[Urological surgery : what's new in 2023]

Urology continues its development in minimally invasive surgery, and the year 2023 is marked by important innovations in the different approaches such as endoscopy, laparoscopy, and open surgery. The following innovations are instruments or medical devices which are still being evaluated. What they have in common is a questioning of our current practices, on the technical side but also for some of them on the ecological vision of our profession with the eternal debate of single use or reusable. Even if the evaluation of new devices is primarily medical and medico-economic, it is actually no longer possible to ignore the ecological aspect and the impact on the environment of the various new products. New technologies also make it possible to think about smart connected prostheses and precision intraoperative imaging that can ultimately guide the surgeon's hand.

Management of high-grade papillary Ta or T1 bladder cancer after restaging transurethral resection: A retrospective study comparing Bacillus Calmette-Guerin therapy upfront versus a third resection

PURPOSE

Performing restaging transurethral bladder resection (reTURB) for high-risk non-muscle invasive bladder cancer (NMIBC) reduces the risk of recurrence and tumour understaging. Management of residual high-grade papillary Ta or T1 after reTURB has changed this last 10years in international recommendations. This study aimed to compare the recurrence free survival according to the different management procedures performed.

MATERIALS AND METHODS

Patients who underwent reTURB for initial high-risk NMIBC between 2011 and 2020 were included. Patients with residual high-grade papillary Ta or T1 tumour after reTURB were divided into two groups: BCG instillations upfront versus BCG following a third-look resection (3TURB). Patient and tumour characteristics, BCG instillations, recurrence-free survival were retrospectively analysed.

RESULTS

A total of 162 high-risk patients were included. Sixty-one (37.7%) had residual high-grade papillary Ta or T1 at reTURB: 35 (21.6%) had BCG instillations upfront, 18 (11.2%) had a 3TURB and 8 (5%) had other management. The mean follow-up was 34.2weeks±20.2. Recurrence-free survival was significantly better in patients who underwent BCG instillations upfront (P<0.0043). Recurrence after BCG therapy following reTURB was significantly lower in patients with no residual NMIBC at 6 (92.5% vs. 72.4%, P<0.004) and 12months (85% vs. 67.3%, P<0.03).

CONCLUSIONS

The efficacy of intravesical BCG is compromised in case of residual tumour following TURB. The role of a 3TURB following a positive reTURB is not yet determined. This study has confirmed that residual tumor following reTURB is a negative predictive factor but could not demonstrate the value of a 3TURB compared to upfront BCG.

LEVEL OF EVIDENCE: 3

Late complications and 5 years outcomes of robotic partial nephrectomy in France: prospective assessment in the French Kidney Cancer Research Network (UroCCR 10)

PURPOSE

To describe the practice of robotic-assisted partial nephrectomy (RAPN) in France and prospectively assess the late complications and long-term outcomes.

METHODS

Prospective, multicenter (n = 16), observational study including all patients diagnosed with a renal tumor who underwent RAPN. Preoperative, intraoperative, postoperative, and follow-up data were collected and stored in the French research network for kidney cancer database (UroCCR). Patients were included over a period of 12 months, then followed for 5 years.

RESULTS

In total, 466 patients were included, representing 472 RAPN. The mean tumor size was 3.4 ± 1.7 cm, most of moderate complexity (median PADUA and RENAL scores of 8 [7-10] and 7 [5-9]). Indication for nephron-sparing surgery was relative in 7.1% of cases and imperative in 11.8%. Intraoperative complications occurred in 6.8% of patients and 4.2% of RAPN had to be converted to open surgery. Severe postoperative complications were experienced in 2.3% of patients and late complications in 48 patients (10.3%), mostly within the first 3 months and mainly comprising vascular, infectious, or parietal complications. At 5 years, 29 patients (6.2%) had chronic kidney disease upstaging, 21 (4.5%) were diagnosed with local recurrence, eight (1.7%) with contralateral recurrence, 25 (5.4%) with metastatic progression, and 10 (2.1%) died of the disease.

CONCLUSION

Our results reflect the contemporary practice of French expert centers and is, to our knowledge, the first to provide prospective data on late complications associated with RAPN. We have shown that RAPN provides good functional and oncologic outcomes while limiting short- and long-term morbidity.

TRIAL REGISTRATION

NCT03292549.

Pathological reporting of cystectomy lymph nodes: a retrospective analysis of experience in Paris

Purpose

Pathological evaluation of pelvic lymph node (LN) dissection (PLND) is important for management of cystectomy patients. However, challenges such as unclear interobserver variability of LN counting remain. Here, we assess interobserver variability of LN measures and their clinical utility, with a focus on variant histology.

Methods

We retrieved radical cystectomy cases with PLND between 2010 and 2016 and reevaluated pathological parameters; number of total and metastatic LN, LN density (LND), length of metastatic LN and metastases, extranodal extension (ENE).

