Geriatric Assessment Can Predict Outcomes of Endoscopic Surgery for Benign Prostatic Hyperplasia in Elderly Patients.

Ojectives: Surgical management of benign prostatic hyperplasia (BPH) in elderly patients is associated with higher morbidity and mortality rate. This raises the question of benefice and risk balance. We conducted a prospective observational study to evaluate the results of endoscopic surgery for BPH in elderly patients, according to geriatric assessment. PATIENTS AND METHODS: We included prospectively 60 patients older than 75 years, with an indwelling catheter for acute or chronic retention, who were candidates to endoscopic surgery for BPH. Patients underwent the brief geriatric assessment (BGA) and the comprehensive geriatric assessment (CGA) to classify them into three groups: "vigorous," "vulnerable," and "sick." Success was defined by the bladder catheter withdrawal after surgery. RESULTS: After geriatric assessment, 33 patients were classified in the "vigorous" group (55%), 25 in the "vulnerable" group (42%), and 2 in the "sick" group (3%). The success rate immediately after surgery was 85% and 41% in the "vigorous patient" group and the "vulnerable and sick" patient group, respectively (p < 0.05). The success rate at 3 months after surgery was 94% and 55% (p < 0.05). The morbidity was higher for the "vulnerable and sick" group (44%) compared with the "vigorous" group (15%) (p < 0.05). The BGA also allowed predicting a higher risk of failure in patients with a score ≥3 immediately after surgery (odds ratio 5.9, confidence interval [95% CI] 1.61, 29.9) and 3 months after surgery (odds ratio 6.9, 95% CI 1.31, 70.8). CONCLUSION: Geriatric assessment can predict the outcome of endoscopic surgery for BPH for patients in retention older than 75 years. "Vulnerable and sick" patients had a higher risk to keep their indwelling catheter after the surgery compared with "vigorous" patients. The complication rate is also higher. The BGA can although predict a poor result of surgery when its score is equal or above 3/6.

Impact of retrograde flexible ureteroscopy and intracorporeal lithotripsy on kidney functional outcomes.

OBJECTIVE: The aim of the study was to evaluate renal function and to identify factors associated with renal function deterioration after retrograde intrarenal surgery (RIRS) for kidney stones. MATERIALS AND METHODS: We retrospectively analyzed patients with renal stones treated by RIRS between January 2010 and June 2013 at a single institute. We used the National Kidney Foundation classification of chronic kidney disease (CKD) to classify Glomerular Filtration Rate (GFR) in 5 groups. The baseline creatinine level was systematically pre-operatively and post-operatively evaluated. All patients had a creatinine blood measurement in June 2013. A change toward a less or a more favorable GFR group following RIRS was considered significant. RESULTS: We included 163 patients. There were 86 males (52.8%) and 77 females (47.3%) with a mean age of 52.8±17 years. After a mean follow-up of 15.5±11.5 months, median GFR was not significantly changed from 84.3±26.2 to 84.9±24.5 mL/min (p=0.675). Significant renal function deterioration occurred in 8 cases (4.9%) and significant renal function amelioration occurred in 23 cases (14.1%). In univariate analysis, multiple procedures (p=0.023; HR: 5.4) and preoperative CKD (p=0.011; HR: 6.8) were associated with decreased renal function. In multivariate analysis these factors did not remain as predictive factors. CONCLUSION: Stone management with RIRS seems to have favorable outcomes on kidney function; however, special attention should be given to patients with multiple procedures and preoperative chronic kidney disease.

