Beyond the First Year: Epidemiology and Management of Late-Onset Opportunistic Infections After Kidney Transplantation.

Late opportunistic infections (OI) occurring beyond the first year after kidney transplantation (KT) are poorly described and not targeted by prophylactic strategies. We performed a ten-year retrospective monocentric cohort study describing epidemiology, risk factors and impact of late OI occurring 1 year after KT. We included clinically symptomatic OI requiring treatment besides BK virus nephropathy. Control groups included early OI occurring in the first year after KT, and KT recipients without OI since KT and alive with a functional allograft at 1 year. Among 1066 KT recipients, 185 (19.4%) presented a first episode of OI 21.0 (8.0-45.0) months after KT: 120 late OI (64.9%) and 65 early OI (35.1%). Late OI were mainly viral (N = 83, 69.2%), mostly herpes zoster (HZ) (N = 36, 43.4%). Pneumocystis represented most late fungal infections (N = 12/25, 48%). Compared to early OI, we reported more pneumocystis (p = 0.002) and less invasive aspergillosis (p = 0.01) among late OI. Patients with late OI were significatively younger at KT (54.0 ± 13.3 vs. 60.2 ± 14.3 years, p = 0.05). Patient and allograft survival rates between late OI and control groups were similar. Only age was independently associated with mortality. While late OI were not associated with higher mortality or graft loss, implementing prophylactic strategies might prevent such infections.

Robotic-assisted laparoscopy living donor nephrectomy: Technique and results of a monocentric retrospective series.

INTRODUCTION: Robot-assisted nephrectomy for living kidney donation (LKD) has been described in the literature as a safe and reproducible technique in high volume centers with extensive robotic surgery experience. Any surgical procedure in a healthy individual ought to be safe in regards to complications. The objective of this study was to evaluate the Robotic-assisted Living Donor Nephrectomy (RLDN) experience in a robotic surgery expert center. METHODS: This is a retrospective study from 11/2011 and 12/2019. In total, 118 consecutive Living Donor (LD) kidney transplants were performed at our institution. All the procedures were performed by robotic-assisted laparoscopic approach. Extraction was performed by iliac (IE), vaginal (VE) or umbilical extraction (UE). The left kidney was preferred even if the vascular anatomy was not modal. RESULTS: For donors: the median operative time was 120min with 50mL of blood loss. The median warm ischemia time was 4min, with a non-significant shorter duration with the UE (4min) in comparison with IE or VE (5min). Nine patients had postoperative complications including 1 grade II (blood transfusion) and 1 grade IIIb (vaginal bleeding after VE). None of our procedures were converted to open surgeries and no deaths were reported. For the recipients: 1.7% presented delayed graft function; their median GFR at 1 year was 61mL/min/1.73m2. CONCLUSION: RLDN in an expert center appears to be a safe technique. The advantages of the robot device in terms of ergonomy don't hamper the surgical outcomes. Donor, recipient and graft survivals seem comparable to the reported laparoscopic outcomes in the literature.

Management of long ureteral stenosis: Alternatives to indwelling ureteral stents.

OBJECTIF: Evaluate kidney autotransplantation (KAT) and ileal ureter substitution (IUS) practice and outcome as alternatives to indwelling ureteral stents for the management of long ureteral stenosis (US). MATERIAL: We included all patients treated for US with KAT or IUS in 5 French university urology centers between 2010 and 2018. We excluded US due to urothelial carcinoma. Primary endpoint was the preservation of ipsilateral kidney and renal function without any urinary diversion. RESULTS: 22 patients were treated with KAT (n=8, 36.4%) and IUS (n=14, 63.6%). Mean US length was 4.6cm and 6cm (P=0.52) in KAT and IUS groups respectively. US etiologies were lithiasis, iatrogenic, retroperitoneal fibrosis or extrinsic compression. US level was varied. The surgery was described as difficult because of peritoneal adhesions or major peri-ureteral fibrosis. Mean operating time and hospital stay were 336 and 346minutes (P=0.87) and 8 and 15 days respectively (P=0.001). Postoperative complications were mostly Clavien ≤2 (n=17, 77.3%). Revision surgery was required in the KAT group in 3 cases (37.5%), for textiles, renal vein thrombosis and anastomotic leak, none in the IUS group. The mean follow-up was 15.7 months. All but one (in the KAT group) ipsilateral kidneys were preserved, without renal function impairment (Δcreat +2.1 vs. +2.4µmol/l respectively, P=0.67), nor urinary diversion. CONCLUSION: KAT and IUS are safe alternatives whose indication depends on surgeons expertise. Our study pointed out the scarcity of this practice suggesting the need to refer patients to expert centers. LEVEL OF EVIDENCE: 3.

