Patient selection for laparoscopic excision of adrenal metastases: a multicenter cohort study

International audienceIntroduction The use of laparoscopy for the excision of adrenal metastasis remains controversial. We aimed to report oncological and perioperative outcomes of laparoscopic excision of adrenal metastases and to seek for predictive factors of unfavourable oncological outcomes. Methods A retrospective chart review was conducted and all consecutive patients who underwent laparoscopic adrenalectomy (LA) in the setting of metastatic cancer in two academic urology departments from November 2006 through January 2014 were included. Primary tumors were categorized as pulmonary, renal or “other primary” tumors to allow statistical comparison. Unfavourable surgical outcomes were defined as the occurrence of either postoperative complications and/or positive surgical margins. Results Forty-three patients who underwent a total of 45 LA were included for analysis. There were 8 complications (17.8%). Positive surgical margins were found in 12 specimens (26.7%). After a median follow-up of 37 months, estimated overall survival rates were 89.5% and 51.5% at 1 year and 5 years, respectively. In multivariable analysis the only predictor of unfavourable surgical outcomes was a tumor size > 5 cm (OR= 20.5; p=0.001). In multivariate analysis the pulmonary (OR=0.3; p=0.008) or “other” (OR= 0.1; p=0.0006) origin of the primary tumor was the only prognostic factor of shorter cancer specific survival. Conclusion Laparoscopic resection of adrenal metastasis can be safely performed in most patients but is associated with an increased risk of positive surgical margins and postoperative complications in larger tumors (>5 cm). Adrenalectomy provides better oncological outcomes in metastases from renal cell carcinoma compared to other primary tumors

Artificial urinary sphincter implantation in women with stress urinary incontinence: preliminary comparison of robot-assisted and open approaches

International audienceIntroduction and hypothesis We aimed to compare outcomes of open and robot-assisted artificial urinary sphincter (AUS) implantation in female patients. Methods The charts of all female patients who underwent an AUS implantation between 2008 and 2014 in a single center were retrospectively reviewed. From 2008 to 2012, AUS were implanted using an open approach and from 2013 to 2014 using a robot-assisted approach. Perioperative and functional parameters were compared between groups. The primary endpoint was continence status. Results Twenty-four women were assessed: 16 in the open group and eight in the robot-assisted group. Three patients had neurogenic stress urinary incontinence. Most patients had undergone previous procedures for urinary incontinence (15 in the open group and seven in the robotic group). Mean operative time was similar in both groups (214 vs. 211 min; p = 0.90). Postoperative complicationsrate was lower in the robot-assisted group (25 vs. 75 %; p = 0.02). There was a trend toward a lower intraoperative complication rate (37.5 vs. 62.5 %; p = 0.25), decreased blood loss (17 ml vs. 275 ml; p = 0.22), and shorter length of stay (3.5 vs. 9.3 days; p = 0.09) in the robot-assisted group. Continence rates were comparable in both groups (75 vs. 68.8 %; p = 0.75). Three AUS explantations were needed in the open group (18.8 %) compared with one in the robot-assisted group (12.5 %; p = 0.70). Conclusions In female patients, the robot-assisted approach compared with open AUS implantation could decrease intraoperative and postoperative complication rates, length of hospital stay, and blood los

Intracavernous Injections in Spinal Cord Injured Men With Erectile Dysfunction, a Systematic Review and Meta-Analysis

International audienceIntroduction: Despite improvements in the care of patients after spinal cord injury (SCI), permanent impairment of locomotion, sensation, and autonomic function remains a major hurdle. After the acute stage of injury, recovering sexual function is a high priority.Aim: To review the efficacy of intracavernous injections (ICIs) in men with SCI and to identify prognostic factors affecting the efficacy of ICIs in this population.Methods: Systematic review of the literature was conducted using the PubMed-Medline, Embase, EBSCO, Web of Science, and Cochrane Library databases. The literature search was restricted to articles published in English, French, and Spanish up to November 2014 using the key words alprostadil, papaverine, moxisylite, alpha-blocking agent, phentolamine, intracavernous injection, spinal cord injuries, paraplegia, quadriplegia, and erectile dysfunction. Studies involving patients with SCI and erectile dysfunction treated with ICIs of alprostadil, papaverine, and α-blocking agents, including retrospective and prospective cohorts, population studies, and randomized controlled trials, were included.Main Outcome Measure:Overall response rate to ICI for erectile dysfunction in patients with SCI.Results: Of 283 studies identified, 23 involved 713 patients with SCI. ICIs resulted in successful erections in 88% of patients (n = 713, 95% CI = 83%–92%). Erections were obtained in 93% of patients (n = 101, 95% CI = 83%–99%) with the combination of papaverine and phentolamine, in 91% (n = 274, 95% CI = 78%–97%) with papaverine alone, and in 80% (n = 119, 95% CI = 64%–90%) with alprostadil. Type of injected drug, doses, level of injury (complete or incomplete), extent of injury, age, time since injury, and persistence or transience of erections were evaluated, but statistical analysis could not identify specific factors predictive of a response to ICI.Conclusion: ICIs are an effective treatment of erectile dysfunction in men with SCI. No predictive factor for efficacy could be identified. Studies comparing the response to ICI in upper vs lower motor neuron lesions could improve our understanding of ICI failure

MP27-10 IMPACT OF DIAGNOSTIC URETEROSCOPY ON THE ONCOLOGICAL OUTCOMES FOLLOWING RADICAL NEPHROURETERECTOMY

International audienceno abstrac

Quelle est la place du gastroentérologue dans la prise en charge des séquelles digestives des patients ayant un Spina Bifida ?

