Progres En Urologie最新文献

Introduction: Patients with neurologic bladder are at an increased risk for urolithiasis, and currently, data on mini-percutaneous nephrolithotomy in this population are limited. Our objective was to compare mini (15F)-percutaneous nephrolithotomy, standard (24F)-PCNL and flexible ureteroscopy in terms of efficacy and safety in treatment of kidney stones in patients with neurogenic lower urinary tract dysfunction (NLUTD).

Methods: We conducted a retrospective monocentric study in our neuro-urological referral centre. All consecutive patients with NLUTD and a cumulative size of renal calculi greater than 15mm or 10mm in the lower calyx, who had extraction surgery between 2005 and 2020, were included. The primary endpoint was the one-session stone-free rate (SFR) at 3 months on a CT scan. The secondary endpoints were complication (Clavien-Dindo grading system), operative time, blood loss and length of hospital stay.

Results: We performed 76 standard PCNL (sPCNL), 46 flexible ureteroscopy lithotripsy (fURL) and 25 miniaturized PCNL (mPCNL). The one-session SFR was 37.5% for the mPCNL group, 38.2% for the sPCNL group and 37% for the fURL group with no significant difference between the three procedures (P=0.99). Early complications, blood loss and transfusion rates were lower in the mPCNL group than in the sPCNL group (P=0.047) and comparable to fURL group. The final SFRs after a second intervention for mPCNL, sPCNL and fURL were 48%, 61.8% and 63%, respectively (P=0.67).

Conclusion: The efficacy of mPCNL in patients with NLUTD was not different from other techniques, but a significantly lower rate of complications than sPCNL was observed.

Level of proof: 3.

Introduction: Intra-lesional injections of collagenase (Xiapex®) were the only non-invasive treatment option for Peyronie's disease (PD), until their withdrawal from the European market.

Objective: To evaluate the feasibility, efficacy, and safety of a combined treatment of percutaneous needle tunnelling (PNT) with penile modelling (PM) and the injection of platelet-rich plasma (PRP) under general anesthesia in the treatment of PD.

Patients and method: A prospective case series study included patients with PD in a stable phase who underwent this procedure between March 2020 and January 2023. The main outcome was an improvement in curvature.

Result: Thirty-six patients underwent this novel approach for the treatment of PD. The pretreatment mean±standard deviation (SD) curvature degree was 57.5±20.61° (range 20-90°). After the protocol, the mean curvature degree was 40.86±25.13° (range 0-90°). The curvature angle improved significantly (P=0.0001), with a mean improvement difference of 16.85±14.81° (range 0-50°) and a mean improvement percentage of 47.7±40.29% (range 0-100%).

Conclusion: Our preliminary experience suggests that PNT and PRP injections with PM are effective and safe for the treatment of penile deformity of PD.

Level of evidence: 4: case series study.

Purpose: To report the long-term oncological outcomes of active surveillance (AS) in selected patients with favorable intermediate-risk (IR) prostate cancer (PCa).

Methods: A retrospective database review of two academic centers was conducted to identify favorable IR PCa patients initially managed by AS between 2014 and 2022. Favorable IR PCa was defined by the presence of one single element of IR disease (i.e., PSA 10-20ng/mL, Gleason Grade Group [GG] 2, or cT2b). All patients were diagnosed and followed up according to a contemporary scheme, including MRI and image-guided biopsies. The primary endpoint was metastasis-free survival.

Results: A total of 57 patients met our inclusion criteria and the median follow-up was 56months. During follow-up, there were no cases of metastasis or death due to PCa, but 6 deaths due to competing causes. A total of 25 (44%) and 6 patients (11%) had definitive treatment and GG 3 reclassification during follow-up, respectively. In multivariable Cox hazard regression analysis, the risk of undergoing definitive treatment was significantly associated with PSA density>0.15 (HR: 4.82, 95% CI: 1.47 to 15; P=0.01) and PI-RADS 4-5 lesions on mpMRI (HR: 2.48, 95% CI: 1.06 to 5.19; P=0.006). Interestingly, tumor burden (P=0.3) and GG (P=0.7) on biopsy were not associated with definitive treatment.

Conclusions: AS is a safe and valuable strategy for well-selected patients with favorable IR prostate cancer, with excellent oncological outcomes after five years' follow-up.

