Among the SAM group, this difference between the B and NB groups, was significant (57.1% versus 0%; p =0.0015) and above all not a single posterior failure was observed in the NB group. Conclusion(s): The placement of a posterior mesh, if highly effective, appeared unnecessary in the absence of an associated Burch procedure or a patent posterior prolapse. The posterior mesh also increased risk of postoperative complications and side effects.

Introduction: Altered p53 gene product correlates with the stage and grade of bladder tumor, but its value as a predictor of BCG response has been disappointing. In order to revisite the prognostic value of pretreatment p53 nuclear overexpression for the BCG response, we studied a large cohort of consecutive patients with superficial bladder cancer treated with BCG. Methods: From 1988 to 2001, 102 patients with a history of multifocal, recurrent, and/or high-risk papillary transitional cell carcinoma or carcinoma in situ, were treated for the first time with BCG. p53 immunostaining was performed on paraffin-embedded tissues using monoclonal antibody DO7 and an automated immunostainer. Special attention was paid to the conditions of tumor fixation. p53 overexpression was defined as more than 20% tumor cells with p53-stained nuclei. Results: Immunostaining was significantly higher for Ta/T1 G3 ± Cis (p

Laparoscopic radical prostatectomy (LRPE) became the operative procedure of choice for patients with clinically localized prostate cancer in selected urologic centers around the world. Principal advantages are the minimal invasive nature of the procedure, a superior visualization of the operative field because of the magnification of the optical system, an exact and watertight anastomosis, the possibility of early catheter removal, and a potentially reduced amount of blood loss. Recent data show that oncologic outcome is not compromised by the minimal invasive nature of the procedure. However, a major drawback of LRPE is the transperitoneal route of access to the extraperitoneal organ of the prostate. Therefore, principal disadvantages of LRPE are potential intraperitoneal complications. Endoscopic extraperitoneal radical prostatectomy is a further advancement of minimal invasive surgery because it overcomes the limitations of LRPE by the strictly extraperitoneal route of access, combining the advantages of minimal invasive surgery with the advantages of an extraperitoneal procedure. This article reviews the literature on minimally invasive (laparoscopic and endoscopic-extraperitoneal) radical prostatectomy.

Laparoscopic surgery was originally developed by gynecologists and general surgeons. Based on their experience, the first successful laparoscopic procedures in urology were performed transperitoneally. However, this novel technique transformed traditionally retroperitoneal procedures into transperitoneal procedures, giving free rein to distinct intraperitoneal complications. Retroperitoneal laparoscopy was a later development in urology. This approach has gained increasing popularity throughout the years and has challenged the transperitoneal laparoscopic route in many aspects. This review focuses on the advantages of retroperitoneal laparoscopic surgery of the upper urinary tract.

Introduction: The results of radical prostatectomy (cancer control, continence and sexual potency) are currently presented separately, while the success of this surgery depends on a combination of good cancer control with maintenance of continence and erections. We propose a score to jointly evaluate and report cancer control and functional results. Methods: The results of 205 radical prostatectomies were studied at one year. Cancer control was evaluated by PSA. Continence and sexual potency were evaluated by a self-administered questionnaire. Each patient was attributed 0 or 4 points according to the presence of absence of biochemical progression (PSA>0.2 ng/ml), 0 or 2 points according to the presence or absence of urinary incontinence (use of pads) and 0 or 1 point according to the presence or absence of impotence (no erections). The sum of these points provided a score classifying the patient into 8 distinct categories, from 0 to 7, each corresponding to a specific status (from 0 (0+0+0): no cancer control-incontinence-impotence to 7 (4+2+1): cancer control-continence-sexual potency). Results: One year after the operation, 175 (85%) of patients had a PSA less than 0.2 ng/ml, 135 (65.8%) were continent and 64 (32.7%) reported erections. All patients with a score ≥4 had good cancer control, with no functional disorders for a score of 7 (4+2+1) (20%), no disorders of continence for a score of 6 (4+2+0) (31.5%), no disorders of erection for a score of 5 (4+0+1) (8.3%), or with incontinence and impotence for a score of 4 (4+0+0) (21.9%). All patients with a score 0.2 ng/ml, but with no functional disorders for a score of 3 (0+2+1) (2.4%), no incontinence for a score of 2 (0+2+0) (8.3%), and no impotence for a score of 1 (0+0+1) (1.9%). 1.9% of patients were incontinent, impotent and showed signs of biochemical progression (score 0=0+0+0). Conclusion: This score allows analysis of the global (cancer control and functional) results of radical prostatectomy and would facilitate comparisons between various surgical techniques (type of approach, nerve-sparing techniques) and various centres.

