[Show abstract][Hide abstract] ABSTRACT: To evaluate renal function and to identify factors associated with renal dysfunction in the elective indications setting of nephron-sparing surgery (NSS).
We retrospectively reviewed operative data and glomerular filtration rate (GFR) of 519 patients treated by NSS in an elective indications setting between 1984 and 2006 in eight academic institutions. A GFR decrease under the thresholds of 60 or 45 ml/min at last follow-up was considered a significant renal dysfunction. Univariate and multivariate regression models were used to assess multiple factors of renal function.
Median age, tumor size, preoperative, and final GFR were 59.5 years (27-84), 2.7 cm (0.9-11), 79 (45-137), and 69 ml/min (p < 0.0001), respectively, with a median follow-up of 23 months (1-416). Hilar clamping was performed in 375 procedures (72.3 %). Significant GFR decrease was observed in 89 patients (17.1 %). Median operating time, hilar clamping duration, and blood loss were 137 min (55-350), 22 min (0-90), and 150 ml (0-4150), respectively. At univariate analysis, age (p = 0.002), preoperative GFR (p = 0.001), pedicular clamping (p = 0.01), and ischemia time (p = 0.0001) were associated with renal dysfunction. Age (p = 0.004; HR 1.2), pedicular clamping (p = 0.04; HR 1.3), and ischemia time (p = 0.0001; HR 1.8) remained independent risk factors for renal function deterioration in multivariate analysis.
Non- or time-limited clamping techniques are associated with preservation of renal function in the elective indications setting of NSS.
World Journal of Urology 04/2014; · 3.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Study Type - Therapy (multi-centre retrospective cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Upper urinary tract urothelial carcinomas (UUT-UCs) are rare tumours. Because of the aggressive pattern of UC, radical nephroureterectomy (RNU) with bladder cuff removal remains the 'gold-standard' treatment. However, conservative strategies, such as segmental ureterectomy (SU) or endourological management, have also been developed in patients with imperative indications. Some teams are now advocating the use of conservative management more commonly in cases of elective indications of UUT-UCs. Due to the paucity of cases of UUT-UC, only limited data are available on the oncological outcomes afforded by conservative management. We retrospectively investigated the oncological outcomes after SU and RNU in a large multi-institutional database. Overall, 52 patients were treated with SU and 416 with RNU. There was no statistical difference between the RNU and SU groups for the 5-year probability of cancer-specific survival, recurrence-free survival and metastasis-free survival. The type of surgery was not a significant prognostic factor in univariate analysis. The results were the same in a subgroup analysis of only unifocal tumours of the distal ureter with a diameter of <2 cm and of low stage (≤T2). Our results suggest that oncological outcomes after conservative treatment with SU are comparable to RNU for the management of UUT-UC in select cases. OBJECTIVE: • To compare recurrence-free survival (RFS), metastasis-free survival (MFS) and cancer-specific survival (CSS) after segmental ureterectomy (SU) vs radical nephroureterectomy (RNU) for urothelial carcinoma (UC) of the upper urinary tract (UUT-UC) located in the ureter. PATIENTS AND METHODS: • We performed a multi-institutional retrospective review of patients with UUT-UC who had undergone RNU or SU between 1995 and 2010. • Type of surgery, Tumour-Node-Metastasis status, tumour grade, lymphovascular invasion and positive surgical margin were tested as prognostic factors for survival. RESULTS: • In all, 52 patients were treated with SU and 416 with RNU. The median (range) follow-up was 26 (10-48) months. • The 5-year probability of CSS, RFS and MFS for SU and RNU were 87.9% and 86.3%, respectively (P= 0.99); 37% and 47.9%, respectively (P= 0.48); 81.9% and 85.4%, respectively (P= 0.51). • In univariable analysis, type of surgery (SU vs RNU) failed to affect CSS, RFS and MFS (P= 0.94, 0.42 and 0.53, respectively). • In multivariable analyses, pT stage and pN stage achieved independent predictor status for CSS (P= 0.005 and 0.007, respectively); the positive surgical margin and pT stage were independent prognostic factors of RFS and MFS (P= 0.001, 0.04, 0.009 and 0.001, respectively). • The main limitation of the study is its retrospective design, which is due to the rarity of the disease. CONCLUSIONS: • Short-term oncological outcomes after conservative treatment with SU are comparable to RNU for the management of UUT-UC in select cases and should be considered an option. • In every other case, RNU still represents the 'gold standard' for the treatment of UUT-UC.
