Multiparametric Magnetic Resonance Imaging in the follow-up of non-muscle-invasive bladder tumors after intravesical instillations: a promising tool.

PURPOSE: The standard follow-up for non-muscle-invasive bladder cancer is based on cystoscopy. Unfortunately, post-instillation inflammatory changes can make the interpretation of this exam difficult, with lower specificity. This study aimed to evaluate the interest of bladder MRI in the follow-up of patients following intravesical instillation. METHODS: Data from patients who underwent cystoscopy and bladder MRI in a post-intravesical instillation setting between February 2020 and March 2023 were retrospectively collected. Primary endpoint was to evaluate and compare the diagnostic performance of cystoscopy and bladder MRI in the overall cohort (n = 67) using the pathologic results of TURB as a reference. The secondary endpoint was to analyze the diagnostic accuracy of cystoscopy and bladder MRI according to the appearance of the lesion on cystoscopy [flat (n = 40) or papillary (n = 27)]. RESULTS: The diagnostic performance of bladder MRI was better than that of cystoscopy, with a specificity of 47% (vs. 6%, p < 0.001), a negative predictive value of 88% (vs. 40%, p = 0.03), and a positive predictive value of 66% (vs. 51%, p < 0.001), whereas the sensitivity did not significantly differ between the two exams. In patients with doubtful cystoscopy and negative MRI findings, inflammatory changes were found on TURB in most cases (17/19). The superiority in MRI bladder performance prevailed for "flat lesions", while no significant difference was found for "papillary lesions". CONCLUSIONS: In cases of doubtful cystoscopy after intravesical instillations, MRI appears to be relevant with good performance in differentiating post-therapeutic inflammatory changes from recurrent tumor lesions and could potentially allow avoiding unnecessary TURB.

Cut-off time for surgery and prediction of orchiectomy in spermatic cord torsion: a retrospective multicentric study over 15 years.

PURPOSE: Cut-off time to avoid orchiectomy relies on small series of patients. The objective was to determine the cut-off time to avoid orchiectomy in torsion of the spermatic cord in a large cohort. METHODS: We performed a retrospective multicenter study (TORSAFUF cohort) of patients with suspected spermatic cord torsion between 2005 and 2019. All patients aged > 12 years who were suspected of having a torsion of the spermatic cord in 14 University Hospitals in France were included (n = 2986). Patients for whom data on pain duration were not available (n = 923) or for whom the final diagnosis was not torsion of the spermatic cord (n = 807) were excluded. The primary outcome was orchiectomy. The secondary outcomes were testicular survival time and the prediction of orchiectomy with the duration of pain. RESULTS: 1266 patients were included with an orchiectomy rate of 12% (150 patients). The mean age was 21.5 years old in the salvage group and 23.7 years old in the orchiectomy group (p = 0.01), respectively. The median time from the onset of pain to surgery was 5.5 (IQR = 5) hours in the salvage group and 51.1 (IQR = 70) hours in the orchiectomy group (p < 0.0001). The risk of orchiectomy increased after a time cut-off of 6 h 30. A delay of 15 h 30 in pain duration was found to predict orchiectomy (sensitivity: 0.81; specificity: 0.87). CONCLUSIONS: Pain duration can predict the probability of salvaging the testicles and performing orchiectomy. Rapid intervention should be recommended, regardless of the time elapsed from the onset of pain.

Radioisotope-guided Lymphadenectomy for Pelvic Lymph Node Staging in Patients With Intermediate- and High-risk Prostate Cancer (The Prospective SENTINELLE Study).