Impact of retrograde flexible ureteroscopy and intracorporeal lithotripsy on kidney functional outcomes

ABSTRACT Objective: The aim of the study was to evaluate renal function and to identify factors associated with renal function deterioration after retrograde intrarenal surgery (RIRS) for kidney stones. Materials and Methods: We retrospectively analyzed patients with renal stones treated by RIRS between January 2010 and June 2013 at a single institute. We used the National Kidney Foundation classification of chronic kidney disease (CKD) to classify Glomerular Filtration Rate (GFR) in 5 groups. The baseline creatinine level was systematically pre-operatively and post-operatively evaluated. All patients had a creatinine blood measurement in June 2013. A change toward a less or a more favorable GFR group following RIRS was considered significant. Results: We included 163 patients. There were 86 males (52.8%) and 77 females (47.3%) with a mean age of 52.8±17 years. After a mean follow-up of 15.5±11.5 months, median GFR was not significantly changed from 84.3±26.2 to 84.9±24.5 mL/min (p=0.675). Significant renal function deterioration occurred in 8 cases (4.9%) and significant renal function amelioration occurred in 23 cases (14.1%). In univariate analysis, multiple procedures (p=0.023; HR: 5.4) and preoperative CKD (p=0.011; HR: 6.8) were associated with decreased renal function. In multivariate analysis these factors did not remain as predictive factors. Conclusion: Stone management with RIRS seems to have favorable outcomes on kidney function; however, special attention should be given to patients with multiple procedures and preoperative chronic kidney disease.

Identification and validation of TGFBI as a promising prognosis marker of clear cell renal cell carcinoma.

OBJECTIVE: To identify prognostic biomarkers in clear cell renal cell carcinoma (ccRCC) using a proteomic approach. MATERIAL AND METHODS: We performed a comparative proteomic profiling of ccRCC and normal renal tissues from 9 different human specimens. We assessed differential protein expression by iTRAQ (isobaric tagging reagent for absolute quantify) labeling with regard to tumor aggressiveness according to the stage, size, grade, and necrosis (SSIGN) score and confirmed our results using Western blot (9 patients) and immunohistochemistry (135 patients) analysis. RESULTS: After proteomic analysis, 928 constitutive proteins were identified. Among these proteins, 346 had a modified expression in tumor compared with that of normal tissue. Pathway and integrated analyses indicated the presence of an up-regulation of the pentose phosphate pathway in aggressive tumors. In total, 14 proteins were excreted and could potentially become biomarkers. Overexpression of transforming growth factor, beta-induced (TGFBI) in ccRCC was confirmed using Western blot and immunohistochemistry analysis. A significant association was found between the presence of TGFBI expression with tumor category T3-4 (P<0.0001), Fuhrman grades III and IV (P<0.0001), tumor size>4cm (P<0.0001), presence of tumor necrosis (P<0.0001), nodal involvement (n = 0.009), metastasis (P = 0.012), SSIGN score≥5 (P<0.0001), cancer progression (P<0.0001), and cancer-specific death (P<0.0001). Cancer-specific survival was significantly better for patients with no cytoplasmic TGFBI expression (1-, 3-, 5-y cancer-specific survival of 94.7%, 87.8%, and 73.4% vs. 92.9%, 71.2%, and 49.8%, respectively; P<0.0001). CONCLUSION: We identified 346 proteins involved in renal carcinogenesis and confirmed the presence of a metabolic shift in aggressive tumors. TGFBI was overexpressed in tumors with high SSIGN scores and was significantly associated with oncologic outcomes.

Transcutaneous posterior tibial nerve stimulation: evaluation of a therapeutic option in the management of anticholinergic refractory overactive bladder.

INTRODUCTION AND HYPOTHESIS: This study evaluated the efficacy and tolerability of transcutaneous posterior tibial nerve stimulation (TPTNS) in the treatment of overactive bladder (OAB) after failure of a first-line anticholinergic treatment. MATERIALS AND METHODS: We performed a prospective observational study and included all patients treated in a single center for OAB persisting after first-line anticholinergic treatment from November 2010 to May 2013. The protocol consisted of daily stimulation at home. The efficacy end point was defined as improvement on the Urinary Symptom Profile (USP) and the French-validated urinary symptom score Mesure du Handicap Urinaire (MHU). RESULTS: We assessed 43 consecutive patients. TPTNS was successful following 1 month of treatment in 23 (53%) patients. Bladder capacity was the only predictive factor for treatment success (p = 0.044). For patients who showed improved symptoms (n = 23; 53%), mean MHU and USP decreased significantly, from 11.8 ± 2.8 to 5.6 ± 3 (p < 0.001) and from 14 ± 3.3 to 6.9 ± 3.2 (p < 0.001), respectively. After a mean follow-up of 10.8 ± 1.6 months, 21 (49%) patients continued the TPTNS. Mean MHU and USP scores were 4.4 ± 2.8 and 5.4 ± 3.5, respectively, and stayed lower than baseline (p < 0.001). Patients reported no adverse events. CONCLUSION: TPTNS is well tolerated and is effective in one half of the patients studied after they failed anticholinergic treatment. TPTNS could become a second therapeutic option before surgical treatment in the management strategy of OAB.