[Urethro-vesical anastomosis reconstruction using extra-peritoneal robot-assisted laparoscopy for anastomotic stenosis after radical prostatectomy]. / Réfection d'anastomose urétro-vésicale par voie extra-péritonéale laparoscopique robot-assistée pour sténose anastomotique post-prostatectomie radicale.

INTRODUCTION: Urethro-vesical anastomosis stenosis following radical prostatectomy is a rare complication but represents a challenging situation. While the first-line treatment is endoscopic, recurrences after urethrotomies require a radical approach. We present the updated results of our patient's cohort treated by pure robotic anastomosis refection. MATERIAL AND METHODS: This is a retrospective, single-center study focusing on one surgeon's experience. Patients presented an urethro-vesical stricture following a radical prostatectomy. Each patient received at least one endoscopic treatment. The procedure consisted of a circumferential resection of the stenosis, followed by a re-anastomosis with well-vascularized tissue. We reviewed the outcomes in terms of symptomatic recurrences and continence after the reconstructive surgery. RESULTS: From April 2013 to May 2020, 8 patients underwent this procedure. Half of the patients had previously been treated with salvage radio-hormonotherapy. The median age was 70 years (64-76). The mean operative time was 109minutes (60-180) and blood loss was 120cc (50-250). One patient had an early postoperative complication, with vesico-pubic fistula. The average length of stay was 4.6 days (3-8). Mean follow-up was 24.25 months (1-66). Half of the patients experienced a recurrence at a median time of 8.25 months (6-11) after surgery. Five patients experienced incontinence of which 3 required an artificial urinary sphincter implantation. CONCLUSION: Extra-peritoneal robot-assisted urethro-vesical reconstruction is feasible and safe to manage bladder neck stricture after radical prostatectomy. The risk of postoperative incontinence is high, justifying preoperative information. LEVEL OF EVIDENCE: III.

[When to introduce hormone therapy after total prostatectomy with positive lymph nodes? Study of the factors influencing the time of introduction of hormone therapy]. / Quand introduire une hormonothérapie après prostatectomie totale avec curage ganglionnaire positif ? Étude des facteurs influençant le délai d'introduction de l'hormonothérapie.

INTRODUCTION: Adjuvant hormone therapy is the standard treatment after total prostatectomy with positive lymph node. However, this treatment has side effects and at the time of the PSA era and extensive lymph node dissection, this principle is questioned. The aim of this study is to describe the oncological characteristics of patients that may explain the delay in introducing hormone therapy in patients with positive lymph node. METHODS: Monocentric, retrospective study of 161 patients from November 1988 to February 2018 in a single French University Hospital, having undergone radical prostatectomy with positive lymph nodes on pathology. For each patient, preoperative data (age, clinical stage, biopsy results, d'Amico classification) and postoperative data (pathological results, number of lymph nodes removed, number of positive lympnodes, recurrence free survival, specific survival and overall survival) were collected. The date of introduction of hormone therapy was noted and survival without hormonal therapy was established according to the Kaplan Meier curve. The pre- and post-operative oncological factors that could influence hormone therapy introduction were investigated with Chi2 and Student tests (statistically significant when P<0.05). RESULTS: The mean number of lymph nodes removed was 12 [1-40]. The mean number of positive lymph nodes was 2.5 [1-24], the mean percentage of positive lymph nodes was 25% (2.5-100). After a mean follow-up of 95 months (3-354), 88 patients (54.6%) had no hormonal treatment. The average time to hormonal treatment was 40 months [0-310]. At 3 years, survival without hormone therapy was 52% and 51% at 5 years. Only the percentage of positive lymphnodes appeared to be a significant predictor of the introduction of hormone therapy. (29.32% vs. 21.99%, P=0.047). Hormone-free survival was significantly higher in patients with lymph node involvement less than 25% (P<0.0001) or with less than 2 positive lymph nodes (P=0.0294). CONCLUSION: Lymph node invasion is a factor of poor prognosis after total prostatectomy and leads to introduce hormone therapy. Our study identified the percentage and number of positive lymph nodes as factors that identify patients who may be delayed in introducing this hormone therapy. LEVEL OF PROOF: 3.