Results

We report 96 patients: median age of 71a, 34 cases pN+, 36 cases with any extent of variant histology, median follow-up 10 months. Perivesical LN were only rarely identified, but frequently metastatic (4/9). Variant histology (34 cases) frequently exhibited LN metastasis (53% of pN+ cases). Interobserver variance was poor for total LN (kappa = 0.167), excellent for positive LN (0.85) and pN staging (0.96), and mediocre for LND (0.53). ROC analysis suggests that both LND and the sum of LN metastasis length may predict outcome (AUC 0.83 and 0.75, respectively).

Conclusion

Our study confirms the notion of LND as a prognostic measure, but cautions due to strong interobserver variance of LN counts. The sum length of LN metastases could be a measure that is independent of LN counts. We find that microscopically identified perivesical LN merit particular attention. In summary, our study highlights current challenges in pathological reporting of PLND, confirms previous observations and forms a basis for further studies.

Renal Oncocytoma: An Algorithm for Diagnosis and Management

Renal oncocytoma is an uncommon tumor that exhibits numerous features which are characteristic but not necessarily unique. Percutaneous biopsy is a safe method of diagnosis. However, differentiation from other tumor subtypes often requires sophisticated analysis and is not universally feasible. This is why, surgical management can be considered as a first-line treatment or after surveillance. Potential triggers for change in management are: tumor size >3 cm, stage progression, kinetics of size progression (>5 mm/y), and clinical change in patient or tumor factors. Long-term follow-up data are lacking and greater centralization should be considered to reach adequate management.

Comparison of Short-Term Functional, Oncological, and Perioperative Outcomes Between Laparoscopic and Robotic Partial Nephrectomy Beyond the Learning Curve

PURPOSE

To compare the short-term outcomes of robot-assisted partial nephrectomy (RPN) and laparoscopic partial nephrectomy (LPN) when performed by highly experienced surgeons.

METHODS

A prospective multicenter study was conducted, including the 50 last patients having undergone LPN and RPN for T1-T2 renal tumors in two institutions between 2013 and 2016, performed by two different surgeons with an experience of over 200 procedures each in LPN and RPN, respectively, at the beginning of the study. Perioperative parameters and functional and oncological outcomes were collected and compared between the LPN and RPN groups.

RESULTS

The laparoscopic approach was associated with a longer warm ischemia time (15.7 versus 23 minutes; P < .001) and hospital stay (3.6 versus 4.6 days; P = .01). Conversely, estimated blood loss was significantly higher in the RPN group (381 mL versus 215 mL; P < .001), but transfusion rates were similar between the two groups (8% versus 6%; P = .33). In the RPN group, three patients (6%) required conversion to open partial nephrectomy and three patients (6%) required a conversion to radical nephrectomy (RN), while no conversion was needed in the LPN group. There were no differences in terms of perioperative complications, and change in renal function was comparable in the two groups postoperatively. Positive surgical margin rates were similar in the RPN and LPN groups (2% versus 6%; P = .36). After a median follow-up of 19 and 14 months in the RPN and LPN groups, respectively (P = .38), recurrence-free survivals did not differ significantly (P = .94).

CONCLUSION

In this series, perioperative and short-term oncological and functional outcomes appeared broadly comparable between RPN and LPN when performed by highly experienced surgeons.

[Non-palpable testicular tumors in adults: A management based on imaging? Issue from the French Urologic Association Genital Cancer committee's edit]

BACKGROUND

Help in management of non-palpable testicular tumors. French Urologic Association Genital cancer committee's Edit.

OBJECTIVES

To review their characterization at imaging findings of non-palpable testicular tumors.

DOCUMENTARY SOURCES

Literature review (PubMed, Medline) of urological and radiological studies dealing with testicular tumors using keywords: non-palpable/incidental testicular tumors; color Doppler ultrasound; US elastography; magnetic resonance imaging; contrast enhanced sonography; partial surgery.

RESULTS

Color Doppler is the basic exam. The size, the presence of microlithts/microlithiasis/macrocalcifications, the vascular architecture are major semiological findings to suggest the benign or the malignant nature of the lesion. Other techniques like multiparametric MRI, contrast-enhanced sonography, sonographic elastography are still in evaluation. The frequency of benign tumors such as Leydig cell tumors lead to preservation management, through improved characterization, monitoring or tumorectomy.

LIMITS

Non-randomized study - a very few prospective studies.

CONCLUSION

The era of total orchiectomy for any uncertain testicular lesion is over. We try the challenge of characterization, and define management's algorithms based on the suspected nature of the tumors.

Efflux pump ABCB1 single nucleotide polymorphisms and dose reductions in patients with metastatic renal cell carcinoma treated with sunitinib

There is growing evidence that sunitinib plasma levels have an impact on treatment outcome in patients with metastatic renal cell carcinoma (mRCC). We studied the impact of single nucleotide polymorphisms (SNPs) in genes involved in sunitinib pharmacokinetics, and additionally, sunitinib pharmacodynamics on dose reductions of the tyrosine kinase inhibitor.

