Volumetric and functional outcomes at 1-year between percutaneous-ablation and partial-nephrectomy for T1b renal tumors

INTRODUCTION

Indication for percutaneous-ablation (PA) is gradually expanding to renal tumors T1b (4-7cm). Few data exist on the alteration of renal functional volume (RFV) post-PA. Yet, it is a surrogate marker of post partial-nephrectomy (PN) glomerular filtration rate (GFR) impairment. The objective was to compare RFV and GFR at 1-year post-PN or PA, in this T1b population.

METHODS

Patients with unifocal renal tumor≥4cm treated between 2014 and 2019 were included. Tumor, homolateral (RFVh), contralateral RFV, and total volumes were assessed by manual segmentation (3D Slicer) before and at 1 year of treatment, as was GFR. The loss of RFV, contralateral hypertrophy, and preservation of GFR were compared between both groups (PN vs. PA).

RESULTS

144 patients were included (87PN, 57PA). Preoperatively, PA group was older (74 vs. 59 years; P<0.0001), had more impaired GFR (73 vs. 85mL/min; P=0.0026) and smaller tumor volume(31.1 vs. 55.9cm3; P=0.0007) compared to PN group. At 1 year, the PN group had significantly more homolateral RFV loss (-19 vs. -14%; P=0.002), and contralateral compensatory hypertrophy (+4% vs. +1,8%; P=0.02, respectively). Total-RFV loss was similar between both (-21.7 vs. -19cm3; P=0.07). GFR preservation was better in the PN group (95.9 vs. 90.7%; P=0.03). In multivariate analysis, age and tumor size were associated with loss of RFVh.

CONCLUSION

For renal tumors T1b, PN is associated with superior compensatory hypertrophy compared with PA, compensating for the higher RFVh loss, resulting in similar ΔRFV-total between both groups. The superior post-PN GFR preservation suggests that the preserved quantitative RFV factor is insufficient. Therefore, the underlying quality of the parenchyma would play a major role in postoperative GFR.

Administration of neoadjuvant chemotherapy for muscle-invasive bladder cancer in real life: Are urologists still too cautious?

INTRODUCTION

Neoadjuvant chemotherapy (NAC) is now recommended to treat muscle-invasive bladder cancer (MIBC) but is not always executed in real life. This study aims to evaluate the proportion of patients with MIBC who receive an optimal NAC, and to present the predictive factors of its achievement.

METHODS

This monocenter retrospective study included all the patients who underwent radical cystectomy for≥pT2NxM0 MIBC between 2013, January and 2018, December. NAC consisted in 4-6 cycles of MVAC (methotrexate, vinblastine, adriamycin, and cisplatin) or 4 cycles of GC (gemcitabin, and carboplatin). Demographic (sex, age, ECOG-PS, glomerular filtration rate [GFR], and cN stage), surgical (urinary derivation, time of surgery, blood loss, and complications), and oncological characteristics were analyzed. Multivariate analysis are made to find predictors of administration of NAC.

RESULTS

One hundred and twenty-seven patients were included. Thirty received CNA (24%). Patients who underwent CNA were younger, with better ECOG and better GFR. Multivariate analysis showed that cN+ stage and better GFR were significantly associated to administration of NAC. Eight patients (27%) couldn't receive an optimal treatment due to toxicity. Perioperative complication rates were similar, with or without NAC. Patients who underwent NAC had a worse GFR after treatment (-17 versus +5mL/min, P<0.01).

CONCLUSION

Due to the risks of toxicity, NAC can only be proposed to selected population, which is not the current patients. Immunotherapy could allow to treat more patients because of better tolerance.

LEVEL OF EVIDENCE

3.

Long-term oncological outcomes of cystic renal cell carcinoma according to the Bosniak classification

OBJECTIVES

To evaluate the prognostic role of the Bosniak classification on the long-term oncological outcomes of cystic renal cell carcinomas.

MATERIAL AND METHOD

In a national multicentric retrospective study, we included patients treated surgically for localized cystic RCC from 2000 to 2010. Patients with a follow-up of less than 4 years, benign tumors, and ablative treatments were excluded. The primary outcome was disease-free survival.

RESULTS

152 patients met the inclusion criteria: Bosniak II (6%), III (53%), IV (41%), with a median follow-up of 61 (12-179) months. Characteristics of the population and the tumors were [median, (min-max)] age 57 (25-84) years old, tumor size 43 mm (20-280), RENAL score 7 (4-12), PADUA score 8 (5-14). Treatments were 55% partial nephrectomy, 45% radical nephrectomy, 74% open surgery, and 26% laparoscopy. In pathological report, cystic RCC were mainly of low grade (1-2, 77%) and low stage (pT1, 81%). The two main histological subtypes were conventional (56%) and papillary (23%) RCC. Staging at presentation and histological characteristics were similar between Bosniak III and IV, except for high grade which was more common in Bosniak IV (12 vs 36%, p < 0.01). The Bosniak classification was not predictive of the recurrence, as 5- and 10-year disease-free survival were similar in Bosniak III and IV (92% vs 92% and 84% vs 83%, p = 0.60).