Double-J ureteral stent under local anesthesia for women.

INTRODUCTION: Ureteral stent placement is a key urologic procedure used to manage ureteral obstructions. It is usually performed under general anesthesia (GA) with its inherent risks. The objective was to evaluate safety, feasibility and tolerance of ureteral stent placement under local anesthesia (LA) in women. MATERIALS AND METHODS: From January 2010 to January 2013, we prospectively and consecutively reviewed all female patients who had an urgent retrograde ureteral stent placement under LA. Only primary stent placements were included in the study. Pain was assessed after surgery by Visual Analog Scale (VAS) and pain and comfort assessment during stent placement were reported. We compared outcomes and tolerance with patients under general anesthesia (GA) matched by age and operatives indications during the same period. RESULTS: We included 36 patients (18 under LA and 18 under GA) with a mean age of 59.4 +/- 22.4 years. The mean operative time was 24.4 +/- 12.9 min and 18.8 +/- 6.5 min in LA group and GA group (p = 0.110), respectively. One patient needed GA due to a poor tolerance. The mean perioperative VAS scores under LA and GA were 5.89 +/-2.95 and 2.06 +/- 2.67 (p < 0.0001), respectively. There were no intraoperative complications in either group. The procedure was painful for 16 (88.8%) patients from the LA group and 9 (50%) patients would not accept to undergo this intervention under LA again. CONCLUSION: Ureteral stent placement under LA in women can be performed safely and effectively. However, this procedure is painful and should be proposed only to selected cases.

Nephron-sparing surgery for renal tumors measuring more than 7 cm: morbidity, and functional and oncological outcomes.

BACKGROUND: The purpose of this study was to evaluate morbidity, functional, and oncological outcomes after NSS in renal tumors > 7 cm. MATERIALS AND METHODS: We retrospectively analyzed data from 168 patients with tumors > 7 cm who were treated using NSS between 1998 and 2012. RESULTS: Imperative and elective indications accounted for 76 (45.2%) and 92 (54.8%) patients, respectively. Major perioperative complications and renal function deterioration occurred in 33 (19.6%) and 51 patients (30.4%), respectively. In multivariate analysis, age older than 60 years (P = .001; hazard ratio [HR], 5) and tumor malignancy (P = .014; HR, 6.7) were prognostic factors for renal function deterioration whereas imperative indication was a risk factor for major postoperative complications (P = .0019; HR, 2.7). In 126 (75%) patients with malignant tumors, after a median follow-up of 30 months (range, 1-254 months), 25 patients (20.2%) died. In multivariate analysis, imperative indication (P = .023; HR, 4.2), positive surgical margin (P = .021; HR, 3.3), and Fuhrman grade > II (P = .013; HR, 3.7) were prognostic indicators for cancer-free survival (CFS). Imperative indication (P = .04; HR, 8.5) and Fuhrman grade > II (P = .04; HR, 3.9) were predictive factors of cancer-specific survival (CSS). In case of elective indication, positive surgical margin, local recurrence, and cancer-related death occurred in 4 (7.6%), 1 (1.1%), and 1 (1.1%) cases, respectively. For elective indication, 5-year estimates of CFS, CSS, and overall survival rates were: 85.7%, 98%, and 93.9%, respectively. CONCLUSION: In this selected population, imperative vs. elective indication status seems to play a critical role in oncologic outcomes. Oncologic results for elective indications are close to those reported with radical nephrectomy.

Impact of lower pole calculi in patients undergoing retrograde intrarenal surgery.