PURPOSE: Our aim was to prospectively evaluate the diagnostic accuracy of sentinel lymph node biopsy-guided lymph node dissection compared to extended pelvic lymph node dissection in patients with intermediate- or high-risk prostate cancer. MATERIALS AND METHODS: We conducted a prospective, single-arm, multicenter study at 3 tertiary centers in France between February 2012 and May 2019. Eligible patients had clinically localized intermediate- or high-risk prostate cancer. After intraprostatic injection of (99m)Tc-nanocolloid, the locations of the sentinel lymph nodes were defined by preoperative lymphoscintigraphy. Surgical excision of the sentinel lymph nodes was performed using intraoperative gamma probe guidance. After resection of the sentinel lymph nodes, extended pelvic lymph node dissection was performed in all patients. We assessed the diagnostic accuracy of the sentinel lymph node biopsy method using extended pelvic lymph node dissection as the reference standard. This trial was registered in ClinicalTrials.gov (NCT02732392). RESULTS: A total of 162 men cN0M0 (CT scan and bone scan) were enrolled: 106 (65.4%) and 56 (34.6%) patients had intermediate- and high-risk prostate cancer, respectively. The median number of nodes retrieved was 14 (mean 16, IQR 10-21) per patient. At final pathological analysis, 22 patients (13.6%) were pN+. Sensitivity, specificity, negative predictive value, and positive predictive value of sentinel lymph node biopsy method in detecting patients with at least 1 lymph node metastasis were 95.4% (95% CI, 75.1-99.7), 100% (95% CI, 96.6-100), 99.2% (95% CI, 95.5-99.9), and 100% (95% CI, 80.7-100), respectively. CONCLUSIONS: Our multicenter prospective study supports that sentinel lymph node biopsy is a very effective and sensitive method for pelvic lymph node staging in patients with intermediate- or high-risk localized prostate cancer.

DDX5 mRNA-targeting antisense oligonucleotide as a new promising therapeutic in combating castration-resistant prostate cancer.

The heat shock protein 27 (Hsp27) has emerged as a principal factor of the castration-resistant prostate cancer (CRPC) progression. Also, an antisense oligonucleotide (ASO) against Hsp27 (OGX-427 or apatorsen) has been assessed in different clinical trials. Here, we illustrate that Hsp27 highly regulates the expression of the human DEAD-box protein 5 (DDX5), and we define DDX5 as a novel therapeutic target for CRPC treatment. DDX5 overexpression is strongly correlated with aggressive tumor features, notably with CRPC. DDX5 downregulation using a specific ASO-based inhibitor that acts on DDX5 mRNAs inhibits cell proliferation in preclinical models, and it particularly restores the treatment sensitivity of CRPC. Interestingly, through the identification and analysis of DDX5 protein interaction networks, we have identified some specific functions of DDX5 in CRPC that could contribute actively to tumor progression and therapeutic resistance. We first present the interactions of DDX5 and the Ku70/80 heterodimer and the transcription factor IIH, thereby uncovering DDX5 roles in different DNA repair pathways. Collectively, our study highlights critical functions of DDX5 contributing to CRPC progression and provides preclinical proof of concept that a combination of ASO-directed DDX5 inhibition with a DNA damage-inducing therapy can serve as a highly potential novel strategy to treat CRPC.

Impact of long-term indwelling JJ stent on renal volume and renal function.

BACKGROUND: Data is lacking about long-term impact of JJ stents (JJst) on renal parenchyma. The aim of the study was to assess the evolution of renal parenchyma in patients with JJst indwelling for more than two years, and to find predictive factors for the development of renal atrophy. METHODS: Consecutive patients with JJst indwelled for more than 24 months, with a history of cancer, were retrospectively included. Replacements of JJst were scheduled every six months, or earlier in case of premature obstruction. Patient characteristics at the time of insertion of JJst, history of indwelling JJst and most recent data (serum creatinine, cancer status, definite JJst removal, renal volume (RV) with3D software) were recorded. RESULTS: With a median follow-up of 4 years, 73 patients were included. The indication of JJst insertion was mostly external compression (65.8%). CT scans were available to assess RV evolution in 66 patients (90.4%). Median shrinkage of RV was higher when JJ stenting was unilateral versus bilateral: -40% (-63; -15) versus -16% (-36; -3), P<0.001. The duration of indwelling JJst was the only statistically significative predictive factor of renal shrinkage in multivariate analysis (OR [CI 95%]: 1.35 [1.10-1.66] P=0.004). Median relative change from baseline in eGFR was -22% (-45%; -5%.). No statistically significant predictive factors of eGFR evolution were found in univariate and multivariate analysis. CONCLUSIONS: Unilateral JJst for more than 2 years was associated with a significant shrinkage of renal parenchyma, especially since the duration of the indwelling stent was long.

Torsion of the spermatic cord in adults: a multicenter experience in adults with surgical exploration for acute scrotal pain with suspected testicular torsion.

