Potential impact of 18F-FDG PET/CT on patients selection for neoadjuvant chemotherapy before radical cystectomy.

BACKGROUND: The detection of lymph node metastases in bladder cancer has a major impact on treatment decisions and patients prognosis. Due to limited value of conventional imaging, the place of molecular and functional imaging needs to be precised, particularly in the neoadjuvant setting. METHODS: From June 2011 to June 2013, 102 patients with clinically localized BCa were simultaneously staged with (18)F-FDG PET/CT before RC. This study assessed the diagnostic accuracy of (18)F-FDG PET/CT for the detection of metastases in normal-sized lymph nodes using extended pelvic lymph node dissection and histopathology as the reference standard. RESULTS: A total of 1211 LNs were examined histopathologically. Sixty-seven (5.5%) metastatic nodes were found in 26/102 patients (25.5%). Lymph node density was 22%. On patient-based analysis, sensitivity, specificity, predictive positive value (PPV), negative positive value (NPV) and accuracy for (18)F-FDG PET/CT were calculated as 50%, 96.2%, 80%, 86.2% and 85.3% respectively. On a field-based analysis, sensitivity, specificity, PPV, NPV and accuracy for (18)F-FDG PET/CT were calculated as 50.0%, 99.0%, 71.9%, 97.4%, and 96.5% respectively. The majority of missed metastases were micrometastasis <5 mm in long axis diameter. CONCLUSIONS: (18)F-FDG PET/CT improves diagnostic efficacy for lymph node staging in patients staged N0 with conventional cross-sectional imaging. (18)F-FDG PET/CT could be used as a surrogate marker for detection of metastases in non-enlarged pelvic lymph nodes and enhances management strategy guiding patients selection for neoadjuvant chemotherapy.

[Update for the management of kidney stones in 2013. Lithiasis Committee of the French Association of Urology]. / Mise au point sur la prise en charge des calculs du rein en 2013. Comité Lithiase de l'Association française d'urologie.

Since the publication of the latest recommendations of the Lithiasis Comity of the French Association of Urology (CLAFU) on the management of ureteral and renal stones, practices have evolved. This text provides an update for the treatment of kidney stones. It is especially the important advances in the field of laser-ureterorenoscopy that changed practices. Percutaneous nephrolithotomy has been enriched by technical modifications and extracorporeal shockwave lithotripsy confirmed its predominant place in the first line of treatment. For stones less than 20mm, extracorporeal lithotripsy remains the standard, but in some cases the possibility of recommending a flexible ureterorenoscopy is possible in first line. For stones more than 20mm, percutaneous nephrolithotomy is the standard treatment, but optional flexible ureteroscopy and extracorporeal lithotripsy are possible. The treatment carried out, collect the stone fragments for a morpho-constitutional analysis and achieve a metabolic evaluation is necessary, to investigate etiologic and give dietary advices to prevent recurrence.

[Management of adult's renal and ureteral stones. Update of the Lithiasis Committee of the French Association of Urology (CLAFU). General considerations]. / Prise en charge urologique des calculs rénaux et urétéraux de l'adulte. Mise au point du Comité Lithiase de l'Association Française d'Urologie (CLAFU). Aspects généraux.

The Lithiasis Committee of the French Association of Urology (CLAFU) aimed to update the current knowledge about urolithiasis. This update will be divided into four parts: 1) general considerations; 2) the management of ureteral stones; 3) the management of kidney stones; 4) metabolic assessment and medical treatment of urolithiasis. Recent technicals advances helped the urologists to improve stones management: new extracorporeal shockwave lithotripsy (ESWL) devices, new flexible ureterorenoscopes, development of laser fragmentation. ESWL, semi-rigid and flexible ureteroscopy and the percutaneous nephrolithotomy (PCNL) remain currently the main therapeutic options. The first part of this update deals with the description and classification of stones, preoperative assessment, post-operative management and clinical follow-up. Main criteria of therapeutic choices are stone location, stone composition and stone size. Stone composition is assessed with infrared spectrophotometry analysis and its hardness is correlated with U.H. density on CT scan assessment. Preoperative assessment consists in urinary cytobacteriological examine, urinary PH, blood creatininemia, hemostasis. Low-dose CT scan is recommended before urological treatment. The result of the treatment must be done 1 or 3 months later with plain abdominal film and ultrasonography. Medical management of urolithiasis will be based on stone composition, metabolic and nutritional evaluation. Treatment success is definited by absence of residual fragments. Annual follow-up is recommended and based either on plain abdominal film and ultrasonography or low-dose CT scan.

