Annales D Urologie最新文献

Two aspects are considered: the prevention of peri-operative venous thromboembolism, and the management of antiplatelet agents (APA) and anticoagulants during the peri-operative period. Thrombotic and haemorrhagic risk factors linked to the patient and to urological surgical procedures are recalled. A decision whether to initiate preventive therapy for peri-operative venous thromboembolism will be based on analysis of these risk factors and of the risk/benefit ratio. The methods for this preventive treatment are recalled. Practical examples in urology are used to illustrate the application of these principles. Similarly, the indications, and thrombosic and haemorrhagic risk factors related to anti-platelet agents and anticoagulants during the peri-operative period are recalled. A decision whether or not to withdraw these anti-platelet agents or anticoagulants will be based on an analysis of their indications, these risk factors and an assessment of the risk/benefit ratio. Replacement therapies are reviewed. Practical examples in the urological setting are given regarding application of these principles.

In storing or withholding a treatment that interferes haemostasis should be considered after assessing the benefit-risk ratio which requires the understanding of the efficacy, safety and pharmacology of heamostatic agents. This benefit to risk assessment is the key stone for the prevention of venous thrombosis, and peri-operative management of antiplatelet agents and vitamin K antagonists.

The treatment of metastatic renal cell carcinoma is deeply evolving. After the cytokines, interleukin 2 and interferon era, which raised great expectations followed by deep disillusions (related to an efficacy limited to a small group of patients and an important toxicity for a majority of them), the time of targeted therapies has come. These new therapies mainly work on the VHL-HIF way, which controls several key molecules involved in the tumour angiogenesis phenomena, especially the VEGF. Several drugs currently being developed allow to stop either the circulating angiogenic factors (mainly the VEGF), or the tyrosine kinase receptors, especially the VEGF and the PDGF receptors. The reported activity and potential of these drugs are: tumour reduction, improvement of progression-free survival, effects on the overall survival. Currently, 4 among these drugs are in phase III (sorafenib, sunitinib, bevacizumab and temsirolimus), sorafenib and sunitinib have been allowed by the FDA, in the USA, and by the EMEA, in Europe, in the treatment of advanced renal cell carcinoma.

Conservative renal surgery for cancer has now achieved consensus for imperative, relative, and elective indications (tumor < 4 cm with healthy contralateral kidney). The results show 90%–100% 10-year survival rates and 0%–3% recurrence rates. Surgical techniques are improving and complication rates are decreasing with experience.

It is now recognized that margin thickness has no real significance provided that it is negative, even if excision is flush with the tumor capsule. Finally, the frequently cited multifocal lesions are no longer an argument against conservative surgery. The usual limitations of conservative surgery are the size and location of the tumor. Nevertheless, there is no statistically significant difference in the survival and recurrence rates between T1 a (<4 cm) and T1 b (4-7 cm) tumors, even if the risk of renal sinus fat tissue involvement increases proportionally with tumor size. Finally, resectiog tumors of the renal sinus is possible without adding to the risk of metastasis but increases the risk of surgical complications.

The risk of deteriorated renal function with radical nephrectomy is now well documented. Laparoscopy, which has become the reference treatment mode for radical nephrectomy, remains reserved for conservative surgery for exophytic tumors less than 3–4 cm because of the technical difficulties involved in resection and hemostasis.

Although conservative surgery is now recognized, extending its indications to tumors greater than 4 cm or in cases of parenchymatous location is supported by real arguments that need to be confirmed. The limit remains the surgical feasibility.

Radical nephrectomy with vena cava thrombectomy remains the treatment of choice in patients with renal cell carcinoma and inferior vena cava involvement. Surgery is performed with curative intent in patients without evidence of metastases or for cytoreduction, followed by possible immunotherapy in patients with distant metastases.

The role of magnetic resonance imaging for evaluating the renal vein and/or IVC to detect thrombus and the proximal extent of thrombus is fully established. Surgical removal of these cancers through a transabdominal approach, even in patients with a level 2 thrombus (involving the retrohepatic IVC with close proximity to the main hepatic veins) is possible, avoiding the potential added morbidity of a throacoabdominal approach or median sternotomy. The application of liver transplant techniques and liver mobilization procedures not generally familiar to urological surgeons facilitates wide exposure and proximal control of the IVC for tumors cephalad to the confluence of the hepatic veins. As an initial step' we believe that cephalad retraction of the liver with mobilization of the IVC by securing the lumbar, small hepatic and other unnamed venous collaterals may be tried to gain exposure of the retrohepatic IVC.

