Étude comparative de l'anastomose one stich modifié et du Lich Gregoir en transplantation rénale. Analyse des complications chirurgicales de la transplantation rénale au CHU de Rouen

L'objectif principal de notre étude était de comparer les complications urinaires entre les techniques de réimplantation urétérovésicale "one stich" modifié et de Lich Gregoir. Nous avons également analysé les facteurs de risque et les complications chirurgicales des greffés rénaux au CHU et Rouen. Matériels et méthodes : Nous avons réalisé une étude prospective monocentrique chez les patients transplantés rénaux du 1er janvier 2011 au 1er août 2013 au CHU de Rouen. Nous avons recensé et étudié de façon prospective le taux de complications urinaires liées à la technique de réimplantation urétérale "one-stitch" modifié en comparaison à la technique de référence selon Lich Gregoir, nous avons aussi étudié toutes les complications de la transplantation rénale en comparaison aux données de la littérature de façon prospective. Nous avons enfin recherché les facteurs influençant la survenue de complications et les répercussions sur la survie des transplants. Résultats : 173 patients ont été transplantés au cours de l'étude 109 selon l'anastomose de Lich Gregoir et 64 selon l'anastomose "one stich" modifié. Le taux des complications était identique avec 15 et 4,5% d'hématurie (p=0,71) ; 0,8 et 1,5% de fistule (p=0,95) ; 7,3 et 7,5% de sténose de l'uretère (p=0,75) ; 3,7 et 3% de reflux vésico-urétéral (p=0,93). La survie des transplants était identique à 6 mois, 1 an et 2 ans (p=0,88). La reprise retardée de fonction (p=0,78) et la durée d'hospitalisation (p=0,71) étaient identiques dans les deux groupes. Le taux de complications selon Clavien Dindo était respectivement de 3 complications de Grade II (3%), 16 complications de Grade III (15%) et 1 de Grade lV (1%) pour le Lich Gregoir contre 3 complications de Grade II (3%) et 13 complications de Gracie III (19,5%) en "one stich" modifié. Dans l'analyse secondaire, les reins marginaux (p=0,02), les patients tabagiques (p=0,01), l'athérome du greffon (p=0,05), les reins avec lésions artérielles lors du PM0 (p=0,02) étaient retrouvés comme facteur de risque de complications de la greffe. Les reins à artères multiples étaient associés aux complications urologiques (p=0,03) et le tabagisme semblait l'être également (p=0,07). Le tabagisme (p=0,01), les reins marginaux (p<0,001 ) ou à artères multiples (p=0,03), l'athérome (p=0,01), l'hémodialyse (p=0,047) étaient retrouvés comme facteurs de complications vasculaires. Les complications urologiques n'étaient pas associées à une reprise retardée de fonction du greffon (p=0,55) ni à une baisse de survie des greffons (p=0,23), à la différence des complications vasculaires (p=0,02) et (p=0,047). La survie des greffons était corrélée aux stades de la classification de Clavien Dindo avec une baisse des survie partir du stade IV. Conclusion : Il n’ a pas été mis en évidence de différence significative en termes de complications chirurgicales urinaires que ce soit avec la technique de "one stich" modifié ou celle de Lich Gregoir. Nous avons retrouvé respectivement 15,3 et 16% de complications urinaires. La survie des transplants n'était pas affectée par les complications urinaires de la greffe, ce qui n'était pas le cas des transplants avec complications vasculaires

Surgical Outcomes of Urinary Tract Deep Infiltrating Endometriosis

International audienceTo report the outcomes of surgical management of urinary tract endometriosis

Diagnostic performance of contrast-enhanced ultrasonography and magnetic resonance imaging for the assessment of complex renal cysts: A prospective study

