Survey on vasectomy practices in France in 2022.

OBJECTIVES: Prior to the publication of the recommendations of the French Association of Urology (AFU) on vasectomy, we conducted a survey to assess current practices and required training interventions in France regarding vasectomy. METHOD: An invitation with a link to a 38-item questionnaire on MonkeySurvey was sent in November 2022 to the 1760 urologist members of the AFU. RESULTS: A total of 352 (20%) urologists completed the survey. Among the participants, 20% reported refusing the surgery to patients aged 25 to 30 years old and 17% if they had no children, respectively. Three quarters of participants mentioned systematically performing a scrotal exam at the time of the pre-vasectomy consultation. Forty-one percent of respondents reported systematically performing vasectomy under general anesthesia. While 56% of participants mentioned performing a minimally invasive technique for exposing the vas, 70% said they were willing to learn the no-scalpel technique for this purpose. The most frequently reported occlusion techniques combine excision of a vas segment and ligation of both ends of the divided vas. Only 26% reported performing fascial interposition and 4% using the "open end" technique. A post-vasectomy semen analysis showing less than 100,000 non-motile sperm per millilitre makes only 38% of respondents recommending stopping other contraceptive methods. Half of the respondents considered that current reimbursement fee structure for the procedure restrains the development of this clinical activity. CONCLUSION: Our survey suggests that vasectomy practice and services in France do not meet the international standards. We identified the clinical and organizational changes needed to improve practices and access to vasectomy services in France. LEVEL OF EVIDENCE: Grade 3.

Postoperative nomogram to predict cancer-specific survival after radical nephroureterectomy in patients with localised and/or locally advanced upper tract urothelial carcinoma without metastasis.

OBJECTIVE: To propose and validate a nomogram to predict cancer-specific survival (CSS) after radical nephroureterectomy (RNU) in patients with pT1-3/N0-x upper tract urothelial carcinoma (UTUC). PATIENTS AND METHODS: The international and the French national collaborative groups on UTUC pooled data from 3387 patients treated with RNU. Only 2233 chemotherapy naïve pT1-3/N0-x patients were included in the present study. The population was randomly split into the development cohort (1563) and the external validation cohort (670). To build the nomogram, logistic regressions were used for univariable and multivariable analyses. Different models were generated. The most accurate model was assessed using Harrell's concordance index and decision curve analysis (DCA). Internal validation was then performed by bootstrapping. Finally, the nomogram was calibrated and externally validated in the external dataset. RESULTS: Of the 1563 patients in the nomogram development cohort, 309 (19.7%) died during follow-up from UTUC. The actuarial CSS probability at 5 years was 75.7% (95% confidence interval [CI] 73.2-78.6%). DCA revealed that the use of the best model was associated with benefit gains relative to prediction of CSS. The optimised nomogram included only six variables associated with CSS in multivariable analysis: age (P < 0.001), pT stage (P < 0.001), grade (P < 0.02), location (P < 0.001), architecture (P < 0.001) and lymphovascular invasion (P < 0.001). The accuracy of the nomogram was 0.81 (95% CI, 0.78-0.85). Limitations included the retrospective study design and the lack of a central pathological review. CONCLUSION: An accurate postoperative nomogram was developed to predict CSS after RNU only in locally and/or locally advanced UTUC without metastasis, where the decision for adjuvant treatment is controversial but crucial for the oncological outcome.

The learning curve of transrectal ultrasound-guided prostate biopsies: implications for training programs.