Acute scrotal pain (ASP) requiring surgical exploration is common in the pediatric population, but little has been reported on this subject with regard to the adult population. The aim of this study was to investigate the demographic and clinical characteristics and outcomes of scrotal explorations performed on adult patients. Patients over 21 years of age who underwent surgical exploration for ASP with suspected testicular torsion (TT) at 14 French hospitals between January 2005 and December 2019 were included in this study. The main outcome measures were demographic characteristics, pathology found during scrotal exploration, and perioperative outcomes. Logistic regression was used to perform univariate and multivariate analyses to identify predictors of TT. Data for 1329 men were analyzed. The median age was 30 (interquartile range [IQR]: 25-35; range: 21-89) years. Regarding the clinical examination, 867 (65.2%) patients presented with an elevation of the testicle, 613 (46.1%) patients with scrotal edema or erythema, and 211 (15.9%) patients with nausea or vomiting. Operative findings identified TT in only 684 (51.5%) patients, epididymo-orchitis in 112 (8.4%) patients, a tumor in 16 (1.2%) patients, and no causes in 475 (35.7%) patients. Orchiectomy for nonviable testes was required in 101 (7.6%) patients. In multivariate analysis, an elevation of the testicle, erythema/swelling, and the presence of nausea/vomiting were found to be associated with the occurrence of TT. Testicular torsion is not exclusive to children and adolescents, so must be considered in males of any age with acute scrotal findings. However, one-third of scrotal explorations in adults did not lead to a diagnosis.

Essential elements of anaesthesia practice in ERAS programs.

PURPOSE: Enhanced recovery pathways vary amongst institutions but include key components for anesthesiologists, such as haemodynamic optimization, use of short-acting drugs (and monitoring), postoperative nausea and vomiting (PONV) prophylaxis, protective ventilation, and opioid-sparing multimodal analgesia. METHODS: After critical appraisal of the literature, studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies. For each item of the perioperative treatment pathway, available English literature was examined and reviewed. RESULTS: Patients should be permitted to drink clear fluids up to 2 h before anaesthesia and surgery. Oral carbohydrate loading should be used routinely. All patients may have an individualized plan for fluid and haemodynamic management that matches the monitoring needs with patient and surgical risk. Minimizing the side effects of anaesthetics and analgesics using short-acting drugs with careful perioperative monitoring should be encouraged. Protective ventilation with alveolar recruitment maneuvers is required. Preventive use of a combination with 2-3 antiemetics in addition to propofol-based total intravenous anaesthesia (TIVA) is most likely to reduce PONV. While the ideal analgesia regimen remains to be determined, it is clear that a multimodal opioid-sparing analgesic strategy has significant benefits. CONCLUSION: Careful evaluation of single patient and planning of the anesthetic care are mandatory to join the ERAS philosophy. Optimal fluid management, use of short-acting drugs, prevention of PONV, protective ventilation, and multimodal analgesia are the cornerstones of the anaesthesia management within ERAS protocols.

Enhanced Recovery after Surgery for Radical Cystectomy Decreases Postoperative Complications at Different Times.

INTRODUCTION: This study aimed to assess whether enhanced recovery after surgery (ERAS) improves, at different time points, postoperative complications in patients undergoing radical cystectomy. METHODS: We performed a retrospective monocentric study using prospectively maintained databases including all patients treated by radical cystectomy between January 2015 and July 2019. An ERAS protocol was applied in all patients from February 2018. We analyzed and compared between non-ERAS and ERAS groups early and 90-day postoperative complications and 90-day readmission. ERAS was analyzed to know its implication in fast recovery improvement over time. RESULTS: A total of 150 patients underwent radical cystectomy, 74 without ERAS and 76 with ERAS protocol. ERAS decreased significantly early (p = 0.039) and 90-day (0.012) postoperative complications. In multivariate analysis, ERAS was an independent factor associated with less early (OR: 0.48, 95% CI: 0.25-0.96; p = 0.37) and 90-day (OR: 0.31, 95% CI: 0.14-0.68; p = 0.004) postoperative complications. There was no significant difference between groups for 90-day readmission (p = 0.349). Mean length of stay did not differ significantly between ERAS and non-ERAS groups (12.7 ± 6.2 and 13.1 ± 5.7 days, respectively; p = 0.743). DISCUSSION/CONCLUSION: Our study shows that ERAS has an early positive impact that lasts over time on postoperative complications. ERAS implementation has decreased early and 90-day postoperative complications without increasing 90-day readmission. In our cohort, length of stay was not improved with ERAS protocol.

