Grade IV renal trauma management. A revision of the AAST renal injury grading scale is mandatory.

INTRODUCTION: The AAST renal injury grading scale is currently the most important variable predicting the need for kidney repair or removal, morbidity and mortality after blunt or penetrating kidney injuries. The 2011 revised version included renal pelvis, uretero-pelvic junction and segmental vascular injuries as grade IV, limiting grade V to severe hilar injuries. However, patients requiring surgery cannot be properly identified because of hemodynamic instability due to grade IV renal injuries. This study proposes an add-on for the AAST grade IV renal injury scale to improve the management of these patients. METHOD: We searched the Medline and Scopus databases up to September 2014. Searches were not restricted by date, language or publication status. Pediatric studies were excluded. RESULTS: 71 articles were found, 57 were pertinent, including 6 directly related to the topic. 3 risk factors were identified to be associated with surgery for hemodynamic instability: perirenal hematoma >3.5 cm, intravascular contrast extravasation and medial renal laceration. Presence of two or more of these criteria has been validated in two other studies to predict the need for intervention. Patients with >25 % devascularized fragments also have poor prognosis and should be treated more aggressively. CONCLUSION: These elements should be included in future classification reassessment to efficiently determine the time for surgery in grade IV renal traumas, generally leading to nephrectomy.

[Use of French version of Ureteral Stent Symptom Questionnaire for tolerance evaluation of ureteral double J-stent]. / Évaluation de la tolérance de la sonde JJ par l'utilisation de l'autoquestionnaire USSQ.

OBJECTIVES: To evaluate the quality of life of the holders of a ureteral double J stent (US) using the USSQ questionnaire (Ureteral Stent Symptom Questionnaire), validated in French in 2010. METHODS: Between January 2009 and December 2011, 249 patients underwent flexible ureteroscopy for urolithiais in our service. Among them, 160 received a US in perioperative, and they were sent self-questionnaire USSQ-FR retrospectively. The questionnaire includes 38 questions, concerning the perioperative period with US, and 4 weeks after its removal, grouped into 6 sections: urinary symptoms, pain, general health, professional resounding, sexual resounding, and other problems. A subgroup analysis was performed, comparing US used in emergency and planned US, active patients or retired, male or female. Statistical analysis used the Chi(2) test for paired data, the Fisher exact test and the Kruskal Wallis test. RESULTS: Of the 157 questionnaires sent (two patients who died, one mentally retarded), we obtained 80 responses. Quality of life appears to be significantly altered in all areas explored by the questionnaire. Urinary symptoms: 26.9 versus 19.9 score (P<0.0001), pain: 16.1 versus 10.7 (P=0.003), general health: 13.9 versus 9.1 (P<0.0001), professional practice: 6.1 versus 3.6 (P=0.0002), female: 3.3 versus 1.8 (P=0.001). There was no significant difference if the US was placed in emergency or programmatically, if patients were professionally active or retired. In addition, women had a significantly impaired quality of life compared to men for urinary symptoms, general health and professional practice. CONCLUSION: US are responsible for a significant impairment of quality of life for patients. The validated, self-administered, USSQ-FR questionnaire is a reliable tool for this evaluation. LEVEL OF EVIDENCE: 5.

[Is obesity a barrier to kidney transplantation?]. / L'obésité est-elle un frein à la transplantation rénale ?

INTRODUCTION: Kidney transplantation is the most suitable of ESRD care. The proportion of obese people is increasing in the general population and patients with kidney impairment. It is important to assess the impact of obesity on surgical complications of kidney transplantation. The aim of this retrospective study was to signify the correlation between obesity and the occurrence of postoperative urological complications during the first year. METHODS: We conducted a retrospective study from March 1999 to December 2009. We conducted a chart review of patients undergoing kidney transplantation. The kidneys were taken from cadaveric donors. Data collected included age, weight, height, preoperative BMI; causal nephropathy, smoking, hypertension, diabetes, anticoagulation therapy. Intraoperative data included operative time (DO), cold ischemia. Urological complications were recorded during the first year after the kidney transplantation (vascular anastomotic strictures, ureterovesical stenosis, lymphorrheas, pyelonephritis, hematoma, wound infection). Statistical analysis consisted of a t-test for independent samples and univariate and multivariate logistic regression for the occurrence of complications. RESULTS: Four hundred and twenty-two patients were transplanted in total. We excluded 20 patients. BMI and duration of surgery patients with complications were significantly different from those of patients with no complications (P=0.016 and P=0.039, respectively). Obese (n=48) had more diabetes (12.5% versus 3.7%, P=0.014), were more often smoking (35.4% versus 22%, P=0.012), had a longer DO (203.64minutes versus 182.46minutes, P=0.006), and complications (62.5% versus 50.28%, P=0.03) than patients with a BMI <30 (n=354). After adjusting for age, smoking, DO, diabetes and BMI showed that only BMI was an independent predictor of the occurrence of postoperative complications with P=0.048 and RR=1.058 [CI: 1 to 1.119]. However, there was no more transplantectomy obese (P=0.911). CONCLUSION: Our study showed that there is a significant risk of surgical complications after kidney transplantation in obese patients. But ultimately, this does not affect graft survival because there are no more transplantectomies or return to dialysis. LEVEL OF EVIDENCE: 5.