OBJECTIVE: To assess the quality of specimens obtained from prostate biopsies performed by urology residents and evaluate the number of procedures required to perform high-quality transrectal ultrasound (TRUS)-guided prostate biopsies. MATERIALS AND METHODS: Between 2006 and 2009, 770 patients underwent TRUS-guided prostate biopsies in our academic center. During the 6 semesters of this period, 24 residents (4 per semester) performed 1 session of 5.6±1.5 procedures each month for a total of 33.6±9 procedures during the study. The first session was performed with a senior urologist. Prostate cancer detection rate and standards of quality (average length of prostatic core biopsy specimens and absence of prostatic tissue) were retrospectively studied between the beginning and the end of each semester. RESULTS: A total of 12,760 biopsy cores were performed for 770 procedures. Mean patient age (64.5±6.1 years), and median prostate-specific antigen (8.7±3.7 ng/mL) were comparable between the study periods. The average length of biopsy cores significantly improved (+10%) from the first (12±2.7 mm) to the last month (13.2±2.1 mm) with a plateau after 12 procedures. Overall, cancer detection rate was 47% and was stable during the semester (41.3% the first month vs 44.1% the last month; P=.39). On univariate and multivariate analysis the mean length of biopsy specimens was associated with the number of procedures (P<.001) and the number of cores performed (P<.001). CONCLUSION: Twelve procedures are necessary to perform high-quality TRUS-guided prostate biopsies without compromising prostate cancer detection. In current training programs, we strongly recommend that residents have direct supervision for a minimum of 12 cases before they are allowed to perform TRUS-guided biopsies with indirect supervision.

A systematic review of the tools available for predicting survival and managing patients with urothelial carcinomas of the bladder and of the upper tract in a curative setting.

OBJECTIVES: To identify the predictive tools which have emerged recently in the field of urothelial carcinomas. MATERIALS AND METHODS: We performed a thorough MEDLINE literature review using a combination of the following keywords: urothelial carcinoma, transitional cell carcinoma, bladder, renal pelvis, ureter, predictive tools, predictive models and nomograms. We found 117 articles, but only the relevant reports were selected. RESULTS: The majority of available tools are prediction models, particularly nomograms. These models combine good performance accuracy with ease of use. They appear to be more accurate than risk grouping or tree modeling and are more suitable for clinicians than artificial intelligence. The most recent nomograms have been designed to be used in daily clinical practice and are even available as computer or smartphone applications. They focus on pathological outcomes or more frequently on survival statistics or recurrence risk after surgery. They provide an accurate prediction of disease evolution and may help clinicians to choose the most appropriate treatment option. However, these prediction tools still need to be validated and regularly utilized. CONCLUSION: Predictive tools represent very helpful clinical decision-making aids but need to be validated in larger populations.

Prediction of cancer specific survival after radical nephroureterectomy for upper tract urothelial carcinoma: development of an optimized postoperative nomogram using decision curve analysis.

PURPOSE: We conceived and proposed a unique and optimized nomogram to predict cancer specific survival after radical nephroureterectomy in patients with upper tract urothelial carcinoma by merging the 2 largest multicenter data sets reported in this population. MATERIALS AND METHODS: The international and the French national collaborative groups on upper tract urothelial carcinoma pooled data on 3,387 patients treated with radical nephroureterectomy for whom full data for nomogram development were available. The merged study population was randomly split into the development cohort (2,371) and the external validation cohort (1,016). Cox regressions were used for univariable and multivariable analyses, and to build different models. The ultimate reduced nomogram was assessed using Harrell's concordance index (c-index) and decision curve analysis. RESULTS: Of the 2,371 patients in the nomogram development cohort 510 (21.5%) died of upper tract urothelial carcinoma during followup. The actuarial cancer specific survival probability at 5 years was 73.7% (95% CI 71.9-75.6). Decision curve analysis revealed that the use of the best model was associated with benefit gains relative to the prediction of cancer specific survival. The optimized nomogram included only 5 variables associated with cancer specific survival on multivariable analysis, those of age (p = 0.001), T stage (p <0.001), N stage (p = 0.001), architecture (p = 0.02) and lymphovascular invasion (p = 0.001). The discriminative accuracy of the nomogram was 0.8 (95% CI 0.77-0.86). CONCLUSIONS: Using standard pathological features obtained from the largest data set of upper tract urothelial carcinomas worldwide, we devised and validated an accurate and ultimate nomogram, superior to any single clinical variable, for predicting cancer specific survival after radical nephroureterectomy.

A prospective comparison of the pathologic and surgical outcomes obtained after elective treatment of renal cell carcinoma by open or robot-assisted partial nephrectomy.