OBJECTIVE: To assess if the presence of a lower pole stone (LPS) decreases the stone-free (SF) rate following retrograde intrarenal surgery (RIRS). The second purpose was to assess the result of RIRS for LPS and to identify predictors of SF status. PATIENTS AND METHODS: We retrospectively analyzed 205 procedures in 162 patients with renal stones treated by RIRS between January 2010 and January 2013 at a single institute. The SF status was defined as no residual fragments. Independent-sample t-tests and Chi-square tests were used for comparisons of means and proportions, respectively, between patients with or without LPS. Logistic regression models were used to assess prognostic factors influencing SF status in cases of LPS. RESULTS: LPS were present in 89 (54.9%) patients. There were no differences between patients with or without LPS regarding the mean operative time (p=0.77), the surgeon's experience (p=0.522), the length of hospital stay (p=0.269), and the SF rate (p=0.224). SF status after RIRS in patients with or without LPS was 74.1% and 78% (p=0.224), respectively. In the case of LPS, the presence of multiple stones and a history of percutaneous nephrolithotomy (PCNL) were predictive factors for occurrence of residual fragments in univariate analysis (p=0.037 and p=0.015). In multivariable analysis, only the presence of multiple stones remained as a predictive factor (p=0.027; HR=3.2), whereas a trend was observed when there was a history of PCNL (p=0.07; HR=3). CONCLUSION: The presence of a LPS does not alter the SF rate of RIRS even in cases of early experience. RIRS for LPS appears to be an effective technique, but special attention should be given to patients with multiple stones and/or a history of PCNL.

Conditional survival predictions after nephrectomy for renal cell carcinoma.

PURPOSE: Conditional survival implies that on average long-term cancer survivors have a better prognosis than do newly diagnosed individuals. We explored the effect of conditional survival in renal cell carcinoma. MATERIALS AND METHODS: We studied 3,560 patients with renal cell carcinoma of all stages treated with nephrectomy. We applied conditional survival methodology to a previously reported posttreatment nomogram predicting survival after nephrectomy for patients with renal cell carcinoma stage I to IV. We used the same predictor variables that were integrated in the original multivariable Cox regression models, namely TNM stage, Fuhrman grade, tumor size and symptom classification. To validate the conditional survival nomogram we used an independent cohort of 3,560 patients from 15 institutions. RESULTS: The 5-year survival of patients immediately after nephrectomy was 74.2%, which increased to 80.4%, 85.1%, 90.6% and 89.6% at 1, 2, 5 and 10 years after nephrectomy, respectively. The predicted probabilities varied by as much as 50% when, for example, predictions of renal cell carcinoma specific mortality at 10 years were made after nephrectomy vs 5 years later. Within the external validation cohort the accuracy of the conditional nomogram was 89.5%, 90.5%, 88.5% and 86.7% at 1, 2, 5 and 10 years after nephrectomy. CONCLUSIONS: We developed (2,530) and externally validated (3,560) a conditional nomogram for predicting renal cell carcinoma specific mortality that allows consideration of the length of survivorship. Our tool provides the most realistic prognosis estimates with high accuracy.

Prognostic value of renal vein and inferior vena cava involvement in renal cell carcinoma.

BACKGROUND: The prognostic significance of venous tumor thrombus extension in patients with renal cell carcinoma (RCC) is a matter of many controversies in the current literature. OBJECTIVE: To evaluate the prognostic role of inferior vena cava (IVC) involvement in a large series of pT3b and pT3c RCCs. DESIGN, SETTING, AND PARTICIPANTS: A total of 1192 patients from 13 European institutions underwent a radical nephrectomy for pT3b and pT3c RCC between 1982 and 2003. The patients were evaluated in a retrospective manner. Age, gender, clinical symptoms, Eastern Cooperative Oncology Group (ECOG) performance status, TNM stage, tumor size, adrenal invasion, perinephric fat invasion, histological type, and Fuhrman grade were reviewed. The log-rank and Cox uni- and multivariate regression analyses were used to evaluate prognostic factors for overall survival. MEASUREMENTS: Overall survival and prognostic factors for overall survival in patients with RCC extending to the renal vein (RV) or to the IVC. RESULTS AND LIMITATIONS: The median follow-up was 61.4 mo (56.3-66.5 mo). The mean age was 63.2 yr. The mean tumor size was 8.9 cm. Group 1 (Gr 1) included 933 patients with a renal vein tumor thrombus (78.3%), Group 2 (Gr 2) included 196 patients with a subdiaphragmatic IVC tumor thrombus (16.4%), and Group 3 (Gr 3) included 63 patients with a supradiaphragmatic IVC tumor thrombus (5.3%). Median survival was 52 mo for Gr 1, 25.8 mo for Gr 2, and 18 mo for Gr 3. In univariate analysis, Gr 1 had a significantly better overall survival than Gr 2 (p<0.001) and Gr 3 (p