[The impact of obesity on renal function at one year after kidney transplantation: single-center experience]. / Impact de l'obésité sur la fonction rénale à 1 an chez les transplantés rénaux: expérience mono centrique.

INTRODUCTION: Kidney transplantation is the treatment of choice for ESRD. Several studies have investigated the factors that may affect kidney function at 1 year. The factors mentioned are anemia, hypercholesterolemia, immunosuppressors, etc. We studied the independent predictors of serum creatinine>100µmol/L at 1 year. MATERIALS AND METHODS: We conducted a retrospective study from March 1999 to December 2009. We conducted a chart review of 402 kidney transplant patients. The kidneys were removed from cadaveric donors. Data collected included age, weight, height, preoperative BMI, the causal nephropathy, smoking, hypertension, diabetes, anticoagulation. Intraoperative data included operative time, and cold ischemia. Statistical analysis consisted of a t-test for independent samples comparing the group with a creatinine≤100µmol/L vs>100 group, and univariate and multivariate Cox regression for a serum creatinine>100µmol/L at 1 year and test of correlation between BMI and serum creatinine at 1 year postoperatively. RESULTS: We found a significant difference in BMI and cold ischemia with P=0.008 and P=0.002, respectively. In contrast there was no difference in age, operative time and blood loss, P=0.758, P=0.941 and P=0.963, respectively. Multivariate Cox regression showed that donor age P=0.004 (HR: 1.016 and CI: 1.005-1.027), a recipient age P=0.023 (HR: 0.986 and CI: 0.974-0.998) and BMI P=0.001 (HR: 1.019 and CI: 1.010-1.028) were independent predictors of serum creatinine>100µmol/L at 1 year. The Pearson correlation coefficient r=0.154 (P=0.004) showed a significant correlation between BMI and serum creatinine. CONCLUSION: Our study showed that donor age, recipient age and BMI were independent predictors of renal function>100µmol/L at 1 year. Our results highlight the difficulty of the management of obesity in renal transplant patients. LEVEL OF EVIDENCE: 5.

[Local consultations by specialists in urology: an answer to patients' expectations and dwindling physician numbers?]. / Les consultations avancées d'urologie peuvent-elles être une réponse satisfaisante aux attentes des patients et au problème de la démographie médicale?

OBJECTIVE: To analyze patients' views with regards to local consultations given by specialists in urology and to an offer of pre- and postoperative visits in the local general hospital with surgical interventions taking place at the university hospital. MATERIALS AND METHODS: An opinion survey by mail questionnaire was carried out in all 473 patients who had had a consultation with a specialist in two local general hospitals between November 2009 and April 2010. RESULTS: Response rate was 74%. Mean patient age was 65.5 ± 12 years [range, 20-90]. The reason for the consultation was cancer-related in 31.2% of patients. The majority (89%) made the journey to hospital under their own steam and would have had to travel a 4 times greater distance if the consultation with the specialist had taken place at the university hospital. Overall, 54.6% of patients were willing to travel 20 km further to see a specialist and 76.5% were willing to travel 20 km further for a surgical intervention. Virtually all of the patients (>99%) saw benefits to local consultations given by specialists. The offer of a consultation at the general hospital and intervention at the university hospital met with the approval of 60.8% patients and 56.3% had already experimented this offer. CONCLUSION: Local consultations by specialists might be an answer to demographic issues in France, that is, to the small number of urologists practicing in general hospitals.

Transrectal high-intensity focused ultrasound (HIFU) treatment of localized prostate cancer: review of technical incidents and morbidity after 5 years of use.

The objective of this study was to report on technical incidents and early and late complications occurring in high-intensity focused ultrasound (HIFU) treatment of patients with localized prostate cancer. We performed a retrospective review of patients who were treated by Ablatherm at our centre. We recorded all technical incidents, treatment discontinuations and early (<1 month) and late complications. A total of 74 HIFU procedures were performed in 65 patients (55 first-line HIFU treatments and 10 cases of salvage therapy after radiotherapy) over a 5-year period. Median follow-up was 41 months (10-64 months). All the procedures were well tolerated and no intra- or peri-operative deaths occurred. Six technical incidents in the overall population (8.1%) led to discontinuation of the procedure. The early complication rate in patients undergoing first-line HIFU was 36.4%: urinary retention (20%), dysuria (5.4%), urinary infection (3.6%), haematuria (3.6%) and urethral stenosis (3.6%). The late complication rate was 12.7%: urethral stenosis (9%) and dysuria (3.6%). There were no cases of rectourethral fistula. The long-term urinary incontinence rate was 20% and the de novo erectile dysfunction rate was 77.1%. Nine complications (16.4%) required surgical management. The overall complication rate was 49%. Ablatherm is a reliable technique with a relatively high complication rate. However, most complications were minor and required surgical management in a few cases only. Our results confirm that all patients who are offered HIFU treatment should be properly informed of the risks, in particular with regard to continence and sexual function.