We developed and assessed the feasibility of extraperitoneal laparoscopic radical prostatectomy performed using the da Vinci (Intuitive Surgical, Mountain View, California) robotic system.In June 2002, 4 consecutive patients with clinically localized prostate cancer underwent extraperitoneal, robotic assisted laparoscopic radical prostatectomy. After development of the extraperitoneal space the surgeon performed laparoscopic prostatectomy from the remote control unit. The assistant aligned and exchanged robotic instruments and used conventional laparoscopic instruments to facilitate prostatectomy. Perioperative data and pathological results were recorded.No difficulties were noted when developing the extraperitoneal space. All additional steps were successfully performed with telerobotics. More distal placement of the robotic ports appeared to improve the feasibility of the extraperitoneal approach. The peritoneum acted as a natural bowel retractor and the distal port placement facilitated use of the assistant ports. Mean operative time was 274 minutes (range 124 to 360). Mean catheterization time and hospital stay were 2.7 and 5.3 days, respectively. A positive margin was observed in 1 patient and pathological stage was pT2 in 3 and pT3 in 1. No postoperative complications or open conversions were observed.The extraperitoneal approach was feasible with the da Vinci robotic system. Distal port placement for the robot appeared to create an ergonomic environment for the surgeon and assistant and more direct prostatic access. While additional clinical experience is required, the extraperitoneal approach may ultimately provide advantages for robotic and nonrobotic laparoscopic radical prostatectomy.

Purpose: We developed a training model and program aimed at improving the skills of urologists with no previous experience in laparoscopy to perform a running suture urethrovesical anastomosis as is done during laparoscopic radical prostatectomy. Materials and Methods: Our program is performed on a pelvic trainer with a videolaparoscopic unit and consists of passage of a ligature, intracorporal knotting, intracorporal suturing, linear anastomosis and circular running suture anastomosis. The trainees performed the first 3 tasks during the initial lessons and then advanced to the 2 final tasks. At the end of each lesson time was recorded and progression curve was plotted for each participant for each task. The end point of the study was participant ability to perform an accurate circular anastomosis. Logarithmic regression analysis was used to assess the significance of progression. Results: All 10 urologists who participated in this study showed a rapid and significant decrease in the time required to perform the first 3 tasks accurately. The participants were able to perform a linear anastomosis after 3 to 5 lessons and an accurate circular anastomosis after 5 to 10 lessons. Conclusions: By using this model and dividing a complicated surgical step to simplified tasks, we were able to improve trainee performance significantly in a short time. A training program for basic and advanced laparoscopic skills should be incorporated into the syllabus of urologists-intraining and available to those who wish to gain experience in laparoscopic surgery.

To create a scoring system which takes into account oncological outcome and functional results (continence and erectile function) of patients after radical prostatectomy.A total of 146 consecutive men underwent radical prostatectomy for localized prostate cancer and were evaluated 1 year after surgery. Biochemical recurrence was defined as a single postoperative prostate-specific antigen (PSA) level of0.2 ng/ml. Continence, defined as not using a pad, and potency, defined as the ability to achieve and maintain an erection suitable for sexual intercourse, were evaluated by means of a prospective, self-administered questionnaire. Each patient received 4 points (if PSA was0.2 ng/ml) or 0 points (if PSA was0.2 ng/ml) for oncological outcome, 2 points (if continent) or 0 points (if incontinent) for urinary continence and 1 point (if potent) or 0 points (if impotent) for erectile function. The total score was calculated, with higher scores indicating a better outcome. The unique feature of this scoring system is that each individual score represents a particular clinical status regarding oncological and functional outcome.One year after surgery, 121 (82.8%) patients had PSA levels of0.2 ng/ml, 103 (70.5%) were continent and 53 (36.3%) were potent. Patients with a total score ofor =4 points had good cancer control and could be further subdivided into those who were continent and potent (7 points; 22.6%), those who were continent but had erectile dysfunction (ED) (6 points; 34.2%), those who were incontinent and potent (5 points; 8.2%) and those who were incontinent and had ED (4 points; 17.8%). Similarly, patients with a score of4 points had no cancer control and could be further subdivided into those who were continent and potent (3 points; 3.4%), those who were continent but had ED (2 points; 10.3%), those who were incontinent and potent (1 point; 2.1%) and those who were incontinent and had ED (0 points; 1.3%).This scoring system includes the three most important outcomes after radical prostatectomy, namely cancer control, continence and erectile function. It may allow us to better evaluate, communicate and compare the results of radical prostatectomy in a multinational, multicenter setting.