[Place of the flexible ureterorenoscopy first choice for the treatment of kidney stones. Survey results practice committee of the AFU lithiasis completed in 2011]. / Place de l'urétérorénoscopie souple en première intention pour le traitement des calculs du rein. Résultats de l'enquête de pratique du comité lithiase de l'AFU réalisée en 2011.

UNLABELLED: The flexible ureterorenoscopy coupled with photovaporisation LASER (USSR-L) for the treatment of kidney kidney is a modern tool whose place is under evaluation. METHODS: Its place has been assessed in France in 2010 by the Committee of urolithiasis of the French Association of Urology (CLAFU). A practice survey among 27 experts concerned the following decision criteria: comorbid patient's supposed nature of the calculation, anatomy of the urinary tract of the patient. This investigation has been proposed to calculate the size not exceeding 20mm, for a calculation of size greater than 20mm and for multiple calculations kidney. RESULTS: Fourteen experts responded. The criteria for the USSR-The first line were: morbid obesity (BMI>30), anticoagulation or anti platelet aggregation, calculations Hard (UH>1000, cystine stones), calculations within diverticular caliceal calculations below, the failure of a first treatment or the wish of the patient. CONCLUSION: The URS-SL was a first-line treatment validated regardless of size and number of kidney stones, when ESWL and PCNL were contraindicated or when their predictable results were poor (hard stones/morbid obesity/lower pole stones) or when stone access is difficult (intradiverticular). It was also the treatment of choice after the failure of a first treatment (ESWL/PCNL).

[Functional evaluation of the orthotopic Z-shaped ileal detubulated neobladder with a minimal 5-year follow-up]. / Evaluation fonctionnelle de la néovessie iléale détubulée orthotopique en Z avec cinq ans de recul minimum.

OBJECTIVE: Study and evaluate the orthotopic Z-shaped neobladder in the long term and life quality of patients bearing this type of replacement. METHODS: Based on 162 medical records of patients who have undergone total cystoprostatectomy and orthotopic Z-shaped replacement because of bladder cancer with a minimal 5-year follow-up. Forty patients (113-month average follow-up) residing in the region were notified for a clinical consultation and were the basis for the target population of this study. A physical examination, a Pad test and a specific consultation allowed for continence evaluation whereas three validated surveys allowed for life quality appreciation. RESULTS: Continence was satisfactory for 82% of the patients during the day and 55% during the night. There was a significant negative correlation between a patient's age at the time of the cystoprostatectomy and diurnal continence. Life quality was estimated as good in the long term. CONCLUSION: The functional results of the Z-shaped ileal detubulated neobladder in the long term are satisfactory. It allows for good urination quality and satisfactory quality of life for patients subject to total cystoprostatectomy because of cancer as well as body schema's conservation.

[The impact of partial nephrectomy on morbidity and on long-term oncological outcomes]. / Impact de l'indication impérative sur la morbidité et les résultats carcinologiques à long terme après néphrectomie partielle.

OBJECTIVE: To evaluate the impact of imperative indication on the rate of complications and long term carcinological results after partial nephrectomy (PN). PATIENTS AND METHOD: Between 1985 and 2005, all patients who had a PN for localized cancer in two centers were reviewed. The rates of global, hemorrhagic and urinary complications were compared between group I (elective indication) and group II (imperative indication). Rates of survival without recurrence and specific at 5, 10 and 20 years were compared between these two groups. A multivariate analysis using the Cox model was carried out to research factors associated with recurrence and death on the whole of the series. RESULTS: Three hundred and five patients were included in the study. No significant difference was found between group I and group II as far as global complications were concerned (17 vs 20%), the rate of hemorrhagic complications (3.5 vs 3.8%) and the rate of urinary complications (3.9 vs 2.5%). The patients who had been operated on for an imperative indication had survived specifically and without recurrence which was significantly lower at 5, 10 and 20 years. On the whole of the series, the imperative indication was the only independent factor associated with recurrence and death in a multivariate analysis. CONCLUSIONS: Even if the rate of complication does not appear to be significantly associated with the indication for operating, patients of imperative indication represented a heterogeneous group with a poorer prognosis. This factor should be taken into account in studies on the subject of PN.