International audienceOBJECTIVES:To compare the diagnostic performance of computed tomography, magnetic resonance imaging and contrast enhanced ultrasonography for the assessment of complex renal cysts.METHODS:We carried out a prospective single-center study from January 2012 to December 2013. We included patients with Bosniak category 2F or 3 renal cysts found on computed tomography and reviewed by two expert radiologists. Magnetic resonance imaging and contrast-enhanced ultrasonography were then carried out. Patients with a Bosniak ≥3 cyst on magnetic resonance imaging, as well as those upgraded as appearing malignant on contrast-enhanced ultrasonography, were surgically managed. Imaging results were compared with histological data. For patients without surgery, imaging examinations were compared with follow-up data. For each imaging examination, diagnostic performance and Cohen's kappa coefficient were assessed.RESULTS:A total of 47 patients were included. The median follow up was 36 months (range 17-48 months). At initial computed tomography, cysts were classified as Bosniak 2F and Bosniak ≥3 in 34 and 13 patients, respectively. Magnetic resonance imaging found 13 Bosniak ≥3 cysts, and contrast-enhanced ultrasonography upgraded six more patients with cysts that appeared malignant. A total of 19 patients had surgery. Histological analysis reported 14 malignant tumors. No tumor progression was found in followed-up patients. Computed tomography showed poor sensitivity (36%) and specificity (76%; κ = 0.11). Magnetic resonance imaging showed 71% sensitivity and 91% specificity (κ = 0.64). Contrast-enhanced ultrasonography showed high sensitivity (100%) and specificity (97%), and a negative predictive value at 100% (κ = 0.95).CONCLUSIONS:The present results suggested that contrast-enhanced ultrasonography could be useful in improving the assessment of complex renal cysts. Indeed, computed tomography accuracy might be limited in this indication requiring further investigations to determine the best treatment strategy

Expression of LHCGR in Pheochromocytomas Unveils an Endocrine Mechanism Connecting Pregnancy and Epinephrine Overproduction

International audienceBackground: The mechanisms by which pregnancy may unmask pheochromocytomas and paragangliomas are not totally understood. We hypothesized that gestational hormones may participate in the pathophysiology of catecholamine excess during pregnancy. We report a case of silent pheochromocytoma revealed in a pregnant woman by life-threatening adrenergic myocarditis. Methods: In vitro studies were conducted to investigate the effect of estradiol and the pregnancy hormone hCG (human chorionic gonadotropin) on epinephrine secretion by cultured cells derived from the patient’s tumor. Expression of LHCG (luteinizing hormone/chorionic gonadotropin) receptor was searched for in the patient’s tumor, and a series of 12 additional pheochromocytomas by real-time reverse transcription polymerase chain reaction and immunohistochemistry. LHCGR expression was also analyzed in silico in the pheochromocytomas and paragangliomas cohorts of the Cortico et Médullosurrénale: les Tumeurs Endocrines and The Cancer Genome Atlas databases. Results: hCG stimulated epinephrine secretion by cultured cells derived from the patient’s pheochromocytoma. The patient’s tumor expressed the LHCG receptor, which was colocalized with catecholamine-producing enzymes. A similar expression pattern of the LHCG receptor was also observed in 5 out of our series of pheochromocytomas. Moreover, in silico studies revealed that pheochromocytomas and paragangliomas display the highest expression levels of LHCG receptor mRNA among the 32 solid tumor types of The Cancer Genome Atlas cohort. Conclusions: Pregnancy may thus favor surges in plasma catecholamine and hypertensive crises through hCG-induced stimulation of epinephrine production by pheochromocytomas

The neuropeptide substance P regulates aldosterone secretion in human adrenals

International audienceAldosterone, produced by the adrenals and under the control of plasma angiotensin and potassium levels, regulates hydromineral homeostasis and blood pressure. Here we report that the neuropeptide substance P (SP) released by intraadrenal nerve fibres, stimulates aldosterone secretion via binding to neurokinin type 1 receptors (NK1R) expressed by aldosterone-producing adrenocortical cells. The action of SP is mediated by the extracellular signal-regulated kinase pathway and involves upregulation of steroidogenic enzymes. We also conducted a prospective proof-of-concept, double blind, placebo-controlled clinical trial aimed to investigate the impact of the NK1R antagonist aprepitant on aldosterone secretion in healthy male volunteers (EudraCT: 2008-003367-40, ClinicalTrial.gov: NCT00977223). Participants received during two 7-day treatment periods aprepitant (125 mg on the 1st day and 80 mg during the following days) or placebo in a random order at a 2-week interval. The primary endpoint was plasma aldosterone levels during posture test. Secondary endpoints included basal aldosterone alterations, plasma aldosterone variation during metoclopramide and hypoglycaemia tests, and basal and stimulated alterations of renin, cortisol and ACTH during the three different stimulatory tests. The safety of the treatment was assessed on the basis of serum transaminase measurements on days 4 and 7. All pre-specified endpoints were achieved. Aprepitant decreases aldosterone production by around 30% but does not influence the aldosterone response to upright posture. These results indicate that the autonomic nervous system exerts a direct stimulatory tone on mineralocorticoid synthesis through SP, and thus plays a role in the maintenance of hydromineral homeostasis. This regulatory mechanism may be involved in aldosterone excess syndromes