Age at diagnosis is a determinant factor of renal cell carcinoma-specific survival in patients treated with nephrectomy.

OBJECTIVE: Based on combined data for 4880 patients, 2 previous studies reported that advanced age is a predictor of increased renal cell carcinoma-specific mortality (RCC-SM). We explored the effect of age in cubic spline analyses to identify the age groups with the most elevated risk for renal cell carcinoma (RCC). METHODS: Our study included 3595 patients from 14 European centres who had partial or radical nephrectomies. We used the Kaplan-Meier method to compile life tables, and we performed Cox regression analyses to assess RCC-SM. Covariates included age at diagnosis, sex, TNM (tumour, node, metastasis) stage, tumour size, Fuhrman grade, symptom classification and histological subtype. RESULTS: Age ranged from 10 to 89 (mean 63, median 67) years. The median duration of follow-up was 2.9 years. The median survival for the cohort was 13.4 years. Stage distribution was as follows: 1915 patients (53.3%) had stage I disease, 388 (10.8%) had stage II, 895 (24.9%) had stage III and 397 (11.0%) had stage IV disease. In multivariate analyses, we coded age at diagnosis as a cubic spline, and it achieved independent predictor status (p < 0.001). The risk of RCC-SM was lowest among patients younger than 50 years. We observed an increase in RCC-SM until the age of 50, at which point the level of risk reached a plateau. We observed a second increase among patients aged 75-89 years. We found similar patterns when we stratified patients according to the 2002 American Joint Committee on Cancer (AJCC) stages. CONCLUSION: The effect of age shows prognostic significance and indicates that follow-up and possibly secondary treatments might need to be adjusted according to the age of the patient.

Prognostic variables to predict cancer-related death in incidental renal tumours.

OBJECTIVE: To identify, in a large multicentre series of incidental renal tumours, the key factors that could predict cancer-related deaths, as such tumours have a better outcome than symptomatic tumours and selected patients are increasingly being included in watchful-waiting protocols. PATIENTS AND METHODS: Data from 3912 patients were extracted from three international kidney-cancer databases. Age, gender, Eastern Cooperative Oncology Group (ECOG) performance status (PS), Tumour-Node-Metastasis (TNM) stage, tumour size, Fuhrman grade, and final pathology were recorded. Benign tumours and malignant lesions with incomplete information were excluded from final analysis. RESULTS: The mean (SD) age of the patients was 60.6 (12.2) years and the mean tumour size 5.5 (3.5) cm. Most tumours were malignant (90.2%) and of low stage (T1-T2, 71.7%) and low grade (G1-G2, 72.4%). There were nodal and distant metastases in 5.7% and 13% of the patients. In all, 525 (14.4%) patients died from cancer; in this group, tumours were >4 cm in 88.2% and had nodal or distant metastases in 20.2% and 49.3%, respectively. Multivariable analysis showed that tumour size >4 cm, ECOG PS >or=1, TNM stage and Fuhrman grade were independent predictors of cancer-related death. CONCLUSION: A significant proportion of incidental renal tumours can lead to the death of the patient. Standard prognostic variables for renal cell carcinoma appear to remain valid for this subset of patients. A watchful-waiting strategy should not be recommended if the tumour diameter is >4 cm, if biopsy confirms high-grade tumours, or if there is an impaired ECOG PS, or computed tomography findings suggest the presence of advanced T stage.