BJU International 03/2012; 110(8):1134-1141. · 3.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of the present study was to analyse whether nephron-sparing surgery (NSS) was superior to radical nephrectomy (RN) in preserving renal function outcome in tumors larger than 4cm.
The data from 888 patients who had been operated upon at eight french university hospitals were retrospectively analyzed. Glomerular filtration rate (GFR) pre- and post-surgery was calculated with the abbreviated Modification of Diet in Renal Disease (MDRD) equation. For a fair comparison between the two techniques, all imperative indications for NSS and all GFR<30 mL/min/1.73 m(2) were excluded from analysis. A shift to a less favorable DFG group following surgery was considered clinically significant.
Seven hundred and thirty patients were suitable for comparison. Median age at diagnosis was 60 years (19-88). Tumors measuring more than 4cm represented 359 (49.2%) cases. NSS and RN were performed in 384 (52.6%) and 346 (47.4%) patients, respectively. In univariate analysis, patients undergoing NSS had a smaller risk than RN of developing significant GFR change following surgery. This was true for tumors≤4cm (P=0.0001) and for tumors>4cm (P=0.018). In multivariate analysis, the following criteria were independent predictive factors for developing significant postoperative GFR loss: the use of RN (P=0.001), decreased preoperative DFG (P=0.006), increased age at diagnosis (P=0.001) and increased ASA score (P=0.004).
The renal function benefit offered by elective NSS over RN persists even when expanding NSS indications beyond the traditional 4 cm cut-off.
Progrès en Urologie 11/2011; 21(12):842-50. · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to compare the postsurgical survival of UUT-UC patients treated with ONU and LNU.
Using a multi-institutional, national, retrospective database, we identified patients with UUT-UC who underwent radical nephroureterectomy by open access (ONU) or by the minimally invasive alternative (LNU). Survival curves were estimated using Kaplan-Meier method. A multivariate Cox model was used to evaluate the association between surgical approach and disease recurrence.
Overall, 609 patients were included (ONU = 459 and LNU = 150). The median age was 69.8 years (range 61.9-76), and the male-to-female ratio was 2:1. Postoperative complications occurred in 80 patients, with no significant difference between ONU and LNU on the whole (P = 0.64). The median follow-up was 27 months. There was no difference between the 2 procedures in the 5-year CSS or 5-year RFS. Moreover, the 5-year CSS (P = 0.053) and 5-year RFS (P = 0.9) for cases with locally advanced disease (pT3/pT4) were similar between ONU and LNU. In the multivariate analysis, the surgical procedure used was not found to be associated with survival. The main limitation of the study is its retrospective design, which is the result of the rarity of the disease.
There is no evidence that oncological outcomes for LNU are inferior to those for open surgery, provided that the appropriate precautionary measures are taken.
Annals of Surgical Oncology 06/2011; 19(1):301-8. · 3.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Evaluation of the effectiveness and tolerance of thermoformable metallic spiral stents Memokath(®) 051 (Bard, Pnn Medical) in the treatment of localized ureteral stenosis in non-operable patients who have JJ ureteral stents.
Prospective, descriptive and multicenter study of patients with ureteral strictures treated with metallic ureteral stents Memokath(®) 051. Assessment criteria (recurrent stenotic, permeability, tolerance) were measured by clinical, biological and radiological examination at 1 month, and then every 3 months.
Fifteen stents (average length: 9.15 cm, range 6-15 cm) were implanted in 14 patients (mean age: 55 years, range: 38-72 years) with secondary suspended ureteral stenosis during 2 years in two centers. The median follow-up was 11 months (range 6 to 24 months). Technical difficulty was observed with two patients. Stents are still up in four patients. The stenosis recurred in four patients with spontaneous progression of stenosis but without endoprosthetics tissue invasion. Two and three migration were observed with spontaneous expulsions. Two lower urinary infections and one high occurred, resolved on antibiotic therapy, no inlay or hematuria, no pain (mean VAS score=3/10) or urinary disorders of the lower unit have been identified.
Stents Memokath(®) 051 are well tolered and seem to position themselves as an interesting alternative to JJ ureteral stent in some frails patients. The refinement of contraindication should help to improve the stent's efficacity and to reduce the risk of migration and expulsion.
Progrès en Urologie 06/2011; 21(6):397-404. · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The advanced renal cell carcinoma (RCC) affects patients mainly ∼60 years of age and who may have an active sex life. The objective of the study was to investigate possible sexual disorders in a male population with advanced RCC treated with a molecular targeted therapy (MTT).