International audienceLe Spina Bifida est une maladie congénitale rare due à une anomalie de fermeture du tube neural. Elle génère un plurihandicap et sa prise en charge doit être pluridisciplinaire. Les troubles digestifs anorectaux rapportés le plus souvent sont la constipation et l’incontinence fécale et constituent la deuxième plainte en terme de fréquence, après les troubles urologiques. La prise en charge des séquelles digestives des patients ayant un Spina Bifida n’est pas codifiée. Le niveau lésionnel n’est pas corrélé aux plaintes digestives, ce qui nécessite une évaluation initiale précise et globale. L’évaluation du terrain et de l’importance du handicap, le recueil des plaintes, un examen clinique notamment neuropérinéal guident la prise en charge thérapeutique initiale. En cas d’échec du traitement de première ligne, la manométrie anorectale et le temps de transit colique peuvent être utiles. Le traitement repose sur les massages abdominaux, les laxatifs oraux et/ou locaux, les manoeuvres défécatoires, la rééducation et les irrigations coliques rétrogrades/antérogrades

Chronic hepatic cytolysis revealing a pheochromocytoma.

International audienceWe report here the first case of chronic cytolysis that led to the diagnosis of pheochromocytoma, in a 48-year-old woman with a recent onset of hypertension. The etiological research ruled out the common causes of raised transaminase levels, and led to the discovery of a left adrenal pheochromocytoma. The sustained normalization of liver function tests after the removal of the tumour strongly suggests that hepatocyte injury was due to catecholamine hyperproduction. The present original clinical case, linking pheochromocytoma and liver dysfunction, raises important mechanistic questions concerning the relationship between catecholamines and liver function. It may also have clinical implications. Indeed, pheochromocytoma should be considered as a possible cause in case of unexplained transaminase increase associated with the recent onset of hypertension

Fecal incontinence in patients with spina bifida The target is the rectum

International audienceAims - The prevalence rate of severe fecal incontinence (FI) in adults with spina bifida (SB) is high. The physiological basis of FI in SB has not been clearly established, which contributes to inadequate care. The aim was to better characterize a large cohort of adults with special consideration of anorectal physiology.Methods - A multidisciplinary team from a French referral centre for SB prospectively collected data on patients who had an anorectal manometry. Factors associated with severe FI (Cleveland clinical incontinence score ≥ 9) were assessed in a multivariate analysis model.Results - A total of 132 adults with SB (sex ratio M/F: 55 [41.7%]/77 [58.3%]; mean age of 38.2 [11.6] years old) were assessed. Among these patients, 83/132 (62.9%) suffered from severe FI. Rectal perception was not evaluable among 17 patients who had a latex allergy. Overall, 29/115 (25.2%) had maximal tolerable volume (MTV) > 330 mL or no sensation. The absence of anal canal sensitivity, MVT > 330 mL and the amplitude of the recto-anal inhibitory reflex (RAIR) >75% after a rectal isovolumic inflation of 50 mL were significantly associated with severe FI in the multivariate analysis model. Neither neurological level nor other neurological features were associated with severe FI.Conclusions - This study showed that FI in patients with SB is mainly associated with rectal abnormalities. This should be taken into consideration to improve incontinence management of patients with SB.<br

La néphrectomie laparoscopique par accès ombilical unique : évolution ou révolution chirurgicale ? [Renal LESS surgery: Slight modification or surgical revolution?].

International audienceOBJECTIVE: to present our initial experience of laparoendoscopic single site (LESS) renal surgery. METHODS: between May 2009 and March 2010, nine nephrectomies and one cyst decortication were performed in nine patients. Eight of the procedures were done with three 5mm trocars inserted through a unique peri-umbilical incision. In two cases, a specific single-port device was used. All operations were achieved with a 5-mm 30° lens and conventional laparoscopic instruments. The specimens were entrapped in a 10mm endoscopic bag and extracted through the umbilical incision. RESULTS: mean age was 56 years old. Mean BMI was 23.5 [19-34]. Mean operative time was 149min [80-240], and estimated blood loss was 90ml [20-250]. None of the patients required blood transfusion. Mean length of stay was 4.1 days [3-5]. Only one major complication occurred (functional occlusion). One conversion to conventional laparoscopy was necessary in a case of inflammatory kidney. Histologic exam showed benign lesions (cyst and non functional kidney) in seven cases, and papillary carcinoma in three cases. CONCLUSION: LESS surgery is feasible. Its advantages over conventional laparoscopy are not clear. LESS is a new procedure that should benefit from the improvement of technical instrumentation