Evaluation of tension-free vaginal tape procedure. Its safety and efficacy in the treatment of female stress urinary incontinence during the learning phase.

INTRODUCTION AND OBJECTIVES: The aim of this study was to evaluate preliminary results of tension-free vaginal tape (TVT), a new surgical procedure, performed during the learning phase for the treatment of stress urinary incontinence. MATERIAL AND METHODS: One-hundred consecutive patients underwent surgery, between June 1998 and December 1999, by six different senior surgeons. Indications were socially annoying urinary stress incontinence which persisted after complete physical therapy education. Preoperative examination included a urodynamic evaluation program. Surgical procedure was performed according to Ulmsten technique under local, regional or general anaesthesia. Results were evaluated by self-evaluation questionnaire and the patients were followed for at least 1 year. RESULTS: Perioperative complications were: 14 bladder injuries and one urethral perforation without sequelae (except prolonged bladder drainage up to 3 days). Postoperative complications were: 13 retentions including 3 persistent after 1 month. During the learning phase (50 first patients) bladder injuries, retention and dysuria were more frequent. Progressively, local anesthesia was abandoned while most of the 50 remaining patients had TVT performed under epidural anesthesia. Functional results were divided into 3 groups according to preoperative urethral closure pressure (UCP) and eventual concomitant prolapse repair (PR): (1) UCP >25 cm H2O no PR (59 patients): 39 were totally dry without any instability, 13 dry with de novo (4) or persistent (7) instability and 5 were moderately improved. (2) UCP <25 cm H2O no PR (25 patients): 11 were dry without instability, 5 dry with instability, 6 were improved and 4 failed. (3) PR (15 patients): 9 were dry, 4 were improved and 2 failed. For 2 patients a bladder erosion due to the tape occurred (7 and 11 months) after the TVT procedure. CONCLUSIONS: During the learning phase, bladder perforation (22%) and retention (20%) were much more frequent than previously reported. Nevertheless, our results confirm that TVT appears to be an efficient procedure: 97% of patients were cured or improved when UCP >25 cm H2O, 85% when UCP <25 cm H2O and 87% when a PR was associated.

[Late rejection of Mersylene mesh used for promontory fixation with colonic obstruction]. / Intolérance des bandelettes de Mersylène dans les suites tardives d'une promontofixation responsable d'un syndrome occlusif colique.

We describe a case of colonic obstruction in a 48-year-old woman, 3. 5 years after surgery for genito-urinary prolapse. The causal agent was the Mersylene mesh used for promontory fixation. Late rejection of this kind of prosthesis has been described previously, but such a digestive complication is exceptional.

[Study of survival after cystectomy for bladder cancer. Report of 504 cases]. / Etude de la survie après cystectomie pour cancer de vessie. A propos de 504 cas.

OBJECTIVES: Cystectomy is the reference treatment for invasive bladder cancer and superficial tumours with a high risk of recurrence. However, the long-term results of this treatment remain controversial. Progress in anaesthesia-intensive care and surgical techniques appear to have improved the prognosis of this disease over the last two decades. The availability of numerous adjuvant therapies (radiotherapy and chemotherapy) and the development of alternative conservative management therefore require a re-evaluation of the long-term results of cystectomy for bladder cancer performed over the last 20 years. MATERIAL AND METHODS: The case files of 504 consecutive patients undergoing cystectomy for bladder cancer in our department from 1981 to 1997 were reviewed. The operative and postoperative morbidity and actuarial survival by stage were studied. Histological prognostic factors and the influence of adjuvant therapies were also studied. RESULTS: According to the TNM 97 classification, 55% of tumours (on the cystectomy specimen) were intravesical (< T3), and 70% of patients had negative lymph nodes (N0). The perioperative mortality was 1.56%. The overall survival at 2 years, 5 years and 10 years for the total patient population was 83.1%, 52.3% and 46.6%, respectively. The 5-year survival of tumours confined to the bladder (< T3) was 79.4% versus 27.5% when the tumour extended beyond the bladder (> T3). The lymph node status considerably influenced survival. N0, N1 and N2-3 patients had 5-year survival rates of 64%, 48% and 14%, respectively. Neoadjuvant chemotherapy or radiotherapy did not appear to improve survival. CONCLUSIONS: Survival after cystectomy for bladder cancer essentially depends on pathological stage and lymph node status. Patients with a localized tumour have a 5-year survival greater than 80%. Prospective studies are required to determine the real benefit of adjuvant chemotherapy, as its value has not yet been formally demonstrated.