Unclassified renal cell carcinoma: an analysis of 85 cases.

OBJECTIVES: To compare cancer-specific mortality in patients with unclassified renal cell carcinoma (URCC) vs clear cell RCC (CRCC) after nephrectomy, as URCC is a rare but very aggressive histological subtype. PATIENTS AND METHODS: Eighty-five patients with URCC and 4322 with CRCC were identified within 6530 patients treated with either radical or partial nephrectomy at 18 institutions. Of 85 patients with URCC, 55 were matched with 166 of 4322 for grade, tumour size, and Tumour, Node and Metastasis stages. Kaplan-Meier and life-table analyses were used to address RCC-specific survival. Subsequently, multivariate Cox regression analyses were used to test for differences in RCC-specific survival in unmatched samples. RESULTS: Of patients with URCC, 80% had Fuhrman grades III or IV, vs 37.8% for CRCC. Moreover, 36.5% of patients with URCC had pathologically confirmed nodal metastases, vs 8.6% with CRCC. Finally, 54.1% of patients with URCC had distant metastases at the time of nephrectomy, vs 16.8% with CRCC. Despite these differences in the overall analyses, after matching for tumour characteristics, the URCC-specific mortality rate was 1.6 times higher (P = 0.04) in matched analyses and 1.7 times higher (P = 0.001) in multivariate analyses. CONCLUSIONS: These findings indicate that URCC presents with a higher stage and grade, and even after controlling for the stage and grade differences, predisposes patients to 1.6-1.7 times the mortality of CRCC.

Patients with renal cell carcinoma nodal metastases can be accurately identified: external validation of a new nomogram.

Outcome of patients with renal cell carcinoma nodal metastases (NM) is substantially worse than that of patients with localized disease. This justifies more thorough staging and possibly more aggressive treatment in those at risk of or with established NM. We developed and externally validated a nomogram capable of highly accurately predicting renal cell carcinoma NM in patients without radiographic evidence of distant metastases. Age, symptom classification, tumour size and the pathological nodal stage were available for 4,658 individuals. The data of 2,522 (54.1%) individuals from 7 centers were used to develop a multivariable logistic regression model-based nomogram predicting the individual probability of NM. The remaining data from 2,136 (45.9%) patients from 5 institutions were used for external validation. In the development cohort, 107/2,522 (4.2%) had lymph node metastases vs. 100/2,136 (4.7%) in the external validation cohort. Symptom classification and tumour size were independent predictors of NM in the development cohort. Age failed to reach independent predictor status, but added to discriminant properties of the model. A nomogram based on age, symptom classification and tumour size was 78.4% accurate in predicting the individual probability of NM in the external validation cohort. Our nomogram can contribute to the identification of patients at low risk of NM. This tool can help to risk adjust the need and the extent of nodal staging in patients without known distant metastases. More thorough staging can hopefully better select those in whom adjuvant treatment is necessary. (c) 2007 Wiley-Liss, Inc.

[Partial thrombosis of the corpus cavernosum. Must a clotting disorder be systematically investigated?]. / Thrombose partielle du corps caverneux. Faut-il rechercher systématiquement une anomalie de la coagulation?

The authors report a case of partial thrombosis of a corpus cavernosum, confirmed by MRI imaging. In this patient, a neuroleptic had been prescribed several days before the thrombosis and the clotting assessment demonstrated protein C resistance. Conservative management comprising low molecular weight heparin and aspirin was instituted. Three months later, pain had resolved and signs of a thrombotic scar persisted on MRI. The aetiology of thrombosis of the corpus cavernosum, a rare disease, remains unknown. Neuroleptic therapy has been incriminated. In the light of this case, the authors emphasize the value of systematic clotting assessment.

A new staging system for locally advanced (pT3-4) renal cell carcinoma: a multicenter European study including 2,000 patients.