The Use of Doppler Ultrasound for Suspected Testicular Torsion: Lessons Learned from a 15-Year Multicentre Retrospective Study of 2922 Patients.

BACKGROUND: Use of Doppler ultrasonography (DUS) for patients with suspected testicular torsion (TT) is highly controversial and remains debated, as it can delay surgery and its performance may vary. OBJECTIVE: To assess the role, impact, safety, and performance of DUS in the management of patients with suspected TT before scrotal exploration. DESIGN, SETTING, AND PARTICIPANTS: The TORSAFUF cohort retrospectively included patients older than 12 yr who underwent surgery for suspected TT in 14 academic hospitals between 2005 and 2019. Perioperative data and surgical and DUS reports were collected. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Clinical factors influencing DUS utilisation were analysed using multivariate logistic regression. The orchidectomy rate and delay to surgery were compared by group with and without DUS receipt using one-to-one propensity score (PS) matching to assess imaging safety. For the group with preoperative imaging, DUS performance was evaluated using a contingency table. RESULTS AND LIMITATIONS: Overall, 2922 patients were included, of whom 956 (32.7%) underwent DUS before surgery. DUS was more likely to be performed in older patients (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.1-1.2), those who experienced progressive onset of pain (OR 1.5, 95% CI 1.1-2), and patients who presented at the emergency department more than 6 h after their first scrotal symptoms (OR 2.3, 95% CI 1.9-2.8). After PS matching, DUS receipt was not significantly associated with orchidectomy but the delay to surgery was 1 h longer. DUS demonstrated strong sensitivity of 85.2% (95% CI 82.1-88.3%) and specificity of 52.7% (95% CI 48.8-56.6%). The performance was better for younger patients and for those with time since onset of pain of >6 h. CONCLUSIONS: In this large retrospective study, DUS before surgery was safe, feasible, and useful in selected cases with suspected TT, but it should not delay or replace surgery in cases with a strong clinical suspicion. PATIENT SUMMARY: We analysed the performance and safety of an ultrasound scan of the scrotum before surgery for patients with a suspected twisted testicle (TT). This scan before surgery was not associated with a higher risk of negative outcomes but was only moderate in accurately diagnosing TT. Surgery to correct TT should not be delayed.

Predictive Factors of Early Postoperative Complications After Robot-Assisted Radical Cystectomy for Urothelial Bladder Carcinoma.

Purpose: To identify protective and risk factors of early postoperative complications after robot-assisted radical cystectomy (RARC) for urothelial bladder carcinoma. Methods: Data of all robot-assisted cystectomies performed in six French centers between February 2010 and December 2019 were retrospectively reviewed. All RARCs for bladder cancer (muscle-invasive and high-risk or Bacillus Calmette-Guerin-resistant nonmuscle-invasive bladder cancer) were included. Perioperative outcomes and early postoperative complications (in the first 30 days) were collected. Multivariable analysis was performed to identify factors associated with early postoperative complications. Results: Two hundred seventy patients were included. The overall incidence of early postoperative complications after RARC was 52.2% (27% of major complications). Most frequent complications were infectious complications (24.4%) and paralytic ileus (15.6%). Anticoagulant therapy (odds ratio [OR] = 2.909, 95% confidence interval [CI]: 1.003-8.432) and ureteroenteric anastomosis-type Wallace II (OR = 4.4, 95% CI: 1.435-13.489) were associated with a higher rate of overall complications. Complete intracorporeal diversion was a protective factor (OR = 0.399, 95% CI: 0.222-0.718). Tobacco consumption, anticoagulant therapy, and ureteroenteric anastomosis-type Wallace II were associated with a higher rate of minor complications (OR = 2.01, 95% CI: 1.079-3.744; OR = 2.495, 95% CI: 1.022-6.089; OR = 3.836, 95% CI: 1.384-10.63, respectively). Opioid-free analgesia (OFA) was associated with a lower rate of infectious complications (OR = 0.148, 95% CI: 0.034-0.644). Conclusion: Early postoperative complication rate after RARC for urothelial bladder carcinoma is high. Encouraging complete intracorporeal diversion and promoting OFA seem to reduce postoperative complications in the first 30 days. Prospective studies are needed to provide a high level of evidence.