[Seminal vesicle dystrophy as the cause of chronic unilateral pelvic pain in a 20-year-old male]. / Dystrophie d'une vésicule séminale responsable de douleurs pelviennes unilatérales chroniques chez un homme de 20 ans.

The authors report on the case of a male patient referred for unilateral pelvic pain. An enlarged right seminal vesicle was showed by clinical examination and radiological technics. Total relief of symptoms was obtained by surgical excision. Pathological examination concluded on a dystrophic lesion of the seminal vesicle. Obstruction of the right ejaculatory duct, which could not be proved anyway is the most probable hypothesis.

[Male urinary incontinence and dynamic graciloplasty]. / Incontinence urinaire masculine et graciloplastie dynamique.

Only a few surgical treatments are available for male urinary stress incontinence and artificial urinary sphincter remains the reference treatment. It is associated with a certain morbidity and specific technical limitations and can therefore not always be used in a given patient. Stimulated graciloplasty could constitute a useful alternative treatment in exceptional situations. The objective of this study was to review the technique, the indications already defined apart from urinary incontinence and the results of stimulated graciloplasty in urology.

[High intensity focused ultrasound (HIFU) in urology]. / Les ultrasons focalisés de haute intensité (UFHI) en urologie.

INTRODUCTION: Focused ultrasound is now well known to urologists in the context of its validated application in extracorporeal lithotripsy. High Intensity Focused Ultrasound (HIFU) represents a potential therapeutic modality for tissue destruction due to its very high energy and its capacity to precisely reach a target with a very short emission time. The authors review the current state of art of HIFU in urology at a time when its indication in prostate cancer is being defined. MATERIAL AND METHOD: After a brief description of the main physical principles of ultrasound and the main data determining focussing of high energy ultrasound, the main machines available (research and clinical) are described. The published clinical literature concerning the tissue destructive action in urology is reviewed. RESULTS: HIFU has been used in urology to treat renal, vesical, prostatic (BPH and cancer), and external genital organ lesions. Purely extracorporeal machines are gradually being replaced by intracorporeal procedures, especially transrectal techniques for prostatic lesions. The quality of ultrasound detection of the target still limits the use of this minimally invasive modality. The intervening tissues are spared with a good therapeutic efficacy on the target tissues, provided optimal firing parameters are used. CONCLUSION: HIFU has a demonstrated potential in the treatment of prostate cancer and studies conducted by several teams have defined the technique and its efficacy. Other indications have been studied, but must be validated by further clinical trials. The future will probably see the design of machines adapted to a specific target tissue rather than a single multidisciplinary extracorporeal machine.

[Materials used in treatment of stress urinary incontinence with suburethral sling]. / Les matériaux utilisables dans le traitement de l'incontinence urinaire d'effort par bandelette sous-uréthro-cervicale.

Suburethral sling is a classical method of surgical repair of female stress urinary incontinence (SUI). Initially reserved for SUI due to sphincter incompetence, this method now appears to be indicated for other types of SUI. A large number of organic and synthetic materials have been used in published series. The long-term functional results reported in the literature vary between 65 and 98%, regardless of the materials used. Some of the complications observed are specific to the type of material. Synthetic slings appear to be associated with a higher complication rate. It is too early, based on data of the literature, to determine the real role of Prolene tape (TVT).

[Erectile dysfunction after radical prostatectomy: value of preoperative programming of intracavernous injections]. / Dysfonction érectile après prostatectomie radicale: intérêt de la programmation des injections intracaverneuses avant l'intervention.

