A prospective clinical trial of HIFU hemiablation for clinically localized prostate cancer.

BACKGROUND: Focal therapy is an emerging mini-invasive treatment modality for localized prostate cancer aimed to reduce the morbidity associated with radical therapy while maintaining optimal cancer control. We report the mid-term oncological and functional results of primary hemiablation high-intensity focused ultrasound (HIFU) in a prospective cohort of patients. METHODS: Over 8 years, hemiablation HIFU was primarily performed in 50 selected patients with biopsy-proven clinically localized unilateral, low-intermediate risk prostate cancer in complete concordance with the prostate cancer lesions identified by magnetic resonance imaging with precise loci matching on multimodal approach. Post-treatment follow-up included regular serial PSA measurements. Biochemical recurrence was reported using Stuttgart and Phoenix criteria. The latter was used as a threshold to offer whole-gland biopsies. RESULTS: Complete follow-up was available for all patients and the median follow-up was 39.5 months (range: 6-94). Mean nadir PSA value was 1.6 ng ml(-1), which represents 72% reduction compared with initial PSA pre-treatment value (P<0.001). Median time to achieve PSA nadir was 3 months. Biochemical recurrence, according to Phoenix and Stuttgart definition, occurred in 28 and 36% of patients, respectively. The 5-year actuarial metastases-free survival, cancer-specific survival and overall survival rates were 93, 100 and 87%, respectively. Out of the eight patients undergoing biopsy, six patients had a positive biopsy for cancer occurring in the untreated contralateral (n=3) or treated ipsilateral lobe (n=1) or bilaterally (n=2). A Clavien-Dindo grade 3b complication occurred in two patients. Complete continence (no pads) and erection sufficient for intercourse were documented in 94 or 80% of patients, respectively. CONCLUSION: Hemiablation HIFU therapy, delivered with intention to treat, for carefully selected patients affords mid-term promising functional and oncological outcomes. The effectiveness of this technique should be now compared with whole-gland radical therapy.

[Approach and complications associated with suburethral synthetic slings in women: Systematic review and meta-analysis]. / Voies d'abord et complications des bandelettes sous-urétrales synthétiques chez la femme : revue systématique de la littérature et méta-analyse.

INTRODUCTION: We aim to assess the complications associated with different approaches used in female suburethral sling surgery. METHOD: We performed a research on Medline using the following keywords: "suburethral slings", "complications", "safety" and "randomized". Only randomized clinical trials including women and reporting intra- and postoperative complications associated with the retropubic (RP) approach; TOT and/or TVT-O were included. The meta-analysis was conducted using the Review Manager (RevMan 5.3) software delivered by the "Cochrane Library". RESULTS: Out of 176 articles, 23 were included in synthesis. Risks of bladder perforation during surgery (60/1482 vs 5/1479; OR=6.44; 95% CI [3.32-12.50]) and postoperative urinary retention (48/1160 vs 24/1159; OR=1.93; 95% CI [1.26-3.12]) were significantly higher with the RP approach, when compared with the transobturator (TO) approach (TOT or TVT-O). Conversely, the risk of prolonged postoperative pain was significantly lower after RP approach, when compared with TO approach (24/1156 vs 69/1149; OR=0.36; 95% CI [0.23-0.56]). Risks of intraoperative urethral injury, postoperative erosion and de novo overactive bladder were comparable between the two approaches. Data regarding the comparison between TOT and TVT-O were scarce and did not allow us to conclude about complications associated with. CONCLUSION: The RP approach was associated with a significant risk of bladder perforation and postoperative urinary retention. The TO approach was associated with a higher risk of prolonged postoperative pain.

A single pipeline embolization device is sufficient for treatment of intracranial aneurysms.

BACKGROUND AND PURPOSE: The Pipeline Embolization Device has emerged as an important treatment option for intracranial aneurysms. The number of devices needed to treat an aneurysm is uncertain and is the subject of vigorous debate. The purpose of this study was to compare rates of complications, aneurysm occlusion, and outcome in patients treated with a single-versus-multiple Pipeline Embolization Devices. MATERIAL AND METHODS: One hundred seventy-eight patients were treated with the Pipeline Embolization Device at our institution. Patients were divided into 2 groups: a single-device group (n = 126) and a multiple-device group (n = 52). RESULTS: There was no statistically significant difference between the 2 groups with respect to baseline characteristics except for age and aneurysm size (higher with multiple Pipeline Embolization Devices). Complications occurred more frequently with multiple (15%) versus a single device (5%, P = .03). In multivariate analysis, the use of multiple devices independently predicted complications. A similar proportion of patients achieved adequate aneurysm obliteration at follow-up in the single-device (84%) and the multiple-device groups (87%, P = .8). In multivariate analysis, age and follow-up time predicted obliteration. At follow-up, a significantly higher proportion of patients treated with a single device (97%) achieved a favorable outcome compared with those treated with multiple devices (89%, P = .03). In multivariate analysis, there was a strong trend for the use of a single device to predict favorable outcomes (P = .06). CONCLUSIONS: Treatment with a single Pipeline Embolization Device provides similar occlusion rates with less complications and better overall outcomes. These findings suggest that a single Pipeline Embolization Device is sufficient for treatment of most intracranial aneurysms.

Cytokines and the malnutrition of chronic renal failure.

Malnutrition in uremic patients remains one of the major causes of morbidity and mortality. Its mediators remain largely unknown. Uremia is characterized by changes in circulating levels of catabolic cytokines and anabolic growth factors. The aim of this study was to investigate whether these changes are associated with the malnutrition of patients with chronic renal failure (CRF). We have studied the prevalence of malnutrition in a small group of patients (n = 20) with CRF (serum creatinine = 551 +/- 105 mumol/l, mean +/- SD) and 25 age-matched controls. Nutritional status was assessed by dietary diaries, subjective global assessment (SGA), and by measurement of anthropometric parameters. Regression analysis was applied to examine the relationship between biochemical and anthropometric parameters. Simultaneously, we have investigated changes in the circulating levels of catabolic cytokines [tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1 beta and IL-6] and an anabolic growth factor [insulin-like growth factor-I (IGF-I)]. We observed a high prevalence of malnutrition as judged initially by SGA: 50% moderately malnourished and 15% severely malnourished. This was confirmed by anthropometric measurements. We noted a significant reduction in both triceps skinfold thickness (TST; 35% of patients < 25th centile) and midarm muscle circumference (MAMC, 65% of patients < 25th centile). We also noted a reduction in serum IGF-I in malnourished patients (IGF-I in well-nourished patients = 207 +/- 48 micrograms/l, in malnourished patients = 133 +/- 33 micrograms/l, p < 0.01). IGF-I correlated with TST (r = 0.71, p < 0.001) and MAMC (r = 0.47, p < 0.05). IGF-I had a high predictive value for TST (R2 = 51%, p < 0.001). In contrast, TNF-alpha levels were higher in malnourished patients: 19.5 +/- 30 pg/ml compared to 3.9 +/- 8 pg/ml in healthy patients (p < 0.001) and TNF-alpha showed a negative correlation with MAMC (r = -0.69, p < 0.01; R2 = 47%, p < 0.01). IL-1 beta levels were higher in CRF than in controls but did not correlate with nutritional parameters. No significant changes could be detected in serum IL-6. A significant percentage of predialysis patients with CRF suffer from some degree of malnutrition. This may be attributed in part to a fall in circulating anabolic growth factors and an increase in catabolic cytokines.