Thirty-eight male patients with a stabilized advanced RCC on MTT were proposed a personal interview about their sexual life, filled in the International Index of Erectile Function (IIEF) auto-questionnaire, and were reassessed if the treatment was modified.
This is the first evaluation of sexual life while on MTT. For 64% of the patients (median age 59 years, treatment duration 12 months), the quality of their sexual life was considered important. The scores of the IIEF were reduced from 30% to 60% in erectile function, intercourse satisfaction, orgasmic function, sexual desire, and overall satisfaction. The erectile dysfunction was more severe in the MTT population compared with age-stratified general or urological populations. The disorders were reversible in a few cases after treatment interruption.
Patients on MTT for an advanced RCC experience a decline of sexual activity. Onco-urologists should systematically inform, screen, initiate management, and refer patients to sexual medicine physicians.
Annals of Oncology 02/2011; 22(10):2320-4. · 6.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Our objective was to compare oncologic results of nephron sparing surgery (NSS) versus radical nephrectomy (RN) in T1aN0-x M0 papillary renal cell carcinoma (PRCC).
We retrospectively reviewed 277 patients treated for a pT1aN0M0 PRCC selected from an academic database from 12 centres. We compared the clinico-pathological features by using Chi-square and Student statistical analyses. Survivals analyses using Kaplan-Meier and Log-rank models were performed.
The two groups were composed by 186 patients treated by NSS and 91 by RN. The TNM stage was fixed and the two groups were, in terms of age and Fuhrman grade, comparable. Median age at diagnosis was 59 years (27-85). Median tumor size was 2.7 cm (0.4-4). The average follow-up was 49 months (1-246). Very few events arose in both groups: two local recurrences were observed in the NSS group (1.07%), three patients died of cancer in the NSS treated group (1.6%) and five in the RN treated group (5.5%). The five and 10 cancer-specific survival rate were comparable in the two groups (98% vs. 100% and 98% vs. 97%). The specific survival curves were perfectly similar for both groups (log rank test, p=0.25).
NSS is equivalent to RN as far as oncologic control of pT1aN0M0 PRCC is concerned.
Progrès en Urologie 05/2010; 20(5):350-5. · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Angiomyolipoma is generally a benign and noninvasive tumor. We report a case of angiomyolipoma with tumor thrombus from the renal vein into the inferior vena cava suggesting a malignant disease.
Progrès en Urologie 05/2010; 20(5):382-4. · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Ipsilateral recurrence after nephron-sparing surgery (NSS) is rare, and little is known about its specific determinants.
To determine clinical or pathologic features associated with ipsilateral recurrence after NSS performed for renal cell carcinoma (RCC).
We analysed 809 NSS procedures performed at eight academic institutions for sporadic RCCs retrospectively.
Age, gender, indication, tumour bilaterality, tumour size, tumour location, TNM stage, Fuhrman grade, histologic subtype, and presence of positive surgical margins (PSMs) were assessed as predictors for recurrence in univariate and multivariate analysis by using a Cox proportional hazards regression model.
Among 809 NSS procedures with a median follow-up of 27 (1-252) mo, 26 ipsilateral recurrences (3.2%) occurred at a median time of 27 (14.5-38.2) mo. In univariate analysis, the following variables were significantly associated with recurrence: pT3a stage (p=0.0489), imperative indication (p<0.01), tumour bilaterality (p<0.01), tumour size >4cm (p<0.01), Fuhrman grade III or IV (p=0.0185), and PSM (p<0.01). In multivariate analysis, tumour bilaterality, tumour size >4cm, and presence of PSM remained independent predictive factors for RCC ipsilateral recurrence. Hazard ratios (HR) were 6.31, 4.57, and 11.5 for tumour bilaterality, tumour size >4cm, and PSM status, respectively. The main limitations of this study included its retrospective nature and a short follow-up.
RCC ipsilateral recurrence risk after NSS is significantly associated with tumour size >4cm, tumour bilaterality (synchronous or asynchronous), and PSM. Careful follow-up should be advised in patients presenting with such characteristics.
European Urology 02/2010; 57(6):1080-6. · 10.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cisplatin-based chemotherapy (MVAC : cisplatin, methotrexate, adriamycin, vinblastine ; or GC : cisplatin, gemcitabine) has been the standard of care for patients with advanced urothelial tumor during the last twenty years. Greater knowledge in the molecular biology of bladder cancer lead to the identification of promising target such as EGFR, HER2, or VEGF-VEGFR pathways. The role of targeted therapies as monotherapy, in combination with chemotheray or as maintenance post-chemotherapy is currently under study.
Bulletin du cancer 01/2010; 97 Suppl Cancer de la vessie:43-50. · 0.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Advanced renal cell carcinoma is associated with a poor prognosis and is refractory to standard chemotherapy. Recent progress in the understanding of molecular biology and pathogenesis of renal cell cancer has been translated into the development of new therapeutic strategies. The management of metastatic RCC has been revolutionized with the development of targeted molecular therapies against VEGF-VEGFR and mTOR. Randomized phase III clinical trials demonstrated clinical benefit for patients with advanced RCC in overall survival and progression free survival. At the moment, six molecules have been approves in advanced RCC: cytokines (IL-2 and IFN), antiangiogenic therapies (sunitinib, sorafenib, bevacizumab) and mTOR inhibitors (Temsirolimus, everolimus). Nephrectomy is an important component of the multimodality treatment of mRCC. Prospective trials will be assessed the value of nephrectomy in patients treated by antiangiogenic therapies. Large randomized trial are ongoing to evaluate these new therapies in adjuvant setting.
Bulletin du cancer 01/2010; 97:17-28. · 0.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the interest carried in andrology within the community of the urology residents.
Between June and October 2008, all urology residents received an anonymous questionnaire by e-mail estimating their interest for andrology. The following elements were reported: age, sex, current status, future activity, participation in theoretical learning and training courses practices, interest for the speciality and the opinion on the current formation. The statistical analysis was performed with the SEM software.
Seventy-seven of the 238 urology residents (32.4%) answered the sent questionnaire. The mean age was 29.2 years (25-36). Thirty-two of them were from a Parisian center (41.6%) and 45 (58.4%) from another city. There are 40.3% of urology residents who wished work on the hospital, 27.3% wished develop an exclusive liberal activity. There are 81.8% of the urology residents who declared to be interested in andrology and 29.9% were registered or wished to join the diplôme d'études spécialisées complémentaires (DESC) of Andrology. Concerning the current formation, only 4% of the participants considered that the theoretical education of the andrology was sufficient and only 6.6% of them considered to have acquired a sufficient practical training in andrology during the cursus.
The andrology is a particularly attractive speciality for the urology residents and the current modalities of formation are considered insufficient by most of them.
Progrès en Urologie 07/2009; 19(6):427-33. · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective was to identify the number of residents registered in the course of urology in France in 2008, and to make a forecast in the number of posts of fellow and specialist assistant available at the end of their course.
From January to February 2008, a questionnaire identified in all French University Hospital the number of residents enrolled in the urology course, and the number of posts of fellow and specialist assistant in urology in the region. The year of the end of the course has been determined for each resident in compliance with seniority, and taking into account the availability. The number of fellow and specialist assistant posts available in the same period was estimated by considering the duration of each postinternship, and any change in the number of posts.
Our census counted 207 residents, 76 fellow posts, 10 specialist assistant posts. Of the 207 residents, 29 completed their studies in 2008, 57 in 2009, 60 in 2010, 61 in 2011. Following our methodology, there was a lack of fellow and specialist assistant posts available from November 2010 (-15 posts in 2010, -7 posts in 2011).
Our study showed an increase in the number of residents enrolled in urology course by years of promotion, causing a lack of fellow and specialist assistant posts from 2010. Apart from an opening of additional fellows and specialist assistants at that time, our study highlights the long-term regulation of entries in the urology course ensuring a postinternship quality.
Progrès en Urologie 06/2009; 19(5):341-7. · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess cancer-specific survival of partial nephrectomy (PN) patients with >or= 7-cm lesions or unfavorable pathology (stage T3a or Fuhrman grades III-IV).
At 13 participation centers, 4072 partial or radical nephrectomies (RN) were performed for RCC between 1984 and 2001. Of all procedures, 925 (22.7%) were for tumors > 7 cm, 973 (23.9%) had Fuhrman grades III or IV, and 861 (21.1%) had stage pT3a. None had nodal or distant metastases. Matched (age, gender, tumor size, T stage, histologic subtype, and Fuhrman grade [FG]) survival analyses addressed the effect of nephrectomy type (partial vs radical) on cancer-specific mortality.
Partial nephrectomy for tumors > 7 cm was associated with higher mortality than RN (HR = 5.3; P = .025). No significant cancer-specific survival differences were recorded after PN for FG III-IV (HR = 0.7, P = .5) or for pT3a lesions (HR = 2.5, P = .9).
Partial nephrectomy may undermine cancer control in patients with tumors > 7 cm. Conversely, after PN, the same cancer control rates as after RN may be expected in patients with Fuhrman grades III-IV or with pT3a histology.
