Avancees récentes en chirurgie percutanée et cas particulier du décubitus dorsal (expérience du centre Henri Mondor)

La chirurgie percutanée a connu ces dernières années des avancées notables. Bien que le décubitus ventral reste la référence, le décubitus dorsal offre de nombreux avantages pour le patient et le chirurgien. Les objectifs de notre étude étaient d évaluer l efficacité et la morbidité de la chirurgie percutanée en décubitus dorsal pour les calculs volumineux du rein.Il s agit d une étude rétrospective incluant 89 patients opérés d une chirurgie percutanée en décubitus dorsal en position de Galdakao-Valdivia modifiée dans le service d urologie de l hôpital Henri Mondor de 2009 à 2012.La taille moyenne des calculs était de 30.3 mm et un total de 91 procédures ont été réalisées dont 6 en chirurgie mini-invasive. Le double abord antéro et rétrograde a été employé dans 29.7% des cas. La durée opératoire moyenne était de 123 min et la durée d hospitalisation moyenne de 3.5 j. Le taux de sans fragment à 1 mois s élevait à 76.9% et était de 95.6% à 3 mois après retraitement par lithotripsie ou urétéroscopie souple. La morbidité était faible avec un taux de complications globales de 25.3% dont une majorité classées Clavien 1 ou 2. Les résultats de cette étude ont montré que la chirurgie percutanée réalisée en décubitus dorsal était sûre et efficace. Ils sont comparables aux résultats des autres études.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocSudocFranceF

Robot-assisted extraperitoneal laparoscopic radical prostatectomy: experience in a high-volume laparoscopy reference centre.

International audienceOBJECTIVE: To describe our current procedure of robot-assisted laparoscopic radical prostatectomy (RALP), and to assess the effect of the learning curve on perioperative data, early oncological outcomes and functional results, as RALP has increasingly become a treatment option for men with localized prostate cancer. PATIENTS AND METHODS: In all, 206 consecutive men had a RALP between July 2001 and November 2008 for localized prostate cancer. Among the overall cohort, the 175 men operated on by the same surgeon were distributed into five groups according to the chronological order of the procedures. The mean follow-up after RALP was 18.3 months. Patient demographics, surgical data and postoperative variables were collected into a prospective database. Data were compared by chronological groups into single-surgeon cohort. RESULTS: The median operative time and blood loss were 140 min and 350 mL, respectively. The complication rate was 8.3%. Cancers were pT3-4 in 34.5%. The mean hospital stay and duration of bladder catheterization were 4.3 and 8.2 days, respectively. The rate of positive surgical margins (PSMs) was 17.2% in pT2 cancers. The recovery rate of continence was 98% at 12 months. Intraoperative time, blood loss and length of hospital stay were significantly improved after a short learning curve. The continence recovery, the rate and the length of PSM were also improved beyond the learning curve, but difference was not statistically significant. CONCLUSIONS: RALP is a safe and reproducible procedure and offers a short learning curve for experienced laparoscopic surgeons. Beyond the learning curve, continued experience might also provide further improvements in terms of operative, pathological and functional results

Pathological findings and prostate specific antigen outcomes after radical prostatectomy in men eligible for active surveillance--does the risk of misclassification vary according to biopsy criteria?

International audiencePURPOSE: We compared the pathological findings and prostate specific antigen outcome after radical prostatectomy in men eligible for active surveillance according to 3 biopsy inclusion criteria. MATERIALS AND METHODS: The study population included 177 men eligible for active surveillance who fulfilled clinicobiological criteria and biopsy criteria as group 1-less than 3 positive cores and less than 3 mm total tumor length, group 2-less than 3 positive cores with cancer involvement of less than 50% in any core and group 3-less than 33% of positive cores. Prostate specific antigen density cutoffs were also studied in these groups. Pathological findings on radical prostatectomy specimens and biochemical recurrence-free survival were studied. Median followup after radical prostatectomy was 34 months. RESULTS: A majority of Gleason score 6 disease was observed in group 1 (51.7%) whereas a majority of Gleason score 7 or greater disease was reported in groups 2 (53.6%) and 3 (55.4%). Extracapsular extension was noted in 17.5% of radical prostatectomy specimens in group 3 vs 11.2% in group 1 (p = 0.175). The risk of overall unfavorable disease (defined as pT3-4 stage and/or Gleason score 8 or greater) was significantly higher in men with cancer involvement of 3 mm or greater on initial biopsy (27.3% vs 13.5%, respectively, p = 0.023). The 3-year biochemical recurrence-free survival rate was 94.0% and was not affected by the 3 active surveillance definitions. CONCLUSIONS: Even with the use of a 21-core biopsy protocol the rate of unfavorable disease in radical prostatectomy specimens remains increased in men eligible for active surveillance. Patients must be informed of this risk of misclassification which ranges from 20% to 28% in men who fulfill the less stringent biopsy criteria

Influence of daily green tea infusions on hypercalciuric renal stone patients: biological and morpho-constitutional analysis.