Contralateral Orchiopexy at the Time of Urgent Scrotal Exploration-Is It Safe? A Propensity Score Matched Analysis from the TORSAFUF Cohort.

PURPOSE: We evaluate the safety of immediate contralateral orchiopexy (ICLO) at the time of scrotal exploration for testicular torsion suspicion. MATERIALS AND METHODS: Patient data were retrieved from the TORSAFUF cohort project, which is a multicenter national study conducted at 14 academic French hospitals between 2005 and 2019. Each patient who underwent surgical exploration for testicular torsion suspicion was included. The primary study outcome was the safety of ICLO compared to ipsilateral scrotal exploration alone. The primary outcome of interest was the complication rate within 90 days of surgery. The end point was planned before data collection. RESULTS: Overall, 2,775 patients were included, of whom 1,554 (56%) underwent ICLO. After propensity score matching and multivariable analysis, ICLO was associated with a higher complication rate (OR 1.51, 95% CI 1.1-2.1, p=0.01), especially a higher rate of hematoma (OR 2.9, 95% CI 1.3-6.6, p=0.01), and delayed wound healing (OR 3.0, 95% CI 1.8-5.2, p <0.001). CONCLUSIONS: At the time of scrotal exploration for acute scrotum, ICLO was associated with an increased postoperative complication rate, with a particular increase in hematoma, and delayed wound healing. ICLO should not be performed systematically.

Sexual-Sparing Robot Assisted Radical Cystectomy in Female: A Step-By-Step Guide.

OBJECTIVE: To show different approaches for sexual-sparing robot assisted radical cystectomy in women. MATERIALS AND METHODS: Radical cystectomy (RC) is a mainstay treatment for localized muscle invasive bladder cancer and high-risk non muscle invasive bladder cancer not responding to adequate endovesical therapy.1 In women traditionally RC is performed with hystero-adnexectomy and resection of the anterior vaginal wall, but this technique often brings sexual disorders. With time, vaginal sparing techniques have been developed to improve functional outcomes in women motivated to preserve their sexual function.2-4 The indications for vaginal-sparing RC are absence of tumor in bladder neck or urethra and no sign of infiltration of anterior vaginal wall and parametria at preoperative staging. RESULTS: Procedure steps as follows. Step 1: Bilateral adnexectomy and ureteral isolation until their distal portion. Step 2: Vesico-vaginal dissection. Step 3: Bilateral pelvic and common iliac node dissection. Step 4: Ureteral clamping and section. Step5: Posterolateral bladder pedicle dissection. Step 6: Anterior dissection of the bladder towards the urethra. In women, this should be achieved without injuring the Santorini plexus and innervation of the clitoris. Step 7: Bladder neck identification and urethral dissection. Cystectomy is completed. Step 8: En bloc hystero-adnexectomy with anterior vaginal wall preservation; the vaginal pedicles are spared too. Step 9: Specimen extraction from the vagina and vaginal suture.It is also possible to perform a fully sexual-sparing robotic RC by following the vesico-vaginal plan without dissecting the vaginal dome and leaving internal genitalia intact. This technique is typically carried out in case of young women with no pathological uterine and ovarian findings.Vesico-vaginal plan can also be developed after opening the vaginal dome. This approach gives the possibility to subsequently dissect the cervix, to identify and spare the vaginal pedicles and to perform an "en bloc" radical cystectomy, with preservation of the anterior vaginal wall.In case of neobladder, diversion is carried out intracorporeally following the principles of the Saint Augustin neobladder.5 CONCLUSIONS: Robot assisted anterior pelvectomy with anterior vaginal wall preservation is a feasible and mini-invasive technique. For a satisfying functional result, it is crucial to preserve the vaginal neurovascular pedicles. This sexual-sparing approach must be carried out after a correct patient selection: women motivated to preserve their sexual function and ideally in the neobladder setting, when a posterior support for the urinary diversion is needed. Absence of tumor in bladder neck and urethra at magnetic resonance imaging could help patient selection.