Level of evidence: 4:

Introduction: Active surveillance (AS) has emerged as a primary management strategy for low-risk prostate cancer (PC) patients. We aimed to assess AS uptake over a 1-year snapshot throughout Quebec and to compare it to 2010 multicentric Canadian data.

Methods: A retrospective chart review and data collection was performed in 1 academic and 2 non-academic community centres from Quebec, among men identified in 2016 with localized T1c-T2c PC on biopsy, fulfilling NCCN criteria of low-risk (LR)-PC, including very-low-risk (VLR) and non-VLR-PC, and favourable-intermediate risk (FIR)-PC. AS adherence was defined when chosen as initial strategy, without any radical treatment within 6 months.

Results: Overall, 259 patients fulfilled the inclusion criteria with 50.2% of VLR-PC patients. At 6 months, 81% patients in the LR group and 65% in the FIR group were considered as adherent to AS, in both centres, but with an increased use of AS in the community centres compared to 2010 data. The rates of AS maintenance decreased at 12 months to respectively 69% and 58%. Among the VLR group, the rate of initiation was 98% and decreased to 85% at 12 months.

Conclusion: Our data suggest that the majority of low-risk PC patients indeed initiated an AS in 2016, with even a greater proportion of VLR-PC patients compared to 2010. This ideal strategy should be encouraged and improved at 12 months, and assessed with recent data and longer follow-up.

Level of evidence: 4:

Introduction: The incidence of small renal tumors (≤4cm) is on the rise. The gold standard treatment is partial nephrectomy (PN) but focal therapy can be a good alternative. We evaluated oncological control after treatment of T1a renal tumors by microwave ablation (MWA) compared to PN.

Methods: This is a retrospective, single-center study of all patients treated for TNM stage T1a renal tumors by either PN or MWA between 2010 and 2020. A propensity score was calculated and patients were matched 2:1 to compare recurrence-free survival, metastasis-free survival and overall survival between groups. We also compared postoperative complications using the Clavien-Dindo classification.

Results: After matching and propensity score, the two groups (41 MWA and 82 PN) were comparable. The median follow-up was 23 months (interquartiles, 9-48 months). Recurrence-free survival was higher in the PN group compared to MWA, with a recurrence rate of 17.1% in the MWA group vs 4.9% in the PN group (P=0.003). MWA treatment was a risk factor for tumor recurrence (P=0.002), but there was no significant difference in terms of metastasis-free survival (P=0.549) or overall survival (P=0.539). MWA was associated with fewer postoperative complications (P=0.0005).

Conclusion: This study shows that MWA was associated with higher risk of recurrence but similar metastasis-free survival and overall survival compared to PN. Recurrence was treated with new MWA or active surveillance. MWA may be an interesting alternative to PN for small renal tumors.

Level of evidence: Grade C.

Background: MRI-guided biopsy (MGB) contributes to the diagnosis of clinically significant Prostate Cancer (csPCa). However, there are no clear recommendations for the management of men after a negative MGB. The aim of this study was to assess the risk of csPCa after a first negative MGB.

Methods: Between 2014 and 2020, we selected men with a PI-RADS score ≥ 3 on MRI and a negative MGB (showing benign findings) performed for suspected prostate cancer. MGB (targeted and systematic biopsies) was performed using fully integrated mobile fusion imaging (KOELIS). The primary endpoint was the rate of csPCa (defined as an ISUP grade ≥ 2) diagnosed after a first negative MGB.

Results: A total of 381 men with a negative MGB and a median age of 65 (IQR: 59-69, range: 46-85) years were included. During the median follow-up of 31 months, 124 men (32.5%) had a new MRI, and 76 (19.9%) were referred for a new MGB, which revealed csPCa in 16 (4.2%) of them. We found no statistical difference in the characteristics of men diagnosed with csPCa compared with men with no csPCa after the second MGB.

Conclusion: We observed a risk of significant prostate cancer in 4% of men two years after a negative MRI-guided biopsy. Performing a repeat MRI could improve the selection of men who will benefit from a repeat MRI-guided biopsy, but a clear protocol is needed to follow these patients.

Level of evidence: 4:

Introduction: Obesity is a risk factor for significant surgical complications following kidney transplantation. We examined morphometric parameters other than the body mass index (BMI) that could predict surgical complications and determine their impact on graft survival.

Materials: Kidney transplantations performed at our center between 2012 and 2019 were retrospectively evaluated. Data for visceral adipose tissue (VAT), subcutaneous adipose tissue, psoas surface, abdominal perimeter (AP), and vessel-to-skin distance (VSK) were collected from pre-transplant computed tomography (CT) scans. The primary outcome was the occurrence of surgical complications within 1 year of transplantation; the secondary outcome was graft survival.