[Evaluation of single kidney graft outcome in patients initially programmed for a dual kidney graft transplantation]. / Évaluation de greffons de bigreffe transplantés en monogreffe.

INTRODUCTION: Kidney transplantation is championed as the gold standard treatment for patients with end-stage kidney disease. According to the biomedical agency, there is an increasing number of patients waiting for kidney transplantation. Faced with organ shortage, the use of marginal grafts may well increase the number of available kidney grafts. Occasionally, during dual kidney graft transplantation, the poor quality of one of the two grafts, or other specific circumstances, may lead to transplantation of only one of the two grafts. We have compared patient outcome concerning single kidney transplantation from an initial dual kidney graft with respect to dual kidney graft transplantation. MATERIAL: Among 67 patients enrolled for a dual kidney graft, 39 dual kidney grafts (group 1) were compared with 12 grafts performed with only one of the two kidneys of a dual kidney graft (group 2) as well as 15 grafts performed following a classic kidney graft protocol (group 3). RESULTS: The survival of grafts was respectively for groups 1, 2 and 3 of 100%, 72,5% and 75,4% (P=0.17). The survival of patients was respectively for groups 1, 2 and 3 of 78.3%, 89.9% and 87.8% (P=0.47). CONCLUSION: Our study suggests that transplantation of a single kidney, initially proposed as dual kidney graft candidate, has satisfying results in terms of graft survival and patient mortality at the expense of poorer renal function in comparison to dual kidney graft. Indeed, there was no significant difference in the survival of patients and grafts. This seems promising taking into consideration that the aim of transplantation in elderly recipients is primarily to avoid dialysis, rather than having optimal post-transplantation kidney function. LEVEL OF EVIDENCE: 4.

[Comparison of operative and oncologic results between partial nephrectomy and radiofrequency ablation for treatment of renal tumors in patients older than 75]. / Comparaison des résultats opératoires et oncologiques de la néphrectomie partielle et de l'ablation par radiofréquence pour traitement des tumeurs rénales chez les patients de plus de 75 ans.

INTRODUCTION: Elderly patients represent a growing part of our society for who treatment strategy for localized renal tumors has to be chosen knowing iatrogen effects and renal function morbidity. The aim was to analyze oncological and functional results of nephron sparing surgery (PN) versus radiofrequency ablation (RFA). MATERIALS AND METHODS: All patients aged more than 75 treated by partial nephrectomy or radiofrequency ablation between 2007 and 2014 in our centre were included. Patient and tumors data were compared and these criteria were analyzed: survival (overall and without recurrence) and loss of renal function (pre- and postoperative MDRD). RESULTS: In total, 100 patients were included (26 partial nephrectomies, group 1 and 74 radiofrequency ablation, group 2) with a 32-months medium follow-up. Medium age and tumor size were significantly different (respectively, 78 versus 81 years old, P=0.001, 38mm versus 29mm, P=0.003). Perioperative results showed no differences in complications. Transfusion rate and duration of hospital stay were significantly higher in the PN group. Median overall survival were 45 vs. 27 months (P=0.23) for PN and RFA and median recurrence-free survival were 28 vs. 10 months (P=0.34). On a multivariate analysis, operative technique (PN or RFA) were not significantly linked to survival (HR 2.37 [95% CI: 0.66-8.5]), P=0.19. Loss of renal function were 1.5±14mL/min/1.73m2 for PN and 3±14mL/min/1.73m2 for RFA (P=0.69). CONCLUSION: Our study showed better perioperative results for RFA than for PN, without significant different survival. Loss of renal function were little and similar. LEVEL OF EVIDENCE: 4.

[Prostate cancer diagnostic by saturation randomized biopsy versus rigid targeted biopsy]. / Détection du cancer de prostate par biopsies de saturation versus biopsies ciblées fusion d'image rigide.