Introduction: The purpose of the present study was to evaluate and compare the risk of progression in organ-confined prostate cancers (stage pT2), according to the location of positive surgical margins. Materials and Methods: Between 1988 and 2001, 538 consecutive men underwent radical prostatectomy for localized prostate cancer. All patients had preoperative physical examinations, serum PSA assays (Hybritech assay, N.l. 0.2 ng/ml. Biochemical progression was studied in patients with organ-confined tumors (stage pT2) according to the location of the single positive margin. Kaplan-Meier analysis was performed to determine the actuarial biochemical recurrence-free likelihood and the log-rank test was used for statistical analysis. Differences were considered significant when the p value was Results: 371 patients had organ-confined tumors, and 60 patients (16.1%) had solitary positive margins (apex 26, bladder neck 14, posterolaterally 20). Eleven patients (18.3%) had biochemical progression. 5-year biochemical free progression was 54.5, 76.9 and 87.9% for apex, bladder and the posterolateral location, respectively (p < 0.05). Conclusions: In the present study, a positve surgical margin at the apex was associated with worse clinical prognosis compared to the bladder neck and posterolateral locations.

We retrospectively evaluated the oncological outcome of radical prostatectomy performed by the retropubic, perineal and laparoscopic approaches.From 1988 to 2000, 401 patients underwent radical prostatectomy for localized prostate cancer by the retropubic, perineal or laparoscopic approach. Age, clinical stage, preoperative PSA and Gleason score of positive biopsies were noted. Operating time, complication rate, transfusion rate, length of hospital stay, catheterization time and pathological results were reviewed. Kaplan-Meier analysis was used to evaluate the likelihood of biochemical recurrence (PSAor =0.2 ng/ml).There were no significant differences between the three groups regarding preoperative characteristics, except for PSA (21.4 ng/ml, 13.2 ng/ml, and 11.6 ng/ml for the retropubic, perineal, and laparoscopic approach, p0.05) and the frequency of stage T1c tumors (31.7%, 47.1% and 63.5%, respectively, p0.05). The operating time was significantly longer in the laparoscopic approach (285 min) compared to the retropubic and perineal techniques (197 min and 178 min, respectively). The retropubic approach was associated with a higher transfusion rate (26.2% versus 15.9% and 2.9% with the perineal and laparoscopic approaches), longer bladder catheterization time (15.9 days versus 11.7 days and 6.8 days, respectively), and longer hospital stay (15.2 days versus 8.5 days and 7.4 days, respectively) (p0.05 for each). With the retropubic, perineal and laparoscopic approaches, medical complication rates were 8.3%, 4.2% and 5.1%, and surgical complication rates were 16.5%, 12.7% and 13.1%, respectively. The rates of pathological stage pT2 tumors were 62.1%, 72.2% and 75.9%, in the retropubic, perineal and laparoscopic groups, respectively. Positive surgical margins in pT2 tumors were noted in 19%, 14% and 22%, respectively. The actuarial 3-year recurrence-free survival rates were not significantly different between the three techniques (75%, 85.2% and 84.1%, respectively; 91.7%, 95.8% and 90.4% among patients with organ-confined tumors).Despite changes in patient selection criteria over time, and the relatively short follow-up, this study showed no significant difference in oncologic outcome between the retropubic, perineal and laparoscopic approaches to radical prostatectomy.