[Show abstract][Hide abstract] ABSTRACT: The occurrence of positive surgical margins (PSMs) after partial nephrectomy (PN) is rare, and little is known about their natural history.
To identify predictive factors of cancer recurrence and related death in patients having a PSM following PN.
Some 111 patients with a PSM were identified from a multicentre retrospective survey and were compared with 664 negative surgical margin (NSM) patients. A second cohort of NSM patients was created by matching NSM to PSM for indication, tumour size, and tumour grade.
PSM and NSM patients were compared using student t tests and chi-square tests on independent samples. A Cox proportional hazards regression model was used to test the independent effects of clinical and pathologic variables on survival.
Mean age at diagnosis was 61+/-12.5 yr. Mean tumour size was 3.5+/-2 cm. Imperative indications accounted for 39% (43 of 111) of the cases. Some 18 patients (16%) underwent a second surgery (partial or total nephrectomy). With a mean follow-up of 37 mo, 11 patients (10%) had recurrences and 12 patients (11%) died, including 6 patients (5.4%) who died of cancer progression. Some 91% (10 of 11) of the patients who had recurrences and 83% of the patients (10 of 12) who died belonged to the group with imperative surgical indications. Rates of recurrence-free survival, of cancer-specific survival, and of overall survival were the same among NSM patients and PSM patients. The multivariable Cox model showed that the two variables that could predict recurrence were the indication (p=0.017) and tumour location (p=0.02). No other variable, including PSM status, had any effect on recurrence. None of the studied parameters had any effect on the rate of cancer-specific survival.
PSM status occurs more frequently in cases in which surgery is imperative and is associated with an increased risk of recurrence, but PSM status does not appear to influence cancer-specific survival. Additional follow-up is needed.
European Urology 04/2009; 57(3):466-71. · 10.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe the practice of partial nephrectomy (PN) in France and assess its results in terms of morbidity and cancer control.
Seven French University Hospitals in which nephron sparing surgery represents at least 30% of the total number of nephrectomies for renal tumour, participated in this study. All centres included, as exhaustively as possible, all their PN cases. For each patient, 70 variables were harvested in order to characterize the patient population, the indications, the operative technique, the per- and postoperative course and complications, the tumor specificities, the carcinologic control and renal function follow-up.
Seven hundred and forty-one PN, of which 579 for malignant tumours were analysed. The mean tumour size was 3.4+/-2.1 cm (0.1-18) and 20.8% of the tumours were larger than 4 cm. In 30.1% of cases, the indication was imperative. Among the PN, 12.2% were performed laparoscopically. The mean operating time was 151+/-54.2 min (55-420). The medical and surgical complications rates were respectively 15.2 and 14.7%. At a mean 38 months follow-up, the local recurrence rate was 3.5% and the specific death rate was 4.5%.
PN is nowadays getting a more and more widely used technique in France. This expansion is completely justified by its results and urologists must consider nephron sparing surgery as the gold standard treatment for renal tumours measuring less than 4 cm.
Progrès en Urologie 08/2008; 18(7):428-34. · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the morbidity of partial nephrectomy (PN) according to tumour size and the type of indication based on a multicentre retrospective study.
Seven French teaching hospitals participated in this study. Data concerning tumour size, indication for PN (elective or necessity), age, gender, TNM stage, histological type, Fuhrman grade, ASA score and performance status (ECOG) were analysed. Medical and surgical complications, intraoperative blood loss, blood transfusion rate and length of hospital stay were also studied. Statistical analysis of qualitative and quantitative variables was performed with Chi-square test (Fisher's test) and Student t-test.
Six hundred and ninety one patients were included. The median tumour diameter was 3cm (0.4-18). Tumours measuring less or equal to 4cm and incidental tumours represented 77.7 and 80.7% of cases, respectively. Clear cell carcinomas represented 75.1% of malignant tumours. Some 89.1% of tumours were T1, 1.6% were N+ and 2.3% were M+. In the 486 elective indications: the operating time (p = 0.03), mean blood loss (p = 0.04), and urinary fistula rate (p = 0.01) were significantly higher in tumours greater than 4cm. These differences were not associated with an increase in the medical (p = 0.7) or surgical complication rate (p = 0.2), or the length of hospital stay (p = 0.4).
Broader indications for elective PN is associated with an increased morbidity but which remains acceptable. This is an important point for patient information and to guide the choice of surgical strategy, particularly in elderly, frail patients or patients with major comorbidities.
Progrès en Urologie 05/2008; 18(4):207-13. · 0.77 Impact Factor