METHODS

We retrospectively analyzed germ-line DNA retrieved from mRCC patients receiving sunitinib as first-line therapy. We genotyped 11 key SNPs, respectively, in ABCB1, NR1/2, NR1/3 and CYP3A5, involved in sunitinib pharmacokinetics as well as VEGFR1 and VEGFR3, which have been suggested as regulators of sunitinib pharmacodynamics. Association between these SNPs and time-to-dose-reduction (TTDR) was studied by Cox regression.

RESULTS

We identified 96 patients who were treated with sunitinib and from whom germ-line DNA and data on dose reductions were available. We observed an increased TTDR in patients carrying the TT-genotype in ABCB1 rs1125803 compared to patients with CC- or CT-genotypes (19 vs. 7 cycles; p = 0.031 on univariate analysis and p = 0.012 on multivariate analysis) and an increased TTDR in patients carrying the TT/TA-variant in ABCB1 rs2032582 compared to patients with the GG- or GT/GA-variant (19 vs. 7 cycles; p = 0.046 on univariate analysis and p = 0.024 on multivariate analysis).

CONCLUSION

mRCC patients carrying the rs1128503 TT-variant or the TT/TA-variant in rs2032582 in ABCB1, which encodes for an efflux pump, do require less dose reductions due to adverse events compared to patients with the wild type or heterozygote variants in these genes.

[Management of testicular teratoma: update by the Oncology Committee of the French Urology Association, section of External Genital Organs (CCAFU-OGE)]

INTRODUCTION

The objective of this article was to focus on the pathological, clinical and therapeutic aspects of the different forms of testicular teratoma in adults.

MATERIAL AND METHODS

The multidisciplinary working group has conducted a literature search on Pubmed with keywords: adult teratoma; malignant transformation; growing teratoma; chemotherapy; surgery with focus on the different forms of adult testicular teratoma.

RESULTS

Teratomas of the adults are malignant and subdivided into localized and metastatic forms that may be distinguished under exclusive teratoma form, growing teratoma or teratoma with malignant transformation. The management is based on an enlarged surgical excision (testis and metastasis) with, in metastatic forms, a chemotherapy adjusted with histology. Extended follow-up beyond 10 years is necessary because of the risk of late relapse.

CONCLUSIONS

Testicular teratoma is a rare tumor, which is considered malignant with a potential of metastasis. The treatment is based mainly on surgical management.

Secondary chemoprevention using short period (3 months) of LHRHa as an option for men with low-risk localized prostate cancer (LRPC) before active surveillance (AS)

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Background: Definition of LRPC and candidates for AS remains problematic. Relevant markers that reflect tumor aggressiveness are still to be determined. When AS is used it can be difficult to assess disease progression despite surveillance with PSA and repeat biopsies. Moreover, 20-50% of patients on AS were over the windows of curability when radical treatment was triggered. The current knowledge of PC suggests that aggressiveness should be assessed not only in terms of clinical features but also in terms of response to Androgen Deprivation Therapy (ADT). Methods: 83 men with LRPC (T1c or T2a PC; PSA ≤10ng/ml; Gleason score ≤6) whom have chosen prostate cancer management without radical therapy were included. They then underwent AS after receiving one injection of ELIGARD-22.5. AS consisted of PSA every 3 months (mo) and biopsies (≥12 cores) every 12mo. Patients were stratified at diagnosis according to age at diagnosis, PSA, PSA density, PSA nadir, bio-testosterone, dynamic MRI staging, % positive cores and length of tumor on the diagnosis biopsy. Predictive factors of recurrent PC observed on biopsy were tested using a Cox regression and Markov models. Results: Mean age at diagnosis of LRPC was 64 years, (standard deviation, 6.2 years). Median time to follow-up after diagnosis biopsy was 31mo. Surveillance biopsies were positive for 37 men (44%) (7 with Gleason score>6). In the subgroup of insignificant PC according EPSTEIN criteria surveillance biopsies were positives for 17/48 men (35%) (2 with Gleason score>6). Expected results from literature on classical AS were 60-70% of positive biopsy and 10-21% of upgraded biopsy at the first repeat biopsy. Predictive factors of prostate cancer observed on biopsy were: PSA nadir at 3mo <0,1ng/ml (OR=1.8; 95%CI 1.0 to 3.3 p=0.04), positive core biopsy>1(OR=1.7; 95%CI 1.0 to 2.9; p=0,03), and >T1c detectable tumor on MRI (OR=2.9; 95%CI 1.4 to 5.9; p=0.003). Conclusions: Results obtained with 3mo of LHRHa for LRPC suggest that ADT response can be used firstly to reduce prevalence of primary PC lesions and secondly in order to identify PC able to castration resistance and consequently which require radical treatment.

Diagnostic, staging, and grading of urothelial carcinomas from urine: performance of BCA-1, a mini-array comparative genomic hybridisation-based test

BACKGROUND

Cytogenetic abnormalities occur at an early stage of bladder urothelial carcinomas (BUC), and their frequency increases as the cancer becomes more advanced.