OBJECTIVE: To prospectively compare surgical and pathologic outcomes obtained by elective robot-assisted (RAPN) or open partial nephrectomy (OPN) for small renal cell carcinoma (RCC). MATERIALS AND METHODS: Between 2008 and 2010, after protocol design and patient consent, we prospectively collected clinical data for 100 patients who concurrently underwent either OPN (58) or RAPN (42) by an individual experienced surgeon. Clinical data included age, BMI, and past medical history. Operative data included operative time, warm ischemia time (WIT), and estimated blood loss (EBL). Postoperative outcomes included hospital stay (LOS), creatinine variation, Clavien complications, pathologic results, and survival. We stratified the complexity of the renal tumor using the R.E.N.A.L Nephrometry score. RESULTS: Of note, RAPN was superior to OPN in terms of EBL (median 143 mL vs. 415; P < 0.001) and LOS (median 3.8 days vs. 6.8; P < 0.0001). The median WIT for the RAPN group was 17.5 minutes (vs. 17.1 OPN; P = 0.3)) and the mean strict operative time was 134.8 minutes (vs. 128.4 OPN; P = 0.097). Regarding immediate, early, and short-term complications, variation of creatinine levels, and pathologic margins, the rates were equivalent for both groups (P > 0.05). According to the R.E.N.A.L nephrometry scores, both groups (RAPN/OPN) had similar rates (%) of low (81/72.4) and intermediate (19/20.7) complexity tumors, though there were 4 high complexity tumors in OPN group (vs. 0; P = 0.03). CONCLUSION: We found that RAPN is superior to the reference standard (OPN) surgical treatment of small RCCs in terms of blood loss and length of hospital stay with equivalent complications, warm ischemia time, and effect on renal function. Larger randomized trials with longer follow-up will give us further information and insight into the oncologic equivalence.

Double J stent reduces the efficacy of extracorporeal shock wave lithotripsy in the treatment of lumbar ureteral stones.

INTRODUCTION: We evaluated the effect of the presence of a double J stent on the efficacy of extracorporeal shock wave lithotripsy (ESWL) in the treatment of lumbar ureteral stones. MATERIAL AND METHODS: Between January 2007 and February 2012, we performed a retrospective cohort study. Forty-four patients were treated by ESWL for lumbar ureteral stones and included into two groups for the analysis: group 1, non-stented (n = 27) and group 2, stented patients (n = 17). Treatment efficacy was evaluated by abdominal X-ray or CT-scan at 1 month. Stone-free patients and those with a residual stone ≤4 mm were considered to be cured. RESULTS: Mean stone size and density in groups 1 and 2 were 8.2mm/831HU, and 9.7 mm/986HU respectively. Both groups were comparable for age, BMI, stone size and density, number, and power of ESWL shots given. The success rates in groups 1 and 2 where 81.5% and 47.1%, respectively (p = 0.017). There was no difference between the groups for stones measuring 8 mm or less (p = 0.574). For stones >8 mm, the success rates were respectively 76% and 22.2% for groups 1 and 2 (p = 0.030). Logistic regression analysis revealed a higher failure rate when a double J stent was associated with a stone >8 mm (p = 0.033). CONCLUSIONS: The presence of a double J stent affects the efficacy of ESWL in the treatment of lumbar ureteral stones. This effect is significant for stones >8 mm. Ureteroscopy should be considered as the first-line treatment in such patients.

Low accuracy of routine ultrasound-guided systematic 12-core biopsies in prostate tumor mapping.

INTRODUCTION: To determine the accuracy of a 12-core biopsy protocol in assessing the location of prostate tumors within radical prostatectomy (RP) specimens. MATERIALS AND METHODS: A consecutive series of patients with T1c stage prostate cancer who had undergone 12 ultrasound-guided prostate biopsies prior to RP was considered. The locations of the biopsies from prostate gland mapping were compared with the locations of tumor tissues obtained after analysis of the prostate specimens. RESULTS: Overall, 78 patients (27.4%) were included. The median PSA level was 6 ng/mL. The median prostate weight was 45 g (range 22 to 102). Overall, 936 biopsies were performed in the 78 men, of which 254 biopsies were positive. The mean number of positive biopsies per patient was 3.7 (range 1 to 12). Pathologic examination of the surgical specimens revealed that 58 (74.4%) patients had pT2 disease and 20 patients (25.6%) had locally advanced disease (pT3). The biopsy protocol's sensitivity, specificity and positive predictive value for tumor location were 0.34, 0.83 and 0.84. The performance of the protocol was modest in assessing the exact tumor location (area under curve (AUC) 0.581, 95% confidence interval (CI) 0.489-0.719). CONCLUSIONS: Routine, ultrasound-guided, systematic 12-core biopsies lack precision in prostate tumor mapping.