Overall survival in patients with IVC involvement after complete surgical removal in the absence of metastatic disease justifies aggressive surgical management.

Economic considerations currently limit the idea of the disposable flexible endoscope, which would guarantee absolute safety against the transmission of infections.

Since the endoscope is made of a heat-sensitive material, it is impossible to sterilize it by autoclave. A disinfection procedure must therefore be applied, which, although it does not guarantee the same level of safety as classical sterilization, provides a sufficient reduction in the microorganism load. This procedure is carried out in two steps: first cleaning by mechanical action using a detergent, then the actual disinfection by soaking in a disinfectant bath. As urine is a sterile milieu, a high-level disinfection - bactericide, virucide, fungicide, and sporicide — should be implemented by soaking for 30 min in a peracetic acid bath.

Prion risk, which must systematically be taken into account, can be controlled by a double cleaning method eliminating all proteic debris and by replacing glutaraldehyde with peracetic acid.

“Often done, better done” is a popular saying that may lead health authorities to use the volume of surgical activity to assess surgical quality, including eventually this criteria in their certification manual. Very few data indeed support this idea in Urology. On the other hand, well-conducted studies clearly show that high volume activity does not always avoid surgical complications. Moreover, fair statistics should be applied to urologists, with proper calculation of confidence intervals, before scrutinizing reasons why they may appear “to differ” from the assigned goal or their colleagues' average. This, for major urologic operations, can only be done after a prolonged observation period, sometimes reaching over a decade.

The DUO study intended to define the factors determining diagnostic and treatment strategies for benign prostatic hyperplasia (BPH) management.

Methods

This longitudinal, observational study was conducted in France (June 2004 to March 2005), with a representative sample of private and hospital urologists.

Results

1027 BPH patients were included by 202 urologists and 856 were followed-up 6 months later. Mean I-PSS was 14.9 (±6.7) at inclusion and 10.5 (±6.7) at the follow up visit. At inclusion, pharmacologic treatment was prescribed to 84% of the patients, surgery to 13% and no treatment to 3%. Factors in favour of surgery (versus drugs) were BPH severity (OR=2.5 if IPSS=20), patients' choice (0R=2.5), quality of life improvement (OR=2.2), post-void residual (OR=2.1) and dribbling (OR=1.6). Patients' age and prostatic volume have no impact on this choice. Factors in favour of a combination of an a-blocker plus an 5α-reductase inhibitor (versus an α-blocker) were prostate volume (OR=7.8), patient's age (OR-3.0 if âge=74) and post-void residual (OR=2.3) and those in favour of a 5α reductase inhibitor (versus an α-blocker) were prostate volume (OR=7.6), PSA results (OR=5.8), patients' age (OR=5.4 if > 74 years, OR= 2.1 if > 68 years).

Conclusion

Medical or surgical treatment of BPH results in IPSS improvement at 6 months. Patients' age and prostatic volume favour 5α-reductase inhibitor initiation and have no impact on surgical treatment decision. Surgery is performed in severe BPH or when patients expecting a quality of life improvement do that choice.

Radiofrequency and cryoablation are both minimally invasive techniques applied to the treatment of renal cell carcinoma. These techniques allow in situ destruction of neoplasm. Although cryotherapy is the most studied, radiofrequency is the most currently used technique. Indications mostly accepted as elective indication are the less than 4 cm in diameter exophytic tumors. Radiofrequency and cryoablation can also be proposed in patients with solitary kidney, multiple bilateral tumors and patients with contraindication for surgical resection.

The radiofrequency parietal tract can be coagulated at the time of radiofrequency electrode withdrawal reducing the rare risk of parietal tumor dissemination.

Preliminary oncological results in exophytic small renal tumors are promising with only few complications. A longer follow up is however mandatory to better define the place of these two new technologies in the treatment of renal cancer.