OBJECTIVE

To assess the diagnostic performance of a test based on cytogenetic abnormalities to diagnose, stage, and grade BUC from the urine.

DESIGN, SETTING, AND PARTICIPANTS

We used a 341 bacterial artificial chromosome (BAC) comparative genomic hybridisation (CGH)-array chip (BCA-1) designed to include loci affected in BUC. The chip was first used on 32 frozen BUC biopsies to design staging (BN0) and grading (BN1 and BN2) prediction models based on Bayesian networks analysis. The models were then validated on external data obtained from 98 tumour samples using a 2464 BAC CGH-array chip. The performance of the test was finally assessed on 44 urine pellets collected, including 22 patients who had BUC and 22 controls.

MEASUREMENTS

We measured sensitivity and specificity to diagnose BUC stage and grade from urine pellets.

RESULTS AND LIMITATIONS

In the urine, BCA-1 test sensitivity was 95%, specificity was 86%, and accuracy was 91%. The BN0 staging model identified T1-4 tumours in the urine with a sensitivity of 90%, a specificity of 83%, and an accuracy of 87%. The BN1 and BN2 grading models detected high-grade disease with a sensitivity, specificity, and accuracy of 86%, 88%, and 87%, respectively, using BN1 and 100%, 63%, and 82%, respectively, using BN2. BN models performed with similar sensitivity but reduced specificity using the external data. BCA-1 failed to produce results for eight additional samples (failure rate: 9%). The test needed high quantities and quality of DNA, and external validation in larger, prospective, and better-designed studies is necessary to confirm feasibility and performance.

CONCLUSIONS

The BCA-1 mini-CGH-array chip detected BUC in urine with a high diagnostic performance. It could also accurately discriminate low-grade from high-grade tumours and, to a lesser extent, lamina propria-invasive tumours from pTa tumours.

[Urethral cancer: report of three cases and review of the literature]

OBJECTIVE

To review the various clinical forms of female urethral cancer in the light of three clinical cases with a review of the corresponding treatment guidelines.

METHOD

The authors report three cases of female urethral cancer. Case 1 consisted of squamous cell carcinoma in a 56-year-old woman with no particular history. Case 2 was a urothelial tumour arising in a urethral diverticulum in a 60-year-old smoker. Case 3 was a 69-year-old woman patient with invasive urothelial carcinoma.

RESULTS

Case 1 was treated by segmental urethrectomy with no adjuvant therapy and a favourable course. Case 2 was treated by anterior pelvic exenteration with no adjuvant therapy. This patient relapsed in the form of peritoneal carcinomatosis two years later and died. Case 3 was initially treated by anterior pelvic exenteration followed by a chemoradiotherapy combination after local recurrence with a favourable course.

CONCLUSION

There are many clinical presentations and histological forms of female urethral cancer. Localized distal lesions can be treated by simple circumferential resection. The treatment of other lesions comprises anterior pelvic exenteration and platinum- or M-VAC-based chemoradiotherapy. The main prognostic factors for these tumours are their size, histological type, site and the presence of pelvic lymph node extension.

[Bladder perforation during transurethral resection of bladder tumour: a review]

Transurethral resection of bladder tumour is a common procedure (10,711 new cases of bladder tumour diagnosed in France in 2000), associated with a certain morbidity. Intra- or extraperitoneal perforation of the bladder wall is a possible complication. The diagnosis is generally established intraoperatively and cystography can be performed in the operating room to demonstrate the diameter of the perforation. Most cases of extraperitoneal perforation can be treated conservatively by simple bladder drainage. Intraperitoneal perforations may require surgical repair Laparoscopy is currently tending to replace open surgery for this repair. One of the risks of perforation is also tumour seeding outside of the bladder However metastases related to perforation appear to be rare and occur rapidly requiring close surveillance.

Improvement of urethral sphincter deficiency in female rats following autologous skeletal muscle myoblasts grafting

Sphincteric deficiency is the most common cause of urinary incontinence in humans. Various treatments have lead to disappointing results due to a temporary benefit. Recent studies raised the possibility that sphincteric deficiency could be treated by implanting skeletal myoblasts. In the present study, we developed in the female rat a model of chronic sphincteric defect to assess the benefit of myoblast injection. Sphincter deficiency was induced by freezing, longitudinal sphincterotomy, and notexin injection, respectively, to obtain a reproducible and irreversible incontinence. Autologous tibialis anteriors were cultured to be injected in the best model. Functional results were evaluated by measuring the urethral pressure with an open catheter. Histology was performed in the excised urethras. Of the three techniques, only longitudinal sphincterotomy caused definitive incontinence by irreversibly destroying the striated sphincter muscle fibers: a 45% decrease of the closure pressure was observed 21 days after the sphincterotomy. At this time, we injected myoblasts at the sphincterotomy site. In the sham-injected group (n = 18), the closure pressure decrease was not significantly modified 21 days after injection. By comparison, a return to near normal value was observed after cell grafting (n = 21). These results and those obtained by others strongly suggest that the use of myoblasts could be a potential innovative therapy for urethral deficiencies leading to incontinence.