A 970 Hounsfield units (HU) threshold of kidney stone density on non-contrast computed tomography (NCCT) improves patients' selection for extracorporeal shockwave lithotripsy (ESWL): evidence from a prospective study.

UNLABELLED: What's known on the subject? and What does the study add? Stone density on non-contrast computed tomography (NCCT) is reported to be a prognosis factor for extracorporeal shockwave lithotripsy (ESWL). In this prospective study, we determined that a 970 HU threshold of stone density is a very specific and sensitive threshold beyond which the likelihood to be rendered stone free is poor. Thus, NCCT evaluation of stone density before ESWL may useful to identify which patients should be offered alternative treatment to optimise their outcome. OBJECTIVE: • To evaluate the usefulness of measuring urinary calculi attenuation values by non-contrast computed tomography (NCCT) for predicting the outcome of treatment by extracorporeal shockwave lithotripsy (ESWL). PATIENTS AND METHODS: • We prospectively evaluated 50 patients with urinary calculi of 5-22 mm undergoing ESWL. • All patients had NCCT at 120 kV and 100 mA on a spiral CT scanner. Patient age, sex, body mass index, stone laterality, stone size, stone attenuation values (Hounsfield units [HU]), stone location, and presence of JJ stent were studied as potential predictors. • The outcome was evaluated 4 weeks after the ESWL session by NCCT. • ESWL success was defined as patients being stone-free (SF) or with remaining stone fragments of <4 mm, which were considered as clinically insignificant residual fragments (CIRF). RESULTS: • Our survey concluded that 26 patients (52%) were SF, 12 (24%) had CIRF and 12 (24%) had residual fragment on NCCT after a one ESWL treatment. • Stones of patients who became SF or had CIRF had a lower density compared with stones in patients with residual fragments [mean (sd) 715 (260) vs 1196 (171) HU, P < 0.001]. • The Youden Index showed that a stone density of 970 HU represented the most sensitive (100%) and specific (81%) point on the receiver-operating characteristic curve. • The stone-free rate for stones of <970 HU was 96% vs 38% for stones of ≥ 970 HU (P < 0.001). A linear relationship between the calculus density and the success rate of ESWL was identified. CONCLUSION: • The use of NCCT to determine the attenuation values of urinary calculi before ESWL helps to predict treatment outcome, and, consequently, could be helpful in planning alternative treatment for patients with a likelihood of a poor outcome from ESWL.

Comparison of the effects of adenosine, inosine, and their combination as an adjunct to reperfusion in the treatment of acute myocardial infarction.

Adenosine and inosine are both key intracellular energy substrates for nucleotide synthesis by salvage pathways, especially during ischemic stress conditions. Additionally they both possess cell protective and cell repair properties. The objective of this study is to detect potential advantages of the combination of adenosine and inosine versus each drug alone, in terms of ventricular function, infarct size reduction and angiogenesis. Myocardial ischemia was created in rodents and treated with adenosine, inosine or their combination. Results of experiments showed that the combination of both drugs significantly reduced infarct size and improved myocardial angiogenesis and ventricular function. The two compounds, while chemically similar, use different intracellular pathways, allowing for complementary biological activities without overlapping. The drug combination at specific 1 : 5 adenosine : inosine dose ratio demonstrated positive cardiologic effects, deserving further evaluation as an adjunct to reperfusion techniques during and after acute coronary syndrome. The association of adenosine and inosine may contribute to reduce myocardial infarction morbidity and mortality rates.

A direct comparison of the diagnostic accuracy of three prostate cancer nomograms designed to predict the likelihood of a positive initial transrectal biopsy.