CONCLUSION

The Bosniak classification is predictive of the risk of malignancy but not of the oncological prognosis. Regardless of the initial Bosniak categories, almost all cystic RCCs were of low stage/grade and had low long-term recurrence rate.

Secondary bladder exstrophy repair with a bilateral gracilis muscle flap in an adult female patient: Case report of an original procedure

Classical bladder exstrophy (CBE), affecting 1 birth out of 30,000, is characterized by an evaginated bladder plate through a defect in the lower abdominal wall, multiple abdominal wall anomalies including a pubic bone arch dehiscence. Numerous approaches from childhood to adulthood are thus required, depending on the severity of the deformity, including the associated genital anomalies. We report the case of a 19-year-old woman with CBE with a history of three-failed primary closure. We performed a secondary neck closure with a concomitant suspension of the bladder neck and reconstruction of the lower abdominal wall using a bilateral gracilis muscle flap transposition. The early postoperative course was uneventful. The patient was discharged at day ten postoperatively. The upper part of the genital sutures (labia minora) secondary healed in three weeks. Assessment at 2, 6 and 16 months postoperatively, respectively noticed a complete healing with successful sexual intercourses, perceived gracilis contraction by the patient, and finally, recent attempts to get pregnant. Neither urinary infection nor urinary leaks occurred. Bilateral crossed gracilis muscles transfer linking both rectus abdominis muscle in front of the reconstructed bladder neck might benefit to bladder exstrophy patients.

Nephron sparing surgery in tumours greater than 7cm

INTRODUCTION

Partial nephrectomy (PN) is the gold standard treatment for renal cell carcinomas under 4cm. No robust data exists to recommend PN for tumours>7cm (cT2). The objective of this work is to evaluate the results of PN for cT2 tumours.

PATIENTS AND METHODS

All patients who underwent PN or radical nephrectomy (RN) for cT2 tumours between 2000 and 2013 at our institution have been included. Patient demographics, postoperative data including renal function, morbidity, mortality and oncologic outcomes were reviewed retrospectively and compared using χ² test, Mann-Whitney test, Kaplan-Meier method and log rank test.

RESULTS

We included 130 patients, 49 (38%) in the PN group and 81 (62%) in the RN group, with a median follow-up of 42 months [19-69]. Variation of postoperative renal function at day 5 and last recorded value was significantly different between the groups (P=0.03 and P<0.001). The PN group had a significantly higher complication rate as compared with RN group (37% versus 14%, P=0.002). There were no significant differences between the two groups for overall, recurrence free and specific survival (P=0.55, P=0.55, P=0.24, respectively). In univariate analysis, the type of surgery (PN versus RN) was not associated with a significant difference of oncologic outcome (margins, survival).

CONCLUSION

PN can be offered for cT2 tumours with oncological outcomes similar to RN. Despite an increased morbidity, it remains acceptable with the demonstrated advantage of preservation of renal function.

LEVEL OF EVIDENCE

4.

[Sporadic kidney cancer of young subjects: Study of the clinical and pathological features of a bicentric cohort]

INTRODUCTION

The epidemiology of kidney cancer is evolving with a net increase in the incidence of renal tumors, globally, and in young people in particular.

OBJECTIVE

To evaluate the incidence and clinical and pathological characteristics of sporadic renal tumors in young subjects and their risk factors.

MATERIAL AND METHODS

A retrospective study aimed at collecting clinical, epidemiological and anatomopathological information from the 118 patients aged 18 to 40 treated for a sporadic kidney tumor in two Parisian university hospital centers between 2003 and 2013.

RESULTS

Our study showed a very significant increase in the incidence of renal tumors in our 11 years of decline (P=6.10^-15). The mode of discovery also seems to have evolved with a majority of tumors (67 %), due to the considerable growth of imaging in recent decades. We also showed a different pathological distribution compared to the literature with a significant increase in the number of papillary tumors (16.9 %) and chromophobes (15.2 %), in addition to a decrease in the number of carcinomas (43.2 %) as well as the appearance of a new pathological entity of particular clinical severity: renal carcinoma related to translocation Xp11.2 (15.3 %) (P<10^-5). Among the risk factors, hypertension seems to be a definite risk factor while tobacco and obesity do not have a significant influence.

CONCLUSION

Our study showed a marked increase in the incidence of renal tumors with specific clinical and epidemiological features in a population of young subjects. The role and importance of oncogenetic management as well as the study of environmental factors could lead to the identification of new risk factors and corollary to their prevention.

LEVEL OF EVIDENCE

4.

[Retrospective comparison of the reproducibility and the performances of R.E.N.A.L. score, 12 segments score and UPRCC score for the partial nephrectomy]

INTRODUCTION

Compare three morphometrics scores of the kidney on the reproductibility and the predictability of complications per- and post-partial nephrectomy.

MATERIALS AND METHODS

This comparative study analyzed a monocentric retrospective cohort of 47 patients affected by a unique renal tumor and operated by partial nephrectomy by lumbotomy excluding the genetic diseases from January till December, 2014. The preoperative scanners were reviewed in double-blind by a radiologist and an internal surgeon who classified each tumor according to the three classifications: R.E.N.A.L. score, score in 12 segments and the University Paris Renal Cancer Classification (UPRCC). The judging criteria were the operative and ischemic duration, the blood loss, the preoperative injuries, the length of the hospital stay, the postoperative complications according to the Clavien-Dindo classification. The Cohen's kappa coefficient and the one-way analysis of variance were used respectively to compare the inter-observer reproducibility and the predictability of the complications for each classification.

RESULTS

Forty-four tumors of which 30 (64%) were on the left kidney, with an average size of 55.19mm with 17 (39%) on the upper pole, 12 (27%) on the lower pole and 15 (34%) medio-renal. The UPRCC was the most reproductible classification with 90% inter-observer concordance against 84% for the R.E.N.A.L. score and 72% for the score in 12 segments. The most predictable classification of complications was the score in 12 segments in particular thanks to the subgroup including the number of segments reached which allows to predict significantly the risk of a duration of intervention, prolonged ischemia and the risk of blood loss (P=0.03, 0.06 and <0.001).

CONCLUSION

The main result of this study is that, as in the majority of the previous studies on morphometrics scores, no score allows to predict the postoperative complications.

LEVEL OF EVIDENCE

4.

Current practice and access to prostate MR imaging in France

PURPOSE

To obtain an overview of the degree of discrepancy between current clinical practice of prostate magnetic resonance imaging (MRI) in France and recommendations.

MATERIALS AND METHODS

A brief survey was sent to 1229 members of the French society of urology in order to identify their indications of prostate MRI and its impact on patient management. The urologists were asked to answer several questions regarding age, practice modality, prostate MRI examinations (technique, indication before first biopsy, second biopsy, cancer staging, active surveillance, recurrence, focal therapy) and quality of reports.

RESULTS

A total of 445 responses were received (participation rate of 36%). The mean delay for obtaining an appointment for prostate MRI ranged between 15-30 days in 54%. Fifty-four percent of MRI reports contained a PIRADS score and 23% a Likert score. The indications of multiparametric-MRI were tumor detection/location prior to repeat biopsy (90%), cancer staging (85%), management of patients under active surveillance (85%), selection of candidates to focal therapy (63%), tumor detection/location in biopsy naïve patients (53%), detection of local recurrence after radical (51%). Only 119 urologists (28.6%) had access to image fusion (MRI and transrectal ultrasound) and 351 (85.4%) used cognitive fusion. Mostly, targeted biopsies are done by urologists alone (nearly 80%), a very few are done by radiologists (8%) or by the two of them in collaboration (12%).

CONCLUSION

The majority of urologists consider that prostate MRI is essential for the management of patients with prostate cancer. Practices are ahead of recommendations particularly before the first biopsy and in active surveillance.

Early Low Urinary CXCL9 and CXCL10 Might Predict Immunological Quiescence in Clinically and Histologically Stable Kidney Recipients

We monitored the urinary C-X-C motif chemokine (CXCL)9 and CXCL10 levels in 1722 urine samples from 300 consecutive kidney recipients collected during the first posttransplantation year and assessed their predictive value for subsequent acute rejection (AR). The trajectories of urinary CXCL10 showed an early increase at 1 month (p = 0.0005) and 3 months (p = 0.0009) in patients who subsequently developed AR. At 1 year, the AR-free allograft survival rates were 90% and 54% in patients with CXCL10:creatinine (CXCL10:Cr) levels <2.79 ng/mmoL and >2.79 ng/mmoL at 1 month, respectively (p < 0.0001), and 88% and 56% in patients with CXCL10:Cr levels <5.32 ng/mmoL and >5.32 ng/mmoL at 3 months (p < 0.0001), respectively. CXCL9:Cr levels also associate, albeit less robustly, with AR-free allograft survival. Early CXCL10:Cr levels predicted clinical and subclinical rejection and both T cell- and antibody-mediated rejection. In 222 stable patients, CXCL10:Cr at 3 months predicted AR independent of concomitant protocol biopsy results (p = 0.009). Although its positive predictive value was low, a high negative predictive value suggests that early CXCL10:Cr might predict immunological quiescence on a triple-drug calcineurin inhibitor-based immunosuppressive regimen in the first posttransplantation year, even in clinically and histologically stable patients. The clinical utility of this test will need to be addressed by dedicated prospective clinical trials.

[Conservative management of upper tract urinary fistulae using ureteral trans-vesico-parietal stent]

OBJECTIVES

Ureteral stents and ureteral catheters externalized through the urethra are not ideal solutions to manage complicated upper urinary tract fistulae. We sought an effective method of drainage, minimally invasive, reproducible allowing a rapid patient's discharge.

PATIENTS AND METHODS

Between November 2013 and February 2015, an ureteral stent was exteriorized in trans-vesico-parietal by an endoscopic and percutaneous access in patients with complicated upper urinary tract fistulae. Monitoring of tolerance, complications and urinary fistula healing was performed.

RESULTS

Nine consecutive patients had an ureteral stent exteriorized in trans-vesico-parietal to manage complicated upper urinary tract fistulae. There was no failure in introducing the catheter, or postoperative complication. Catheters were left in place on average 36.1days (24-55). The patients were able to return home with the catheter in place in 77.8% of cases. The tolerance of the catheter was good. All fistulae were able to be treated conservatively at the end of the drainage period.

CONCLUSION

Trans-vesico-parietal ureteral catheters enable efficient and reproducible conservative treatment of upper tract urinary fistulae regardless of their cause.

LEVEL OF EVIDENCE

5.

[Observational survey of the French Urological Association Oncology Committee (CCAFU) evaluating the practice of immediate postoperative instillation (IPOP) using mitomycin C for non-muscle invasive bladder cancer (NMIBC) treatment]

OBJECTIVE

To evaluate the practice of immediate postoperative instillation (IPOP) using mitomycin C for non-muscle invasive bladder cancer (NMIBC) treatment by urologists members of the French Association of Urology (AFU).

MATERIAL AND METHOD

Internet-based observational survey evaluating indications and practical modalities of IPOP in NMIBC treatment using questionnaire sent in May 2014 to 915 urologists.

RESULTS

Two hundred ninety-eight urologists participated in the survey (response rate: 32.6%) and 57% prescribed the IPOP. The median frequency of IPOP prescription was 3.3%, and was higher in the academic public sector. The CASE recommendations were self-assessed as known or well-known in 67% of cases. The selections criteria for IPOP were adequately identified by 62% of urologists, without differences according to sectors of activity. The IPOP prescription modalities were declared as an obstacle to the completion for 41.9% of urologists, and especially in the private sector. Completion times of IPOP were declared <24h in 91% of cases. We see that 28.5% of urologists prescribed an urinary alkalization. The average frequency of complications of IPOP was 0.91 per urologist.

CONCLUSIONS

The IPOP prescription frequency was higher among urologists practicing in the academic sector. Neither the level of knowledge of the recommendations nor the frequency of complications of IPOP had explained this difference. However, the prescription modalities were more frequently reported as an obstacle to their completion in the private sector.

LEVEL OF EVIDENCE

3.

[Molecular, preclinical, and clinical comparative data regarding different strains of bacillus Calmette-Guérin (BCG): Review by the French Urological Association Oncology Committee (CCAFU)]

OBJECTIVE

To review the differences between the BCG strains used for the treatment of non-muscle invasive bladder cancer (NMIBC) at the molecular level, regarding cytotoxicity, immunogenicity, clinical efficiency, and safety.

MATERIAL AND METHOD

A systematic review of the literature search was performed from the database MedLine, focused on the following keywords: BCG; bladder; strain; genome; cytotoxicity; immune response; efficiency; safety.

RESULTS

Genetic differences between BCG strains have been identified and correlated to their time to differentiation from their initial cultures start, assuming a lower resistance to the host immune defenses of Tice and Danish strains compared to the Connaught strain. Preclinical comparative data showed superior cytotoxic effect and immunogenicity of the Connaught strain compared to Tice and Danish strains. The phase III trials have shown superior efficiency of BCG Connaught compared to BCG Tice and BCG Danish compared to BCG Tice regarding recurrence-free survival.

CONCLUSIONS

Among BCG strains used in France in NMIBC treatment, preclinical and clinical efficiency of Connaught strain was higher than that of the Tice strain. The limits of the currently available studies lie primarily in the lack of use of maintenance therapy.