[Medium-term results of grade 3 and 4 cystocele repair by porcine xenograft matrix (pelvicol)]

OBJECTIVE

To evaluate the medium-term results of grade 3 and 4 (Baden-Walker classification) cystocele repair by transvaginal porcine xenograft matrix (Pelvicol).

MATERIALS

Between February 2002 and October 2005, fifty patients with grade 3 or 4 cystocele were treated by Pelvicol matrix. The preoperative grade of prolapse and symptoms (urinary and pelvic heaviness) were recorded and a sexuality questionnaire was completed retrospectively (BISF-W questionnaire). All patients were reviewed in the outpatients department at 1 month and at the date of last follow-up. The success of the surgical procedure was defined by postoperative grades 0 and 1. Preoperative and postoperative symptoms and sexuality were compared. The operative morbidity was recorded. The success of the surgical procedure was compared in patients operated for the first time and in redo patients.

RESULTS

The mean age was 69.4 years; 29 patients had a grade 3 cystocele (58%), and 21 had a grade 4 cystocele (42%). Preoperative symptoms consisted of dysuria (32%) and symptoms of overactive bladder (22%), accompanied by symptomatic (36%) or asymptomatic (20%) stress urinary incontinence. Pelvic heaviness was present in 100% of cases. An associated procedure was necessary in 70% of cases (29 suburethral tapes, 6 rectocele repairs, 3 vaginal hysterectomies). Mean follow-up was 27.2 months (95%CI [23.3-31.1]). No intraoperative or postoperative complications were observed. During follow-up, no cases of rejection of material, vaginal erosion or delayed healing were observed. The surgical success rate was 94% (37 grade 0 and 10 grade 1). Dysuria and pelvic heaviness were significantly improved. None of the 10 women who were sexually active preoperatively reported postoperative discomfort. Among the 50 operated patients, 35 (70%) were treated by Pelvicol as first-line procedure and 15 were redo procedures (30%); no significant difference in surgical success rate was observed between these two groups (94.3% versus 93.4%).

CONCLUSION

The use of a porcine xenograft matrix (Pelvicol) appears to be a safe and effective technique in the medium term for first-line treatment of grade 3 and 4 cystocele.

[Infertility and testicular seminoma]

INTRODUCTION

Infertility in men may be associated with an elevated risk of testicular cancer. The authors report a case of testicular seminoma discovered fortuitously during a workup for infertility.

CASE

A 30 year-old male was seen for infertility. Physical examination and testicular ultrasonography were normal. The sperm count found oligoasthenospermia related to the excretory ducts. The patient underwent testicular biopsies for infertility, which showed an intratubular germ cell tumor. Tumor markers (beta HCG, alpha FP, LDH) were normal. Computed tomography was normal for the thorax, abdomen, and pelvis. We performed an inguinal orchiectomy. The pathology examination found seminoma, at a pT1 stage. One course of chemotherapy followed.

DISCUSSION

The incidence of testicular cancer is increasing throughout the world. Recent studies show a strong relation between infertility and an increased risk of testicular cancer, and some authors even suggest a causal relation.

Risk factors for early epithelial to mesenchymal transition in renal grafts

Epithelial-to-mesenchymal transition (EMT) of tubular epithelial cells (TECs) may participate in the pathogenesis of renal fibrosis. We performed a prospective study of EMT markers in protocol biopsies obtained 3 months after engraftment from 56 patients who received deceased donor kidneys and who had stable renal function. The presence of EMT was examined, and quantified by immunohistochemical staining for vimentin and translocation of beta-catenin to the cytoplasm. EMT status was defined as the presence of EMT markers in > or = 10% of TECs. EMT features were virtually absent in implantation biopsies, whereas 41% of the grafts were EMT-positive in the absence of advanced chronic allograft nephropathy. Thirteen patients (23%) had borderline changes or acute rejection. EMT features were more frequent in these patients than in those with normal kidney grafts (vimentin expression, p = 0.003; beta-catenin translocation, p = 0.002). EMT in grafts corresponded with elevated serum creatinine of the donor before the recovery of kidney (p = 0.02) and longer cold ischemia time (p = 0.02). In contrast, the donor age had no influence on the expression of EMT markers. These results suggest that EMT is an early and frequent phenomenon in kidney transplants that could be triggered by immunological and/or ischemic tubular injury.

Fate of implanted syngenic muscle precursor cells in striated urethral sphincter of female rats: perspectives for treatment of urinary incontinence

OBJECTIVES

To analyze the outcome of syngenic skeletal muscle precursor cells (MPCs) after implantation in the striated urethral sphincter of the female rat.