BACKGROUND: Several tools have been developed to predict the outcome of prostate biopsies performed to diagnosis prostate cancer (PCa). However, few studies have focused on the comparative accuracy of these predictive tools. We aim to establish the predictive accuracy of three commonly used nomograms by comparing their prostate biopsy outcome predictions with actual pathological results. METHODS: From January 2008 to December 2010, 708 consecutive patients with an elevated serum PSA level and/or abnormal DRE were referred to our institution. All data were collected prospectively. All patients underwent a TRUS 12-core biopsy. Probability of a positive biopsy was predicted using three online risk calculation nomograms. The discriminative ability of the nomograms was assessed via AUC and the most accurate model was calibrated and compared to actual biopsy results. RESULTS: Of 667 patients fulfilling all three nomograms criteria, 384 (57.5%) had PCa and 283 (42.5%) did not. AUC for the PCPT-CRC, SWOP-PRI, and Montreal nomograms was 0.68 (95% CI, 0.63-0.72), 0.72 (95% CI, 0.68-0.76), and 0.79 (95% CI, 0.76-0.82), respectively. A comparison of the three models' performance showed that the Montreal model provided the greatest predictive accuracy (P = 0.03). CONCLUSIONS: External validation of three commonly used nomograms designed to predict the likelihood of a positive prostate biopsy reveals the Montreal model was more accurate than either the PCPT-CRC or SWOP-PRI models. The Montreal nomogram achieves a diagnostic accuracy of 79% and is superior to PSA alone though we await further research to define the probability (of cancer) threshold above which a prostate biopsy would be advised.

Impact of elective versus imperative indications on oncologic outcomes after open nephron-sparing surgery for the treatment of sporadic renal cell carcinomas.

PURPOSE: To determine the effect of nephron-sparing surgery (NSS) on cancer control in renal cell carcinomas (RCC) and to compare the outcomes of patients who had elective versus imperative indications for surgery. METHODS: We performed a retrospective review of the data for patients treated with open NSS between 1980 and 2005 for sporadic RCCs. The following data were analyzed: age, intraoperative parameters, tumor size, Fuhrman grade, tumor, node, metastasis system disease stage, pathological data, and outcome. RESULTS: A total of 155 patients with a median age of 60 years were included. The mean preoperative and postoperative creatinine levels were 1.1 ± 0.3 mg/dl (range 0.6-2.6 mg/dl) and 1.2 ± 0.4 mg/dl (range 0.5-3.4 mg/dl), respectively. The mean tumor size was 3.8 ± 2 cm (range 1-10 cm). Margin status was positive in 15 cases (9.70%), and multifocal RCCs were observed in 36 patients (23.2%). Overall, NSS indications were elective in 96 cases (61.9%) and imperative in 59 cases (38.1%). Univariate analysis found that elective cases were associated with better perioperative outcomes (P = 0.01). In univariate analysis, tumor, node, metastasis system disease stage, multifocality, and indication were associated with recurrence (P < 0.05). In the multivariate analysis, only multifocality status and imperatives indications were significant (P < 0.05). The mean follow-up was 118.2 ± 151 months. The 5- and 10-year tumor-free survival rates were 81.8% and 78.7% in elective and imperatives cases, respectively. CONCLUSIONS: Oncologic control seems to be better for cases of elective open NSS. Thus, NSS should be advocated as soon as it is technically possible, regardless of the size of the tumor.

Pathological findings and oncological control afforded by radical prostatectomy in men with high-risk prostate cancer: a single-centre study.

OBJECTIVE: To assess pathological findings and oncological control afforded by radical prostatectomy (RP) in high-risk prostate cancers (PCa) at our institution. MATERIALS AND METHODS: We performed a retrospective review of prostate cancer patients who underwent RP between 1995 and 2006 for a high-risk prostate cancer (i.e., PSA >20 or biopsy Gleason ≥8 or clinical stage ≥T2c). Biochemical recurrence was defined as a single rise in PSA levels over 0.2 ng/ml after surgery. Survival curves were elaborated by the Kaplan-Meier method and Cox proportional hazard regression analysis. For each patient, a prognostic score for recurrence was estimated, and a prediction model was then constructed. RESULTS: Overall, 138 patients were included and followed for a median time of 53 months. Mean age at diagnosis was 63.4 years (range 39-80) and mean pre-operative PSA was 15.5 ng/ml (range 7.4-31). The median follow-up was 53 months (range 6-166). Overall, 82 patients (59%) had biochemical recurrence. The five-year PSA recurrence-free survival rate was 40%. In univariate analysis, clinically palpable tumours (T2-T3) (P = 0.032), biopsy Gleason score ≥8 (P = 0.031), seminal vesicle invasion (pT3b), positive margins and positive lymph nodes (P < 0.001) were significantly associated with recurrence. In multivariate analysis, the biopsy Gleason score ≥8, seminal vesicle invasion, positive margins and positive lymph nodes predicted recurrence (P < 0.05). CONCLUSIONS: RP affords an acceptable oncological control at first-line treatment of selected patients with high-risk PCa. However, in certain cases, surgery alone might not be sufficient and may be part of a multimodal treatment including either adjuvant radiotherapy or androgen deprivation.