INTRODUCTION: Optimal diagram teaming up randomized biopsy (BR) to targeted biopsy (BC) is still missing for the diagnostic of prostate cancer (CP). This study compares diagram of 6, 12 or 18 BR with or without BC rigid. METHODS: Between January 2014 and May 2016, 120 patients had prostate biopsy BR and BC. Each patient had 18 BR and BC. Results compared sextant (6 BR), standard (12 BR) and saturation (18 BR) protocol with or without the adding of BC for the detection of CP. RESULTS: Rectal examination was normal, mean PSA at 8.99ng/mL and mean volume at 54cm3. It was first round for 48% of patients. Forty-four cancers were found by the group 18 BR+BC (control). The detection rate was respectively, for 6, 12 and 18 BR of 61%, 82% and 91%. The add of BC increased this detection of +27% for 6 BR+BC, +13% for 12 BR+BC and +9% for 18 BR+BC. BC found 70% of all CP. Nine percent of CP were missed by BR only. Significant CP (Gleason≥7) diagnostic was the same for 12 BR+BC and 18 BR+BC. CONCLUSION: The add of BC to BR increase the detection of CP by 10%. Twelve BR+BC is the optimal diagram for the diagnostic of CP finding 95% of CP and 97% of significant CP. LEVEL OF EVIDENCE: 4.

[Influence of plasmatic testosterone during natural history of prostate cancer: a review]. / Influence de la testostérone plasmatique au cours de l'histoire naturelle du cancer de la prostate : analyse de la littérature.

INTRODUCTION: Prostate cancer (PCa) is the most common disease in male patients and it has the particularity to be androgen dependent. The aim of the current study was to provide an overview about the interest of testosterone dosage during the management of PCa regardless of the stage of the disease. PATIENTS ET METHODS: A systematic review of the literature was done from the PubMed database by searching the following key words alone or in combination: prostate cancer; testosterone; risk; aggressiveness; hormonotherapy; active surveillance; prognosis; androgen; cardiovascular risk; biochemical recurrence. RESULTS: The level of plasmatic testosterone depends on the moment of the day with a peak between the end of the night and in the morning. We can test either the whole testosterone level, the free testosterone level or the bioavailable testosterone. The bioavailable testosterone is more representative of the presence of androgen in tissues but a specialized laboratory is mandatory. The testosterone plasmatic rate is potentially useful during several steps of the PCa management: in localized prostate cancer cases, men with low testosterone levels are more likely to have an aggressive disease and are therefore not good candidates for active surveillance. An extensive radical prostatectomy should be considered in case of young men since these patients are more likely to recur subsequently; in advanced prostate cancer cases, a testosterone level has to be less or equal to 0.2 ng/mL to guarantee an appropriate castration when a patient is undergoing an androgen deprivation treatment. A dissociation between the trend of PSA and testosterone levels can be the starting point of the castration-resistant period of the disease. CONCLUSION: The testosterone level can bring useful information regarding the profile of PCa and its ability to evolve during the whole natural history of the disease.

[Prognostic influence of prostate gland invasion by bladder tumour and/or prostate cancer in cystoprostatectomy specimen: a review]. / Influence pronostique de l'envahissement tumoral de la glande prostatique par la tumeur de vessie et/ou du cancer de la prostate découvert après cystoprostatectomie : analyse de la littérature.

INTRODUCTION: Cystoprostatectomy (CPT) is the gold standard surgical treatment for muscle invasive bladder cancer (MIBC). In certain cases, MIBC can invade the prostate gland and/or a prostate cancer (PCa) can be discovered fortuitously on the pathologic specimen. The aim of the current study was to report the prognostic influence of PCa in patients who underwent a CPT for MIBC. MATERIALS AND METHODS: A systematic review of the scientific literature was achieved in the Pubmed database, using the following keywords: prostatic neoplasm; urinary bladder neoplasm; cystectomy; surgery; recurrence; prognosis; survival. Clinical cases and series of less than five cases were deliberately excluded herein. RESULTS: Overall, ten studies published between 2004 and 2011 and involving 2196 patients were selected. Only retrospective studies of low level of evidence (NP 4) were available. The incidence of neoplastic invasion of the prostate gland by MIBC ranged from 25 to 48%. Preoperative predictors were multiple BC, recurrent, location in the trigone and existence of CIS. Overall survival at 3 years was significantly affected by the invasion of the prostate gland (pT4a) in these patients. The incidence of PCa discovered incidentally pathologic specimen CPT ranged from 14 to 49%. Only age was found as a positive predictor. The diagnosis of PCa did not influence survival of patients with MIBC and no specific PCa adjuvant treatment was systematically advocated. CONCLUSION: Fortuitous diagnosis of PCa and/or neoplastic invasion of the prostatic gland by BC on CPT specimen is not uncommon but this is variable across studies, depending on the quality of the pathological analysis. The invasion of the prostate gland by MIBC is a serious situation (pT4a) and linked with a poor prognosis. In case of concomitant PCa and MIBC, the prognosis is much more related to the natural history of the bladder tumour.