METHODS

MPCs were isolated from the striated muscles of the lower limbs and infected with a retrovirus carrying the gene for green fluorescent protein. Approximatively 10(5) cells were injected longitudinally in the striated urethral sphincter of 24 animals using a 10-muL Hamilton syringe. The whole urethra was excised at 0, 1, 7, 10, 14, 30, and 90 days after implantation for histologic study and fluorescence analysis of the transections.

RESULTS

At days 0 and 1, some small, round, fluorescent MPCs were observed at the injection site. At day 7, significant MPC persistence was noted, with infiltration of inflammatory cells in the whole urethral wall (striated muscle layer, smooth muscle layer, and connective tissue). At day 10, some fusiform cells appeared in the striated muscle layer, suggesting the incorporation of MPCs into the striated myofibers. Inflammatory cells were no longer visible. At day 14, the fusiform cells tended to be larger. The small, round cells were no longer seen. At days 30 and 90, all myofibers of the striated muscle layer were strongly fluorescent, and no fluorescence was detectable in the smooth muscle layer.

CONCLUSIONS

Implantation of skeletal MPCs in the urethral sphincter resulted in selective incorporation into striated myofibers. Muscle-derived cell autografting could represent a new approach for the treatment of urinary incontinence in humans.

[Comparative study of two latest generation flexible ureterorenoscopes]

INTRODUCTION AND OBJECTIVES

Miniaturization and development of flexible instruments have led to the development of flexible ureterorenoscopy. The objective of this study was to compare the capacities of active deflection of two latest generation flexible ureterorenoscopes and to evaluate alteration of deflection and flow of irrigating fluid in the presence of instruments in the operating channel.

MATERIAL AND METHODS

Two ureterorenoscopes were evaluated in this study. The Karl STORZ Flex-X and the ACMI DUR-8 Elite. Comparison of deflection movements was performed ex situ by super-imposing all active movements of the two ureterorenoscopes. Alteration of deflection was performed by alternately placing an extraction or fragmentation instrument of variable dimensions in the operating channel. Alteration of flow was also assessed in the presence of the same instruments.

RESULTS

The ex situ deflection capacities of the DUR-8 Elite flexible ureterorenoscope were more extensive than those of the Flex-X, but it was more complicated to manipulate. Alterations of deflection and flow of irrigation fluid were comparable for the two ureterorenoscopes.

CONCLUSION

On the basis of these data, we can confirm that the two latest generation ureterorenoscopes present comparable capacities, but different functioning modalities. We therefore recommend that each operator test the two ureterorenoscopes to become familiar with their manipulation. Other studies are necessary to evaluate the optical properties, ease of use in clinical practice and fragility of these new ureterorenoscopes.

[Value of infrared spectrophotometry morpho-constitutional analysis of double J stent encrustations for indirect determination of urinary stone composition]

INTRODUCTION

A single stone analysis is necessary during the patient's clinical history in order to institute specific drug treatment and health and dietary measures to prevent stone recurrence. In practice, only one in every two stones is recovered for morpho-constitutional analysis. The objective of this study was to determine the place of double J stent encrustation analysis for indirect determination of stone composition.

MATERIAL AND METHODS

Double J stents and stones from all patients treated in the same centre over 24 months were consecutively analysed by infrared spectrophotometry. The correlation coefficient 1, evaluating the concordance between the composition of stones and double J stent encrustation was estimated statistically by SPSS 12.0 software (0<1<1; 1=0: no concordance; 1=1: perfect concordance).

RESULTS

45 males and 27 females with a mean age of 45.3 years (range: 29-70) were included Double J stents were placed for: febrile obstruction (N=52; 72%), acute renal colic (N=15; 21%) and impaired renal function (N=5; 7%). Calculated values for 1 were: 0.78 for the concordance between the predominant constituent of the stone and the encrustation (N=72; p < 0.0005); 0.91 for the concordance between the nature of the encrustation of the upper loop and that of the lower loop of the stent (N=30, p < 0.0005).

CONCLUSION

The composition of mineral encrustation of double J stents is a good marker of stone formation. This constitutes an alternative method that can be used by urologists when no stone is available for spectrophotometric analysis.

FETAL DEVELOPMENT OF THE FEMALE EXTERNAL URINARY SPHINCTER COMPLEX: AN ANATOMICAL AND HISTOLOGICAL STUDY

PURPOSE

We investigated the fetal development of the smooth (lissosphincter) and striated (rhabdosphincter) female external urinary sphincter. Growth and organization of the muscle fibers around the urethra and morphological modifications due to the development of the vagina were analyzed in detail.

MATERIALS AND METHODS

A total of 28 human female fetal specimens were investigated in an anatomical and histological study. The sections were processed according to plastination technology. This technique allows examination of structures and organs of the small pelvis with minimal artifacts in all 3 planes.