Comparison of mid-term carcinologic control obtained after open, laparoscopic, and robot-assisted radical prostatectomy for localized prostate cancer.

OBJECTIVE: To determine the cancer control afforded by radical prostatectomy in patients who underwent either an open, laparoscopic, or robotic procedure for localized prostate cancer. METHODS: We collected data on all patients treated between 2000 and 2004. We recorded age, BMI, PSA, Gleason score and 2002 TNM stage, type of surgery, perioperative parameters, postoperative complications, pathological data, recurrence and outcome. RESULTS: Data were analyzed for 239 patients. Overall, the mean follow-up was 49.7 (18-103) months. Surgical procedures were open in 83 patients, laparoscopic in 85, and robot-assisted in 71. The transfusion rate was 5.6% for robotic cases, 5.9% for laparoscopic cases and 9.6% for open prostatectomy (p = 0.03). The positive margin rates in open, laparoscopic, and robotic cases were 18.1, 18.8, and 16.9% (p = 0.52), respectively. Only margin status, PSA level (>10), and Gleason score (>7) were associated with recurrence in univariate analysis (p < 0.05), and only the margin status and the Gleason score were significant in multivariate analysis. The statistical power was 0.7. Overall, the 5-year PSA-free survival rate was 88%. The 5-year PSA-free survival rates for the specific surgical approaches were 87.8% in open cases, 88.1% in laparoscopic cases, and 89.6% in robot-assisted prostatectomies, and there was no statistical difference between the approaches (p = 0.93). CONCLUSION: Although open radical prostatectomy remains the gold standard procedure, we found no differences between these three techniques regarding early oncologic outcomes. These results are still preliminary, however, and further studies of larger populations with a longer follow-up are needed to make any statement regarding surgical strategy.

Cross-cultural validation of a prognostic tool: example of the Kattan preoperative nomogram as a predictor of prostate cancer recurrence after radical prostatectomy.

OBJECTIVE: To establish the predictive accuracy of the Kattan preoperative nomogram by comparing predictions at 5 years with actual progression in patients who had a radical prostatectomy (RP). MATERIALS AND METHODS: We reviewed the data for 928 patients treated by RP as a first-line treatment for localized prostate cancer, between 1994 and 2005. Recurrence was defined as one prostate-specific antigen (PSA) level of >0.4 ng/mL. The 5-year progression-free probability (PFP) rate was evaluated on censured data using the Kaplan-Meier method. Relationships between all predictor variables included in the Kattan nomogram (PSA level, biopsy Gleason scores and clinical stage) and survival were evaluated by Cox proportional-hazards regression analysis. The discriminating ability of the nomogram was assessed by the concordance index (c-index). Bootstrapping was used to assess confidence intervals (CIs), and then the calibration was assessed. RESULTS: The median follow-up was 60 months. Overall, 177 (19%) patients had a recurrence; the 5-year PFP rate (95% CI) was 80.9 (78-83)%. Of the three variables included in the nomogram, all were associated with recurrence in a multivariate analysis (P < 0.001). The c-index (95% CI) was only 0.664 (0.584-0.744). In general, the nomogram was not well calibrated. CONCLUSIONS: There was a discrepancy between the predicted PFP as estimated by the Kattan nomogram and actual relapse in this group of patients. Clinicians should be aware that the nomogram is less accurate when used outside the population used to formulate the nomogram. Although more accurate tools are needed, the Kattan nomogram is still the best choice for urologists so far.

Long-term outcomes after nephron sparing surgery for renal cell carcinoma larger than 4 cm.