Active Surveillance for Biopsy Proven Renal Oncocytomas: Outcomes and Feasibility.

OBJECTIVES: To report the outcomes and feasibility of active surveillance (AS) of biopsy-proven renal oncocytomas. METHODS: Multicentric retrospective study (2010-2016) in 6 academic centers that included patients with biopsy-proven renal oncocytomas who were allocated to AS (imperative or elective indication) with a follow-up ≥1 year. Imaging was performed at least once a year, by CT-scan or ultrasound or MRI. Conversion to active treatment (surgical excision or ablative treatment) was at the discretion of the urologist. The primary endpoint was renal tumor growth (cm/year). Secondary outcomes included accuracy of biopsy, incidence, and reason to change AS to active treatment. RESULTS: Eighty-nine patients were included: Median age 67 years (26-89) and median tumor size 26 mm [15-90] on diagnosis. During a mean follow-up of 43 months'' (median 36 [12-180]), mean tumor growth was 0.24 cm/year. No predictive factors (demographical, radiological or histologic) of tumor growth could be identified. Conversion from AS to active treatment occurred in 24 patients (27%) (13 surgical excisions, 11 ablative procedures), in a median time of 45 (12-76) months'' after diagnosis. Tumor growth was the main indication to convert AS to active treatment (58%) with 8% of the patients opting to discontinue AS. No patient had metastatic progression nor disease-specific death. The correlation between biopsy and surgical specimen was 92%. CONCLUSION: Active surveillance for biopsy-proven renal oncocytomas was oncologically safe and patient adherence was high. No predictive factor for tumor growth could be identified but the tumor growth rate was low, and biopsy efficacy was high.

Nanovectorization of Prostate Cancer Treatment Strategies: A New Approach to Improved Outcomes.

Prostate cancer (PC) is the most frequent male cancer in the Western world. Progression to Castration Resistant Prostate Cancer (CRPC) is a known consequence of androgen withdrawal therapy, making CRPC an end-stage disease. Combination of cytotoxic drugs and hormonal therapy/or genotherapy is a recognized modality for the treatment of advanced PC. However, this strategy is limited by poor bio-accessibility of the chemotherapy to tumor sites, resulting in an increased rate of collateral toxicity and incidence of multidrug resistance (MDR). Nanovectorization of these strategies has evolved to an effective approach to efficacious therapeutic outcomes. It offers the possibility to consolidate their antitumor activity through enhanced specific and less toxic active or passive targeting mechanisms, as well as enabling diagnostic imaging through theranostics. While studies on nanomedicine are common in other cancer types, only a few have focused on prostate cancer. This review provides an in-depth knowledge of the principles of nanotherapeutics and nanotheranostics, and how the application of this rapidly evolving technology can clinically impact CRPC treatment. With particular reference to respective nanovectors, we draw clinical and preclinical evidence, demonstrating the potentials and prospects of homing nanovectorization into CRPC treatment strategies.

Selective Trans-arterial Embolization of Iatrogenic Vascular Lesions Did Not Influence the Global Renal Function After Partial Nephrectomy.

OBJECTIVE: To evaluate the renal function outcomes after selective trans-arterial embolization (SAE) of iatrogenic vascular lesions (IVL), including pseudoaneurysm and arteriovenous fistula, following partial nephrectomy (PN). MATERIALS AND METHODS: A multi-institutional study was conducted including consecutive patients who underwent PN between January 2009 and March 2019. Two surgical approaches were used: open and robot-assisted PN. Patients with SAE were identified and matched (1:2) with patients without IVL. The matching criteria were age, gender, Charlson score, creatinine clearance, RENAL score, and tumor size. The primary outcome was the evolution of global renal function at 6-months postoperatively. RESULTS: A total of 493 consecutive PN (360 open PN and 133 robot-assisted PN) were included. IVL occurred in 17 cases (3.4%) without statistical difference according to the surgical approach (P = .78). Patients from embolization group were matched to 34 cases without postoperative IVL. Groups were comparable concerning clinical, tumor and surgical characteristics. The clinical success of SAE, defined as the absence of recourse to a second embolization or a total nephrectomy, was obtained in 16 (94.1%) cases. No minor or major complications were reported after SAE. The preoperative estimated glomerular filtration rate (eGFR) was similar between control group (93 [85-102] ml/min) and embolization group (95 [83-102] ml/min) (P = .99). Median (IQR) eGFR between control group (87 [72-95] ml/min) and embolization group (83 [76-93] ml/min) at a follow-up of 6 months showed no significant difference (P = .73). CONCLUSION: IVL are rare complications of PN. SAE is an effective and minimally invasive management tool, with no deleterious effect on global renal function.

Comparison between Zumsteg classification and Briganti nomogram for the risk of lymph-node invasion before radical prostatectomy.

PURPOSE: To evaluate the performance of the Zumsteg classification to estimate the risk of lymph-node invasion (LNI) compared with the Briganti nomogram (BN) in prostatectomy patients with intermediate-risk prostate cancer (IRPC). METHODS: We included consecutive patients who had extended pelvic lymph-node dissection associated with radical prostatectomy for IRPC. To be classified favorable intermediate risk (FIR), patients could only have one intermediate-risk factor, fewer than 50% positive biopsies and no primary Gleason score of 4. RESULTS: On the 387 patients included, 149 (38.5%) and 238 (54.3%) were classified FIR and unfavorable intermediate risk (UIR), respectively, and 212 (54.8%) had a BN inferior to 5%. Thirty-eight patients (9.8%) had LNI: 6 FIR patients (4.0%) versus 32 UIR patients (13.4%) and 14 patients (6.6%) with a BN inferior to 5% versus 24 patients (13.7%) with a BN superior to 5%. Eight patients with a BN inferior to 5%, but classified UIR, had LNI. Sensitivity to detect LNI was higher with the Zumsteg classification than with the BN: 84.2% (CI 95% [68-93]) versus 63.2% (CI 95% [46-78]). Both screening tests were concordant to predict LNI (kappa coefficient of 0.076, p < 0.05 for Zumsteg and Briganti) CONCLUSIONS: Zumsteg classification appeared to be more sensitive and as effective (despite the impossibility to make decision curve analysis) than the BN to estimate the risk of LNI. Regarding the modest number of pN+ patients, further studies are needed to see the interest of proposing ePLND for UIR patients only.

Diagnostic ureteroscopy prior to nephroureterectomy for urothelial carcinoma is associated with a high risk of bladder recurrence despite technical precautions to avoid tumor spillage.

PURPOSE: There have recent reports in the literature of increased rates of bladder recurrence (BR) after radical nephroureterectomy (RNU) when diagnostic flexible ureteroscopy (DFU) was performed before RNU. The technical heterogeneity of DFU was a major bias in these studies. Our purpose was to evaluate the impact of a standardized DFU technique before RNU on the risk of BR. METHODS: A retrospective monocenter study including patients who underwent RNU for upper tract urothelial carcinoma (UTUC) between 2005 and 2017. 171 patients were identified. 78 patients were excluded owing to a history of bladder cancer before RNU or neo-adjuvant/adjuvant chemotherapy. 93 included patients were stratified according to pre-RNU ureteroscopy (DFU + 70 patients) or no pre-RNU ureteroscopy (DFU-23 patients). The standardized DFU technique consisted of systematic ureteral sheath (ch9-10), flexible ureteroscopy, biopsy, and drainage with a mono-J/bladder catheter to avoid contact of contaminated urine of the upper tract with the bladder. RESULTS: Epidemiological, initial staging, and postoperative tumoral characteristics were similar in both groups. Mean follow-up was 35 months [2-166], 47(50%) BR occurred with 41(87%) in the DFU + group, and pre-RNU-DFU was an independent predictive factor of BR (OR = 4[1.4-11.9], P = 0.01) (Cox regression model). The characteristics of BR were similar in both groups, although BR occurred earlier in DFU + (427 days vs. 226 days (P = 0.07)). CONCLUSION: Bladder recurrence after diagnostic ureteroscopy + nephroureterectomy was high despite technical precautions to avoid contact of bladder mucosa with contaminated urine from the upper urinary tract. Post-DFU endovesical instillation should be investigated.