PURPOSE: We provide an adequate prognostic stratification for locally advanced renal cell carcinoma and propose a new TNM classification. MATERIALS AND METHODS: We analyzed clinical and pathological data on a large series of patients undergoing radical nephrectomy for pT3-4 renal cell carcinoma at 12 European centers. Cancer specific survivals were estimated using the Kaplan-Meier method. The log rank test was used for comparing survival curves and for univariate analysis. The Cox proportional hazards regression model was used for multivariate analysis. RESULTS: The analysis included 1,969 patients. Median survivor followup was 49 months. Five-year cancer specific survival was 60% for pT3a, 46.2% for pT3b, 10% for pT3c and 12% for pT4 tumors (p <0.0001). According to median survival we identified 3 prognostic groups, including 1--patients with renal vein thrombosis (117 months), fat invasion (98 months) or infradiaphragmatic vena caval thrombosis (67 months), 2--patients with adrenal invasion alone (24 months), renal vein thrombosis plus fat invasion (24 months) or infradiaphragmatic vena cava plus fat invasion (24 months) and 3--patients with renal or infradiaphragmatic caval thrombosis plus adrenal involvement (11 months), supradiaphragmatic vena caval thrombosis (12 months) or Gerota's fascia invasion (12 months). Five-year cancer specific survival rates in groups 1 to 3 were 61%, 35% and 12.9%, respectively (p <0.0001). On multivariate analysis the proposed classification had an independent prognostic value. CONCLUSIONS: Our results suggest the necessity of reclassifying locally advanced renal cell carcinoma according to the 3 described prognostic categories.

Multi-institutional validation of a new renal cancer-specific survival nomogram.

PURPOSE: We tested the hypothesis that the prediction of renal cancer-specific survival can be improved if traditional predictor variables are used within a prognostic nomogram. PATIENTS AND METHODS: Two cohorts of patients treated with either radical or partial nephrectomy for renal cortical tumors were used: one (n = 2,530) for nomogram development and for internal validation (200 bootstrap resamples), and a second (n = 1,422) for external validation. Cox proportional hazards regression analyses modeled the 2002 TNM stages, tumor size, Fuhrman grade, histologic subtype, local symptoms, age, and sex. The accuracy of the nomogram was compared with an established staging scheme. RESULTS: Cancer-specific mortality was observed in 598 (23.6%) patients, whereas 200 (7.9%) died as a result of other causes. Follow-up ranged from 0.1 to 286 months (median, 38.8 months). External validation of the nomogram at 1, 2, 5, and 10 years after nephrectomy revealed predictive accuracy of 87.8%, 89.2%, 86.7%, and 88.8%, respectively. Conversely, the alternative staging scheme predicting at 2 and 5 years was less accurate, as evidenced by 86.1% (P = .006) and 83.9% (P = .02) estimates. CONCLUSION: The new nomogram is more contemporary, provides predictions that reach further in time and, compared with its alternative, which predicts at 2 and 5 years, generates 3.1% and 2.8% more accurate predictions, respectively.

[Anastomosis of ectopic trifid ureter into the prostatic urethra with ureteropelvic reflux]. / Abouchement dans l'urètre prostatique d'un uretère ectopique trifide avec reflux urétéro-rénal.

Trifid ureter is a rare malformation with less than one hundred cases reported in the literature. However, like ectopic ureter, it is often asymptomatic and its real incidence is uncertain. The authors report a unique case of ectopic ureter draining into the prostatic urethra associated with trifid ureter, discovered during adulthood in a context of symptomatic ureteropelvic reflux. Laparoscopic assessment and treatment of this malformation are discussed, together with the hypotheses concerning its embryogenesis, based on a review of the literature.

[Biopsy technique and biopsy schemes for a first series of prostatic biopsies]. / Conditions de réalisation et schéma de ponctions lors d'une première série de biopsies prostatiques.

OBJECTIVE: To define the modalities of prostatic biopsies in patients with suspected prostate cancer, particularly concerning prevention of complications, the number of biopsies and the biopsy schemes ensuring an optimal cancer detection rate, and recording of prognostic elements, all with an acceptable morbidity, METHOD: Review of the literature. RESULTS: Information before biopsy: A preliminary visit with oral and written information is necessary before any biopsy procedure in order to: describe the modalities of the procedure to improve the patient's cooperation, detect contraindications, guide preparation, explain the risks and elements of surveillance, and describe the management in the case of complications (level of evidence: IV-3). PREPARATION BEFORE BIOPSY: A single dose of prophylactic antibiotic is necessary before the examination. Longer antibiotic prophylaxis is necessary in patients with risk factors for infection (level of evidence: II). A rectal enema is recommended (level of evidence: III). Routine urine bacteriology and blood coagulation tests are unnecessary (level of evidence: II). In patients taking anticoagulants, this treatment must be stopped before the examination (level of evidence: IV-2). BIOPSY TECHNIQUE: Local anaesthesia with 1% lidocaine by ultrasound-guided injection into the periprostatic spaces is recommended to improve tolerability, when the number of biopsies is > 6 (level of evidence: II-2). General anaesthesia may be necessary in a minority of cases, for local anatomical reasons or when preferred by the patient. Prostatic aspiration biopsies should be performed via a transrectal approach with ultrasound guidance, especially in the absence of a palpable lesion (level of evidence: IV-1). The examination must start with digital rectal examination and complete analysis of the echostructure of the prostate to identify suspicious zones that will also be aspirated. Biopsy scheme as a function of stage: In the case of palpable or visible lesion (stage T2 or T3), at least six transrectal ultrasound-guided lateral sextant biopsies including the peripheral glandular zone at the base, in the middle and at the apex of each lobe as well as a biopsy in a suspicious zone are necessary for cancer detection and staging. Each biopsy must be identified or embedded separately to facilitate identification by the pathologist (level of evidence: IV-1). In the absence of palpable or visible lesion (stage T1a, b, c), another 6 sextant midlobar biopsies are recommended (12 biopsy plan). In the case of prostate volume < 40-50 cm3, the two midlobar biopsies of the apex may be eliminated (10 biopsy plan) (level of evidence: III-2). In the case of prostate volume > 40-50 cm3, anterior biopsies (4 additional biopsies, 16 biopsy scheme) including the glandular zone of benign hyperplasia are not routinely recommended (level of evidence: III-2). In stage T4, a biopsy in each lobe is sufficient for histological confirmation of the diagnosis. CONCLUSION: Complementary studies are necessary to validate the 12 biopsy or 16 biopsy plans, especially as a function of prostatic volume, clinical stage and biopsy sequence (first or second series).

Prognostic value of uPA, PAI-1, and DNA content in adult renal cell carcinoma.

OBJECTIVES: To examine whether urokinase-type plasminogen activator (uPA) and type 1 plasminogen inhibitor (PAI-1), DNA ploidy, and S-phase fraction (SPF) add supplementary prognostic information relative to stage and Fuhrman's grade in renal cell carcinoma. METHODS: A total of 100 patients with primary renal adenocarcinoma treated by nephrectomy were followed up for a median of 42 months. Of the 100 patients, 78 with Stage M0N0-Nx tumors were studied by multivariate analysis. The study population was dichotomized on the basis of the median cytosolic uPA and PAI-1 concentrations (30 pg/mg protein and 12.7 ng/mg protein, respectively). DNA content was measured by flow cytometry (FCM) on multiple tumor samples from each patient. DNA aneuploidy was observed in 67% of cases. The SPF was calculated for aneuploid samples. RESULTS: An FCM classification based on a combination of DNA content and SPF was obtained. High-risk patients were those with aneuploid tumors and high SPF values (greater than 1.7%) and included 23% of patients with M0N0-Nx tumors. Cytosolic uPA and PAI-1 levels were not predictive of metastasis. The stage, grade, SPF, and FCM classification were statistically significant prognostic factors in the univariate analysis, in both the overall population and the M0N0-Nx subgroup. In multivariate analysis, tumor grade and the FCM classification were the only independent predictors of disease-free survival (P = 0.018 and P = 0.046, respectively). CONCLUSIONS: We defined a group of M0N0-Nx patients with aneuploid tumors and high SPF values who are at a high risk of metastasis and who may benefit from closer long-term follow-up.