OBJECTIVES: Vasoactive drugs used for self-administered intracavernous injections are currently the reference treatments for erectile dysfunction after radical prostatectomy. The acceptability of and compliance with this treatment often limit their use. This study analysed these two parameters as a function of the type of andrological management decided before radical prostatectomy. MATERIAL AND METHOD: From January 1996 to January 1997, 45 sexually active patients, aged 52 to 69 years, requiring radical prostatectomy without preservation of the nervi erigentes, for localized prostate cancer, were included in this prospective study. Before the operation all 45 patients were informed about the high risk of erectile dysfunction following radical prostatectomy. Fifteen patients (group 1) did not receive any particular advice concerning the management of erectile dysfunction after radical prostatectomy, but were possibly referred for an andrology consultation depending on their complaints. Fifteen patients (group 2) were systematically referred for an andrology consultation three months after radical prostatectomy for information about the available treatment options. For 15 patients (group 3), the andrology consultation (3 months after the operation) had been planned before radical prostatectomy to perform a test injection of prostaglandin E1. The injections, started before the operation in this group 3, therefore constituted an integral part of the global management of prostate cancer. All these patients were followed for at least 1 year in the urology department. RESULTS: Only 7 of the 15 patients of group 1 consulted an andrologist. Five of these patients received a test intracavernous injection versus 14 in group 2 and 15 in group 3. The 5 patients of group 1 who received an intracavernous injection accepted this modality as treatment versus 8 in group 2 and 12 in group 3. After one year, 4, 5 and 9 patients in groups 1, 2 and 3, respectively, continued intracavernous injections. CONCLUSION: The management of erectile dysfunction after radical prostatectomy must start with the decision to operate. Systematic encouragement to use intracavernous injections after radical prostatectomy helps to improve access to this treatment for impotence. The acceptability, and especially the compliance, appear to be better in patients in whom intracavernous injections were integrated into the global management of their prostate cancer.

[Isolated ureteral metastasis of prostatic adenocarcinoma. Apropos of a case]. / Métastase urétérale isolée d'un adénocarcinome de prostate. A propos d'un cas.

A ureteric tumour was discovered in a patient presenting with an episode of renal colic and a history of prostatectomy for prostatic adenocarcinoma. Segmental ureterectomy was performed. Histological examination showed a metastasis from prostatic adenocarcinoma. This is a rare site of secondaries: less than 40 cases have been reported in the literature, essentially based on autopsy series. Metastatic spread occurs via lymphatics or the blood stream, and the secondary tumour develops from the adventitia before invading the ureteric wall. Although this diagnosis may be suggested by the clinical features and imaging, it can only be confirmed by histology. After ureterectomy, treatment can combine all of the recognized treatment modalities against prostatic adenocarcinoma: endocrine therapy and adjuvant radiotherapy.

[Isolated Burch type indirect colposuspension of the bladder neck in the treatment of stress urinary incontinence in women. Long-term results]. / Colposuspensions indirectes du col vésical type Burch isolées dans le traitement de l'incontinence urinaire à l'effort de la femme. Résultats à long terme.

OBJECTIVES: Burch indirect colposuspension remains the reference surgical operation in the treatment of female urinary stress incontinence. The stability of the results is highly controversial and the causes of failure remain hypothetical. The objective of this study was to analyse the long-term results of this technique. METHODS: 100 women suffering from pure urinary stress incontinence, in whom a Burch indirect colposuspension was performed, were included in this study. These patients were reviewed with a mean follow-up of 5.2 years and a questionnaire designed to assess the results was sent to their homes. RESULTS: 64% of patients no longer suffered from incontinence. Deterioration of the results was observed up to 5 years after the operation, but subsequently remained stable. The results were operator-independent. Low sphincter pressure (< 30 cm H2O), preoperative detrusor instability, insufficient hormonal impregnation and a history of pelvic surgery were the main factors predictive of failure of this technique. CONCLUSION: This study confirms the benefit provided by this technique in almost two-thirds of patients and indicates the risk factors of failure which must be taken into account before proposing Burch indirect colposuspension to a woman suffering from urinary stress incontinence.

[Choledochoduodenal fistula: an unusual complication of duodenal ulcer]. / Fistule cholédocoduodénale: complication rare de i'ulcère duodénal.

We report a case of choledochoduodenal fistula in a patient with a duodenal ulcer and poor compliance to treatment. The fistula tract was demonstrated on a plain abdominal X-ray (presence of air in the biliary tract), and was confirmed by a fistulography from the site of the ulcer (opacification of the bile duct). A Finsterer type 2/3 gastrectomy was performed in this patient, leading to the treatment of the ulcer and disappearance of the fistula following a gastrojejunal shunt of the duodenum. Clinical outcome was excellent.