RESULTS

At gestational week 9 the primordium of the external urethral sphincter complex was observed extending along the anterior aspect of the urogenital sinus, before the development of the primitive urethra and the vaginal primordium. From 15 weeks of gestation the lissosphincter and rhabdosphincter could be identified and clearly distinguished. After 20 weeks of gestation both elements acquired an omega-shaped configuration with a narrow posterior connective tissue raphe that was constantly present, fixing both components to the ventral vaginal wall. Both muscles were mainly located in the middle third of the urethra. In the proximal third of the urethra growth of the vagina led to disappearance of the striated muscle fibers of the rhabdosphincter, whereas the lissosphincter seemed to intermingle with the internal layer of the detrusor musculature of the bladder.

CONCLUSIONS

The important morphological characteristics of the female adult rhabdosphincter and lissosphincter (omega-shaped configuration, presence of a narrow connective tissue raphe posteriorly and maximum thickness in the middle third of the urethra) are already evident early in fetal development and do not evolve during postnatal growth or by the influence of sex hormones.

Fetal development of striated and smooth muscle sphincters of the male urethra from a common primordium and modifications due to the development of the prostate: an anatomic and histologic study

BACKGROUND

The aim of the study was to investigate the development of the human urethral sphincter complex during fetal development.

METHODS

23 human male fetal specimens were investigated. The histological sections were processed according to the epoxy resin-based plastination technology.

RESULTS

At 9th week of gestation, a combined sphincteric primordium of the rhabdosphincter and the lissosphincter is situated at the anterior and lateral aspects of the membranous and prostatic urethra. Both muscular components assume an omega-shaped configuration due to the presence of a constant connective tissue raphe posterior to the urethra that anchors the rhabdosphincter in the perineal body. Development of the prostate laterally and posteriorly does not modify the growth of the urethral sphincter complex anteriorly but inhibits its development laterally and posteriorly.

CONCLUSIONS

The important morphological characteristics of the male adult rhabdosphincter and lissosphincter can be seen very early in fetal development.

AN EMBRYOLOGICAL STUDY OF FETAL DEVELOPMENT OF THE RECTOURETHRALIS MUSCLE—DOES IT REALLY EXIST?

PURPOSE

The so-called rectourethralis muscle is widely described in the urological literature. However, its description is subject to variations concerning extent and morphology. Moreover, little is known about its fetal development, which would allow a better understanding of the adult anatomy. The aim of this study was to investigate the morphology, extent and development of the rectourethralis muscle in fetal specimens.

MATERIALS AND METHODS

A total of 15 normal human male fetuses were included in the study. Age ranged from 13th week of gestation to term. The histological study used plastination and standard and immunohistochemical techniques to identify the developing muscular structures in serial sections of the rectourethral space. Investigations in all 3 planes (coronal, sagittal and transverse) were performed.

RESULTS

In all sections of the proximal aspect of the rectourethral space no developing muscle fibers could be identified leaving the anterior wall of the rectum to join the rhabdosphincter or the apical prostate. In the distal aspect of the rectourethral space an independent muscular structure located between the external muscular layer of the anorectal canal and the dorsal bundles of the rhabdosphincter could be clearly demonstrated. This structure consisted of connective, smooth and striated muscle tissue, and was deeply anchored to the apical perineal body.

CONCLUSIONS

This study suggests that the so-called rectourethralis muscle is a misnomer in the urological literature. In the fetal period a developing muscular structure could be clearly identified as a part of the apical perineal body, which would correspond to the rectoperinealis muscle in the adult.

Prostatic capsule- and seminal-sparing cystectomy for bladder carcinoma: initial results for selected patients

OBJECTIVE

To evaluate the oncological outcome and functional results of prostate-sparing cystectomy (PSC), proposed for treating bladder cancer, used since 1999 in our institution in an attempt to preserve male sexuality and to increase continence after cystectomy.

PATIENTS AND METHODS

Between January 1999 and December 2001, 111 men were candidates for cystectomy; 42 were selected for a prostatic capsule- and seminal-sparing cystectomy with orthotopic urinary diversion. All patients had clinically organ-confined tumours (clinical stage </= T2, N0M0). The first stage of the procedure was a transurethral resection of the prostate to exclude the involvement of transitional cell carcinoma (TCC) in the prostate.

RESULTS

Eight patients were excluded from PSC because they had TCC (seven) or prostate adenocarcinoma (one). The mean age of the remaining 34 patients was 61 years and all underwent PSC. After a mean follow-up of 26 months, seven patients (21%) had a recurrence; one developed a local recurrence, there were widespread metastases in six (18%), and five had histologically confirmed organ-confined tumour (T1-2N0M0). Rates for daytime and night-time continence were 90% and 85%, and in 29 patients potency was unchanged.

CONCLUSION

These early results suggest that PSC is not equivalent to radical cystoprostatectomy for bladder cancer control, despite marked improvements in the functional results. Moreover, in carefully selected patients this approach appears to dramatically increase an unusually high metastasis rate. Therefore, the indications for PSC should be either clearly well defined or abandoned in these patients.