PURPOSE: We determined the cancer control provided by nephron sparing surgery for renal cell carcinoma greater than 4 cm. MATERIALS AND METHODS: We performed a retrospective review of data on patients treated between 1980 and 2005. The case characteristics analyzed were patient age, surgical procedure, intraoperative parameters, complications, tumor size, Fuhrman grade, TNM stage, pathological data and outcome. Kaplan-Meier survival curves were generated. RESULTS: Median age of the 61 patients was 64 years (range 40 to 83). Mean +/- SD intraoperative blood loss was 622 ml +/- 691 (range 50 to 4,800) and mean operative time was 155.7 +/- 82 minutes (range 52 to 360). Mean creatinine preoperatively and immediately postoperatively was 1.16 and 1.25 mg/dl, respectively. Mean renal cell carcinoma size was 56.3 +/- 18 mm (range 41 to 100). Margin status was positive in 11 cases (18%). Median followup was 70.7 months. The 5 and 10-year cancer specific survival rate was 81% and 78%, respectively. The tumor-free survival rate was 92% at 5 years and 88% at 10 years. On univariate analysis tumor size more than 7 cm (p = 0.002), pathological stage (p = 0.001) and Fuhrman grade (p = 0.004) were associated with survival. On multivariate analysis only pathological stage and Fuhrman grade were significant (p <0.0001 and 0.007, respectively). CONCLUSIONS: Our results support the fact that nephron sparing surgery is a useful and acceptable approach to renal cell carcinoma greater than 4 cm. When technically possible, nephron sparing surgery provides acceptable long-term cancer specific survival rates. However, oncological safety is less evident in cases of renal cell carcinoma greater than 7 cm. To date in such cases nephron sparing surgery should only be considered for absolute indications.

A comparison of the performance of microsatellite and methylation urine analysis for predicting the recurrence of urothelial cell carcinoma, and definition of a set of markers by Bayesian network analysis.

OBJECTIVE: To compare the potential of two diagnostic methods for detecting recurrence of urothelial cell carcinoma (UCC) of the bladder, by (i) detecting alterations in microsatellite DNA markers and loss of heterozygosity (LOH), and (ii) detecting aberrant gene hypermethylation, as UCC has a high recurrence rate in the urinary tract and the disease can invade muscle if new tumours are overlooked. PATIENTS AND METHODS: Over 1 year, urine samples were retrieved from 40 patients already diagnosed with bladder UCC (30 pTa, two pTis, eight pT1). Samples were collected 6 months after bladder tumour resection, during the follow-up schedule. We used samples to analyse nine microsatellite markers and the methylation status of 11 gene promoters. Receiver operating characteristic curves were generated and Bayesian statistics used to create an interaction network between recurrence and the biomarkers. RESULTS: During the study, 15 of the 40 patients (38%) had a tumour recurrence and 14 were identified by cystoscopy (reference method). Overall, microsatellite markers (area under curve, AUC 0.819, 95% confidence interval, CI, 0.677-0.961) had better performance characteristics than promoter hypermethylation (AUC 0.448, 0.259-0.637) for detecting recurrence. A marker panel of IFNA, MBP, ACTBP2, D9S162 and of RASSF1A, and WIF1 generated a higher diagnostic accuracy of 86% (AUC 0.92, 0.772-0.981). CONCLUSION: Microsatellite markers have better performance characteristics than promoter hypermethylation for detecting UCC recurrence. These data support the further development of a combination of only six markers from both methods in urinary DNA. Once validated, it could be used routinely during the follow-up for the early detection and surveillance of UCC from the lower and upper urinary tract.

Prostate cancer characteristics in a multiracial community.