The management of polycystic kidney disease is mostly restricted to conservative measures. However, nephrectomy may be indicated in particular cases, especially when there are infective complications. To decrease the morbidity of the procedure, the laparoscopic approach has become appealing. We present a laparoscopic retroperitoneal approach to complicated polycystic kidney disease in a high-risk patient. CASERESPORT: We performed right retroperitoneal laparoscopic nephrectomy in a 39-year-old man who had autosomal polycystic kidney disease and had undergone heart transplantation. The immunosuppressed patient presented with severe flank pain, generalized signs of infection, and acute renal insufficiency. With the patient in the right lateral decubitus position, the retroperitoneal space was entered by the open technique, and the posterior pararenal space was developed with finger dissection. Five trocars were used. After the renal vessels had been secured and divided, the cysts were successively punctured, gradually shrinking the operative specimen. The kidney was placed in an Endo-catch and removed after morcellation, with no need to enlarge the 2-cm lumbotomy. The operating time was 80 minutes, and the hospital stay was 4 days. Histologic examination revealed a polycystic kidney with Aspergillus infection.The laparoscopic approach is a less-invasive option for removing a polycystic kidney when nephrectomy is indicated. The retroperitoneal route has the advantage of minimizing infection risks because of the absence of peritoneal opening.

Objective To determine whether muscle precursor cells (MPCs) harvested from limb skeletal muscle can enhance the regeneration process of the striated urethral sphincter after injury. Material and methods Striated urethral sphincters of male mice were injured by an injection of a myotoxic substance (notexin). In the experimental group, 2 days after injury, MPCs were enzymatically harvested from striated muscles of the lower limbs and labelled with PKH 26, then immediately re-injected into the injured urethral sphincter of the same animal. In the control group, saline buffer was injected instead of MPCs. Animals were killed 7 days or 1 month after injury and the sphincters removed for histological study (the presence of PKH 26-labelled myofibres, measurement of myofibre diameter and total number of myofibres). Results MPC autografting accelerated sphincter muscle repair, as shown by a higher myofibre diameter (P = 0.03) and number (P = 0.01) in the experimental group than in the controls at 7 days. One month after their injection MPCs were still detectable in the regenerating sphincters and participated in the formation of new myofibres. Conclusion This study provides the experimental basis for a new therapeutic approach to urethral sphincter insufficiency after surgical or obstetrical injury, based on MPC autografting.

Objective To compare the immunological status of normal and peritumoral bladder walls, and to characterize immunocompetent cells before and during intravesical instillations of bacillus Calmette-Guerin (BCG). Patients and methods Twenty-three patients with superficial urothelial bladder carcinoma (stages pTa to pT1, grades 1–3) were treated with six weekly instillations of 150 mg of BCG (Pasteur strain). Biopsies of cystoscopically normal bladder wall were taken before, 3 weeks and 3 months after BCG instillation. The controls comprised bladder biopsy specimens from 13 brain-dead ventilated kidney donors. Local infiltrating cell types, i.e. lymphocyte infiltrates (CD4, CD8, CD20, CD3, interleukin-2-receptor-positive, natural killer, γδ), macrophages and dendritic cells, adhesion and costimulatory molecules (ICAM-1 and B7-BB1) and major histocompatibility complex (MHC) class I and class II antigens were assessed using semi-quantitative immunohistochemical analysis. Results Before BCG the peritumoral bladder wall had fewer macrophages than control bladder wall. BCG treatment restored normal numbers of macrophages and enhanced T helper lymphocytes, B lymphocytes, natural killer cells, activated lymphocytes, dendritic cells, normal MHC class I, adhesion (ICAM-1) and costimulatory (B7-BB1) expression. The enhancement of these immunological variables was transient, with a return to baseline 3 months after BCG instillation. Conclusions These results support the concept that there is a host-immune escape associated with bladder cancer. BCG therapy may temporarily restore impaired tumour rejection mechanisms in the peritumoral bladder wall, suggesting a need for maintenance therapy after the first course of BCG.

Lumboscopy provides an approach to the retroperitoneum for the majority of upper urinary tract operations. The technique involves a knowledge of specific anatomical landmarks that differ from those in classical open surgery, because of the inferior approach to the renal pedicle with the kidney initially mobilized in a ventral and cranial position. An anatomical study was conducted on five cadavers, using images from surgical operations, in order to describe the vascular elements of the retroperitoneal spaces as they are approached during lumboscopy, as well as to define specific anatomical landmarks. Identification of psoas major is crucial as it is then possible to locate the renal pedicle opposite and the area of the great vessels medially. During dissection of the renal pedicle the renal vein and its branches are the first elements to be approached. On the left side the distal portion of the renal vein can be confused with a reno-hemi-azygo-lumbar trunk, due to the initial ventral mobilization of the kidney stretching it. Because of the inferior view of the renal pedicle the reno-hemi-azygo-lumbar trunk can obscure part of the renal artery and may be confused with the renal vein. On the right side initial identification of the inferior vena cava on the medial aspect of psoas major facilitates identification of the gonadal, renal and suprarenal veins all located in the same plane.