International audienceCalcium stones contain predominantly calcium oxalate monohydrate (COM) and calcium oxalate dihydrate (COD). Catechins of green tea may prevent crystallization of calcium oxalate crystals but tea is also a source of oxalates. Here we evaluate the influence of regular daily green tea intake on stone risk factors in 273 hypercalciuric renal stone formers, their stone morphology and composition and a potential in vitro solubilizing effect of epigallocatechin (EGC) on calcium stones. Green tea ‘’drinkers’’(n=48) and ‘’non drinkers’’(n=225) were compared according to gender with biochemical analyses and stone composition performed by infrared spectroscopy (IRS) on 117 patients. Scanning electron microscopy (SEM) renal stone analysis was realized of 57 stones containing COD as major component in the two groups. Different criteria were collected including the presence of pores and their shape. In vitro SEM analysis were performed after incubation with different solutions containing either EDTA 0.1 M, green tea, EGC 10- 300μM and sodium citrate 10-300 mM. The groups were similar for 24 hours calciuria and bone remodeling biomarkers but a green tea diuretic effect was suggested. IRS analysis showed a significant higher prevalence of COD in female “drinkers” whereas COD was found in nuclei in male “drinkers”. SEM analysis revealed a higher prevalence of square pores detected in “drinkers” and similar holes at the surface of COD crystals after incubation with green tea solution, EGC and calcium chelators, EDTA and sodium citrate. Green tea through catechins has a pharmacological effect with no influence on stone risk factors but a significant change on calcium stones composition and structure

Laparoscopic Partial Nephrectomy: Is It Worth Still Performing the Retroperitoneal Route?

Objective. The objective of this study was to compare perioperative, oncologic, and functional outcomes of TLPN (transperitoneal laparoscopic partial nephrectomy) versus RLPN (retroperitoneal). Patients and Methods. From 1997 to 2009, a retrospective study of 153 consecutive patients who underwent TLPN or RLPN for suspicious renal masses was performed. Complications, functional and oncological outcomes were compared between the 2 groups. Results. With a mean followup of 39 and 32 months, respectively, 66 and 87 patients had TLPN and RLPN, respectively. Tumor location was more often posterior in the RLPN and more often anterior in the TLPN. Mean operative time and mean hospital stay were longer in the TLPN group with 190±85 min versus 154±47 (=0.001) and 9.2±6.4 days versus 6.2±4.5 days (<0.05), respectively. Transfusion and urinary fistulas rates were similar in the 2 groups. After 3-year followup, chronic kidney failure occurred in 6 and and 4% (=0.67) in after TLPN and RLPN, respectively. After 3-year followup, recurrence free survival was 96.7% and 96.6% (=0.91) in the TLPN and RLPN groups, respectively. Conclusion. Our study confirmed that TLPN had longer operative time and hospital stay than RLPN. The complication rates were similar. Furthermore, mid-term oncological and functional outcomes were similar

Analysis of complications from 600 retroperitoneoscopic procedures of the upper urinary tract during the last 10 years.

International audienceINTRODUCTION: The aim of this study is to review 10 years experience of retroperitoneoscopy procedures. METHODS: A total of 600 patients treated between 1995 and 2007 by retroperitoneoscopy (nephrectomy, partial and total nephrectomy, adrenalectomy, pyeloplasty, renal cyst, calyceal diverticulectomy) were reviewed for per, peri and postoperative complications including patients in the learning curve. RESULTS: The mean blood loss was 159 mL. Conversion to open surgery was required in 28 patients (4.6%) primarily due to technical problems during dissection (elective). There were 32 (5.3%) surgical complications, including bleeding or hematomas in 12 cases and 2 of them required reintervention, urinomas in 8 which were treated by installation of a ureteral drainage (JJ stent). Wound or deep abscesses happened in four, urinary fistula in one and pancreatic fistula in another. Evisceration (hernias) was seen in three patients. Intestinal injury occurred in two. The complication rate depended on the difficulty of the procedure and learning curve of the surgeon. A total of 28 patients (4.6%) presented medical postoperative complications (hyperthermias, deep venous thrombosis, pyelonephritis, pulmonary superinfections, pulmonary atelectasia and transient vascular ischemic accident). Mean postoperative hospital stay was 6.2 days (ranged from 2 to 20). CONCLUSION: Retroperitoneoscopy can be the technique of choice for accessing and carrying out all the surgery of the upper urinary tract respecting the principles of oncological surgery. After experience with 600 cases during the last 10 years the technique has become safe, simplified, reproducible and effective although not easy. Most complications are minor and easily managed