[Anatomic variations of the vascularization of the pelvic kidney: apropos of a case and review of the literature]

Blood supply in pelvic kidney presents with more anatomic variations than in a normal positioned lumbar kidney. We report a patient with a right pelvic kidney and a particularly atypic vascularisation. In addition we present a review of the literature with all possible pelvic arterial variations and their frequency.

Three-dimensional ultrasound guidance for percutaneous drainage of prostatic abscesses

OBJECTIVES

To evaluate the feasibility and effectiveness of three-dimensional ultrasound-guided transperineal puncture and drainage of prostatic abscesses.

METHODS

Between 1985 and 2003, a prostatic abscess was diagnosed in 22 patients. One of the therapeutic modalities used to drain the abscesses was transperineal puncture under three-dimensional ultrasound guidance. The postoperative results were compared with the outcomes of other modalities.

RESULTS

The average patient age was 52 years. Predisposing factors were present in 12 patients. Transperineal puncture was performed in 7 patients under general anesthesia. In addition to antibiotic therapy, a nephrostomy tube was left in place in all cases for a mean period of 3 days to drain the abscess. All patients were treated effectively without additional therapy or complications.

CONCLUSIONS

Three-dimensional ultrasound-guided transperineal puncture is a minimally invasive and effective technique for the treatment of prostatic abscesses.

Combined reporting of cancer control and functional results of radical prostatectomy

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 > or =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 <4 had a PSA>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.

[Laparoscopic nephrectomy for benign kidney disease. Review of a 12-year experience and review of the literature]

Based on 12 years of experience, laparoscopic nephrectomy has become the reference approach to benign kidney disease. This technique is effective, safe and reproducible. The complication rate is comparable or even lower than that of open nephrectomy and the postoperative course is more favourable. Based on a review of the literature, this paper reviews the technique, indications and results of laparoscopic nephrectomy for benign kidney disease.

Radical retropubic prostatectomy in men younger than 45 years diagnosed during early prostate cancer detection program

OBJECTIVES

To evaluate the incidence and outcome of prostate cancer in men younger than 45 years of age treated with radical retropubic prostatectomy after screening in an early prostate cancer detection program.

METHODS

Our study group comprised 19,302 men younger than 45 years old who participated in this program. The indications for prostate biopsy were a prostate-specific antigen (PSA) level of 1.25 ng/mL or greater and a percent-free PSA value of 18% or less. Patients with prostate cancer underwent nerve-sparing radical retropubic prostatectomy. Intraoperative and early postoperative complications, clinical and pathologic stage, Gleason score, and surgical margins were reviewed retrospectively. In addition, potency, continence, and biochemical recurrence were assessed at the last follow-up visit.

RESULTS

Of the study population eligible for prostate biopsy (1027 patients), only 175 (17%) consented to undergo the procedure (mean PSA 3.8 ng/mL). Twenty-eight men were diagnosed with prostate cancer, corresponding to 0.14% of the screened population and 16% of the biopsied patients. Twenty-six patients agreed to undergo radical retropubic prostatectomy. Pathologic examination revealed organ-confined disease in 22 (84.6%) and extraprostatic extension in 4 (15.4%). Positive surgical margins were seen in 2 patients (7.7%). The Gleason score was 7 or greater in 11 (42.3%) and 6 or less in 15 patients (57.7%). During a mean follow-up period of 15.8 months (range 3 to 36), all patients were continent, and 13 of the 16 patients with a follow-up of 12 months or longer were potent.

CONCLUSIONS

In a large screening population younger than 45 years old, 16% of biopsied patients were positive for prostate cancer. These tumors were clinically significant but of a low stage and therefore potentially curable by surgery.

Laparoscopic radical nephrectomy for T1 renal cancer: the gold standard? A comparison of laparoscopic vs open nephrectomy

OBJECTIVE

To evaluate the complication rate and clinical follow-up of patients treated for T1 renal cancer by open or laparoscopic nephrectomy at the same institution, as this approach appears to be attractive for treating small renal cancers.

PATIENTS AND METHODS

Between 1995 and 2002, 39 patients underwent retroperitoneal laparoscopic and 26 transperitoneal open radical nephrectomy for T1 renal cancer (TNM 1997). Variables before during and after surgery, e.g. cancer recurrence, were compared between the groups.

RESULTS

There were no differences between the laparoscopic and open groups in age, sex ratio, weight, height, fitness score, operative duration (134 vs 133 min), minor or major complications, tumour diameter, Fuhrman grade or length of follow-up. Patients who underwent laparoscopic surgery had less blood loss (133 vs 357 mL, P < 0.001), less need for transfusion (none vs 150 mL, P = 0.04), a lower consumption of analgesia drugs, and shorter hospitalization (5.5 vs 8.8 days, P < 0.001). With a mean follow-up of 20.4 months there was no recurrence or tumour progression.

CONCLUSION

Laparoscopic radical nephrectomy for patients with T1 renal cancer is a safe, reliable procedure that decreases hospitalization time and bleeding, and ensures the same cancer control as open nephrectomy.