Purpose: Although laparoscopic adrenalectomy has become the preferred surgical treatment of benign adrenal masses, for pheochromocytoma it is limited by concerns over hypertensive events related to early access to the adrenal vein. We report our experience with retroperitoneal laparoscopic adrenalectomy for pheochromocytoma.Materials and Methods: From January 1995 to December 1999, 21 retroperitoneal laparoscopic adrenalectomies (left 12 and right 9) were performed for symptomatic pheochromocytoma in 11 men and 9 women 17 to 68 years old (mean age 46). To our knowledge pheochromocytoma was always diagnosed by increased urinary catecholamine, computerized tomography, magnetic resonance imaging and 131iodine iobenguane scintigraphy.Results: There were no conversions to open surgery. The operating time ranged from 100 to 150 minutes (mean 116). Mean blood loss was 140 ml. (minimum 550), and none of the patients required transfusion. Hemorrhage due to adrenal vein injury occurred in 1 patient and was controll...

Objectives. Erectile function is usually assessed by neurophysiologic tests such as the bulbocavernosus reflex or pudendal nerve somatosensory evoked potentials. These tests investigate only large nerve fibers, although erection depends on autonomic nerve fibers, which are of small diameter. Warm and cold sensory fibers have similar calibers as the autonomic nerve fibers, and their integrity can be reliably evaluated by the measurement of thermal sensory thresholds. We studied penile thermal sensory testing in parallel with standard electrophysiologic tests to assess their sensitivity in the diagnosis of penile neuropathy. Methods. Twenty-five normal male subjects without erectile dysfunction or evidence of diffuse neuropathy (group 1) and 35 diabetic patients who complained of impotence (group 2) were studied. Erectile function was quantitated using the erectile dysfunction symptom score. Warm, cold, and vibratory sensory thresholds were assessed on the dorsal aspect of the penis. In addition, penile sympathetic skin responses and pudendal nerve somatosensory evoked potentials were recorded. Results. We found a significant difference between the two groups in the erectile dysfunction symptom score (P

The p15 gene which encodes a cyclin-dependent kinase inhibitor, is located in the 9p21 chromosomal region that is frequently deleted in human bladder transitional cell carcinomas (TCCs). The aim of the present paper is to study the potential involvement of the p15 gene in the evolution of TCCs. p15 mRNA expression was investigated by semi-quantitative RT-PCR in a series of 75 TCCs, 13 bladder cell lines and 6 normal bladder urothelia by semi-quantitative RT-PCR. p15 was expressed in the normal urothelium but p15 mRNA levels were significantly decreased in 66% of the superficial (Ta-T1) TCCs (P = 0.0015). In contrast, in muscle-invasive (T2-T4) TCCs, p15 expression differed widely between samples. p16 mRNA levels were also studied and there was no correlation between p15 and p16 mRNA levels, thus indicating that the two genes were regulated independently. Lower p15 expression in superficial tumours did not reflect a switch from quiescence to proliferative activity as normal proliferative urothelial controls did not present decreased p15 mRNA levels relative to quiescent normal urothelia. We further investigated the mechanisms underlying p15 down regulation. Homozygous deletions of the p15 gene, also involving the contiguous p16 gene, were observed in 42% of the TCCs with decreased p15 expression. No hypermethylation at multiple methylation-sensitive restriction sites in the 5′-CpG island of p15 was encountered in the remaining tumours. Our data suggest that decreased expression of p15 may be an important step in early neoplastic transformation of the urothelium and that a mechanism other than homozygous deletions or hypermethylation, may be involved in p15 down regulation. © 2001 Cancer Research Campaign http://www.bjcancer.com

Purpose: Living–donor nephrectomy is performed via a standard flank approach during open surgery in contrast to laparoscopy where kidneys are procured transperitoneally. Being more

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

Objectives: In an effort to reduce the morbidity associated to radical prostatectomy, we implemented laparoscopic surgery to this advanced ablative and reconstructive procedure. In

Vesicourethral reconstruction is the most critical and time-consuming step of laparoscopic radical prostatectomy. We describe the use of two hemicircumferential running sutures that has significantly simplified the procedure in our last 30 patients. The vesicourethral reconstruction took 31 minutes on average. Six months postoperatively, 84% of the patients were fully continent, and no bladder neck stenosis had occurred. The economy of intracorporeal suturing provided by this novel method, together with geometric factors such as the optimal position of the trocars, contributes to the improvement of ergonomy, allowing the surgeon to decrease operating times.

Purpose: To determine the occurrence of penile small nerve fiber damage following transurethral resection of the prostate (TURP) for benign prostatic hypertrophy (BPH).Materials and Methods: Penile nerve function was evaluated in 18 consecutive patients prior to and one month after TURP for BPH. To test nerve fibers of small diameter, the penile warm and cold sensory thresholds were measured by means of a Peltier-based device, as well as the penile sympathetic skin potentials obtained following electrical stimulation at the wrist. To test nerve fibers of large diameter, the pudendal nerve somatosensory evoked potentials (pSEPs) and the penile vibratory thresholds were recorded. Clinical erectile function was quantified using a standardized questionnaire (erectile dysfunction symptom score, EDSS). Urinary handicap was assessed by the measurement of maximum flow rate (MFR) at uroflowmetry and by a standardized questionnaire (AUA symptom score, AUASS).Results: Penile warm threshold (+7.8 vs +6.3C, p = 0.005)...

Objectives. To assess the feasibility and results of retroperitoneal laparoscopic pyeloplasty in the treatment of ureteropelvic junction obstruction. Methods. From September 1996 to January 1999, 15 patients underwent extraperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction. Aberrant vessels were noted in 4 patients. Dismembered pyeloplasty was performed in 7 patients and nondismembered Fenger plasty in 7 patients. Pyeloplasty was not possible in 1 patient. Results. Fourteen of the 15 procedures were successfully completed. The procedure was not possible in 1 patient who had already undergone endopyelotomy repair. The mean operating time was 178 minutes (range 100 to 250), and the mean postoperative hospital stay was 4.8 days (range 1 to 14). Postoperative complications occurred in 3 patients (two hematomas and one urinoma). Radiographic assessment by intravenous urography 3 months after the procedure showed good results. Conclusions. Retroperitoneoscopy, by providing easy and rapid access to the retroperitoneal space, seems to be a valuable alternative treatment for ureteropelvic junction obstruction.

To evaluate our preliminary experience with laparoscopic radical prostatectomy. The indications for laparoscopy are currently being extended to complex oncologic procedures.Forty-three men underwent laparoscopic radical prostatectomy. We used five trocars. The surgical technique replicates the steps of traditional retropubic prostatectomy, except that the rectoprostatic cleavage plane is developed transperitoneally at the beginning of the procedure. In the first 10 patients, we performed the vesicourethral reconstruction with interrupted sutures; in the remaining 33 patients, we performed it with two hemicircumferential running sutures. The specimen was removed through the umbilical port site.Once the developmental phase with the first 10 patients was concluded, the median operating time was 4.3 hours without pelvic lymphadenectomy, and the median postoperative bladder catheterization was 4 days. Two (4.7%) of 43 patients underwent transfusion. Twelve patients (27.9%) had positive surgical margins; all patients had a postoperative prostate-specific antigen level of less than 0.1 ng/mL at 1 month. Rectal injury occurred in 1 patient, requiring colostomy, and 4 patients had urethrovesical anastomotic leakages requiring surgical repair. One month postoperatively, 36 patients (84%) were fully continent (no leakage). Six patients had had erections, and four stated they had had sexual intercourse.Laparoscopic radical prostatectomy has evolved to a fully standardized and reproducible procedure. The short-term oncologic and functional efficacy rates are equivalent to those for open surgery. The operating time is reasonable once the learning curve is over, and postoperative morbidity is diminished. Because of the improved visual accuracy, permitting more precise dissection, this technique has the potential to become an important advancement in urologic surgery.

Resume Le carcinome lymphoepithelial-like de la vessie est une tumeur rare qui tire son appellation de la ressemblance sur le plan histologique avec le carcinome lymphoepithelial du nasopharynx. Sa pathogenie n’est pas encore elucidee et le traitement conservateur occupe une place de choix dans le traitement des formes pures. Les auteurs rapportent un nouveau cas et discutent des aspects pathogeniques, des facteurs pronostiques et des aspects therapeutiques.