OBJECTIVES: To investigate the hypothesis that Northern Africans differ from Caucasians with regard to their PCa characteristics, using our 1988-2006 database we retrospectively reviewed the preoperative and pathological features of consecutive patients subjected to radical prostatectomy (RP) for localized prostate cancer (PCa) and stratified according to their ethnic origin. METHODS: In 727 consecutive patients (616 Caucasians; 61 Blacks originating from Central Africa and the French West Indies; 50 Northern Africans from Morocco, Algeria, Tunisia), we preoperatively analyzed and compared age, clinical stage of the tumour, prostate-specific antigen (PSA), transrectal ultrasound prostate volume, PSA density (PSAD), biopsy Gleason score, number of positive cores (NPC), and percentage of tissue core invaded by cancer (PTIC); postoperatively, we determined the status of the capsule, seminal vesicles, and margins of the RP specimen, as well as Gleason score and prostate weight. Statistical analyses (chi-square test and ANOVA) were performed to compare the results between the three groups of patients. A multivariate analysis was carried out to test the independence of variables. RESULTS: Black patients were the youngest at the time of surgery (by 3-4 yr) and had the highest rates of final Gleason score>or=8. The Northern Africans had more favourable features than did Caucasian and Black patients: mean PTIC was 7.1% versus 14.6% and 12.5%, respectively (p=0.005), mean NPC was 26.4% versus 34.7% and 36.4%, respectively (p=0.034), rates of biopsy and final Gleason score>or=8 were significantly lower (p=0.02 and p=0.028, respectively), and there were positive margins in 26% versus 36% and 35.6%, respectively (p>0.05). CONCLUSIONS: This study showed that a French Black population is the most likely of those studied to have unfavourable PCa characteristics at the time of RP. Albeit in a limited series, we show for the first time that Northern Africans have significantly better features in this regard than Caucasians and Blacks. Although Northern Africans did not have a better pathological stage outcome, they did have a more favourable Gleason score.

Promoter hypermethylation in circulating blood cells identifies prostate cancer progression.

Promoter hypermethylation of circulating cell DNA has been advocated as a diagnostic marker for prostate cancer, but its prognostic use is currently unclear. To assess this role, we compared hypermethylation of circulating cell DNA from prostate cancer patients with (Group 1, n = 20) and without (Group 2, n = 22) disease progression and age-matched controls (benign prostatic hyperplasia, Group 3, n = 22). We measured hypermethylation of 10 gene promoters in 2 sequential venous samples, obtained at diagnosis and during disease progression (median time, 15 months later). Matched time samples were obtained in the nonprogressing patients. We found that more hypermethylation was detected in the diagnostic sample from the patients with cancer than in controls for GSTP1, RASSF1 alpha, APC and RAR beta (p < 0.0001). Patients undergoing disease progression had a significant increase in methylation levels of these 4 genes when compared to the other patients (p < 0.001). Patients at risk of disease progression have higher detectable concentrations of circulating cell hypermethylation, than those without progression. The extent of this hypermethylation increases during disease progression and can be used to identify the extent and duration of treatment response in prostate cancer.

Oncologic control after open or laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: a single center experience.

OBJECTIVES: To determine the surgical and oncologic outcomes in patients who underwent either open nephroureterectomy (ONU) or laparoscopic nephroureterectomy (LNU) for upper urinary tract transitional cell carcinoma. METHODS: We performed a retrospective review of data for patients who underwent ONU or LNU for upper urinary tract transitional cell carcinoma from 1994 to 2004 at one institution. The recorded data included sex, age, mode of diagnosis, smoking, history of bladder cancer, type of surgery, complications, tumor site, tumor size, tumor stage, tumor grade, length of hospital stay, recurrence, and progression. We also determined the recurrence and survival rates. RESULTS: We reviewed the data for 46 patients. The median age was 70 years. Seven patients had a history of bladder cancer. Overall, 26 patients underwent ONU and 20 LNU. No differences in the complication rate (15% versus 15%) were observed. The median hospital stay was 4 days (range 3 to 6) after LNU and 9 (range 7 to 12) after ONU (P <0.001). The tumor stage and grade were independent prognostic factors for survival on multivariate analysis (P <0.05). The 5-year disease-specific survival rate was 89.4% for low-grade tumors and 63.1% for high-grade tumors (P = 0.04). ONU was associated with high-grade (P = 0.02) or invasive (P = 0.001) tumors. The 5-year tumor-free survival rate after ONU and LNU was 51.2% and 71.6%, respectively (P = 0.59). CONCLUSIONS: LNU does not affect the mid-term oncologic control and enables a shorter hospital stay. It can be recommended as an alternative to ONU in the management of low-risk upper urinary tract transitional cell carcinoma (Stage T1-T2 and/or low-grade disease). However, long-term follow-up is necessary to recommend it for highly invasive tumors (Stage T3-T4 or N+).