Results: We included 321 (88%) of 364 kidney transplant recipients, of which 154 (46.5%) patients experienced some form of surgical complication in the 1st year of follow-up. Univariate analysis revealed that higher VAT (P=0.004), VSK (P=0.007), and AP (P=0.01) values were potential risk factors for early postoperative morbidity. However, none of these factors were significant in the multivariate analysis. Concerning the secondary outcome, while the univariate analysis identified higher VAT (P=0.001) value as a risk factor, in the multivariate analysis only delayed graft function demonstrated a significant impact on graft survival (P=0.002).

Conclusions: Although morphological parameters showed greater accuracy in predicting surgical complications in univariate analysis, these results were not significant in multivariate analysis. Moreover, these factors were not significantly associated with graft survival. Therefore, routine application of analyses based on these parameters, regardless of BMI, may not be useful.

Level of evidence: 5:

Introduction: This study aimed to evaluate the feasibility of switching from transrectal to transperineal prostate biopsy (TPPBx) by urologists with no previous experience with TPPBx. Material A monocentric clinical study with exhaustive and consecutive inclusions was conducted between January and November 2021, including 105 consecutive patients who underwent TPPBx performed by two senior urologists with no previous experience of TPPBx (GR, FB). Biopsies were performed under local anesthesia (LA) without antibioprophylaxis. The main objective was to assess the safety of this procedure. Adverse events were classified according to the Clavien-Dindo score. The secondary objectives were to assess the level of pain experienced during the different steps of the procedure using a numerating rating scale (NRS), the rate of clinically significant prostate cancer (csPCa) detected, and the level of anxiety using the Hospital Anxiety and Depression Scale (HAD).

Results: No major complications (Clavien-Dindo score≥3) were reported. One patient presented with acute urinary retention (1%) and a urinary tract infection (1%). Other adverse events were hematuria (43%), hemospermia (23%), rectal bleeding (1%), perineal hematoma (3%), persistent perineal pain (5%), and de novo erectile dysfunction (2%). The median level of pain on NRS for the procedure was 2.00 (IQ: 1.00-4.00); it was 3.00 (IQ: 2.00-5.00) during LA and 3.00 (IQ: 2.00-5.00) during punctions. In anxious patients (HAD score>10), the level of pain during the procedure was 2.5 (IQ: 2.00-3.00). Overall, csPCa was detected in 63%.

Conclusion: TPPBx under LA without antibioprophylaxis provides few complications, an acceptable pain threshold, and a satisfactorily rate of csPCa detection, even if performed by urologists with no previous experience of TPPBx.

Level of evidence: 3:

Purpose: Performing restaging transurethral bladder resection (reTURB) for high-risk non-muscle invasive bladder cancer (NMIBC) reduces the risk of recurrence and tumour understaging. Management of residual high-grade papillary Ta or T1 after reTURB has changed this last 10years in international recommendations. This study aimed to compare the recurrence free survival according to the different management procedures performed.

Materials and methods: Patients who underwent reTURB for initial high-risk NMIBC between 2011 and 2020 were included. Patients with residual high-grade papillary Ta or T1 tumour after reTURB were divided into two groups: BCG instillations upfront versus BCG following a third-look resection (3TURB). Patient and tumour characteristics, BCG instillations, recurrence-free survival were retrospectively analysed.

Results: A total of 162 high-risk patients were included. Sixty-one (37.7%) had residual high-grade papillary Ta or T1 at reTURB: 35 (21.6%) had BCG instillations upfront, 18 (11.2%) had a 3TURB and 8 (5%) had other management. The mean follow-up was 34.2weeks±20.2. Recurrence-free survival was significantly better in patients who underwent BCG instillations upfront (P<0.0043). Recurrence after BCG therapy following reTURB was significantly lower in patients with no residual NMIBC at 6 (92.5% vs. 72.4%, P<0.004) and 12months (85% vs. 67.3%, P<0.03).

Conclusions: The efficacy of intravesical BCG is compromised in case of residual tumour following TURB. The role of a 3TURB following a positive reTURB is not yet determined. This study has confirmed that residual tumor following reTURB is a negative predictive factor but could not demonstrate the value of a 3TURB compared to upfront BCG.

Level of evidence: 3: