Purpose To evaluate trimodal conservative treatment as an alternative to radical surgery for urothelial muscle-invasive bladder cancer (MIBC). Patients and methods This retrospective study reported the carcinologic and functional results of patients (pts) presenting a cT2/T3 N0M0 operable MIBC and fit for surgery, treated by a conservative strategy. Treatment consisted of a transurethral resection (TURB) followed by concomitant bi-fractionated split-course radiochemotherapy (RCT) with 5FU-Cisplatine. A control cystoscopy was performed six weeks after the induction RCT (eq45Gy) with systematic biopsies. Patients with complete histologic response achieved RCT protocol. Salvage surgery was proposed to pts with persistent tumor. Results 313 pts (83% cT2 and 17% cT3) treated between 1988 and 2013 were included, with a median follow-up of 59 months and 67-year mean age. After the induction RCT, the histologic response rate was 83%. After five years, overall, disease-free, and functional bladder-intact survival rates were respectively 69%, 61%, and 69%, significantly better for pts in complete response after induction RCT. Late urinary and digestive toxicities were limited, with respective rates of 4% and 1.5% of grade 3 toxicity. Conclusion Trimodal strategy with RCT after TURB showed interesting functional and oncologic results and should be considered as an alternative to surgery in well-selected pts.

Renal cancer accounts for 3% of all cancers; even in 2007 the diagnosis is often too late requiring a radical nephrectomy with an overall mediocre prognosis of 70% at 5 years. Nowadays, thanks to considerable improvement in imaging technique, 60% at least of tumors are early discovered on ultrasound examination; often of moderate size and less than 4 cms in diameter, which enables a more conservative approach to treatment. 740 radical nephrectomy were carried out in NECKER Hospital between 1985 and 2000; the results were similar to those in the literature; mediocre, with 85% survival at 5 years when the tumour was confined to the kidney (grades I and 2); 17% in the presence of lymph node involvment. Of the 722 conservative procedures carried out between 1987 and 2008, only 386 patients operated between 1987 and 2005 are being considered here. Although follow up is limited, the results are encouraging. In Keeping with the literature, our results confirm the value of conservative surgery for early tumors with diameter of less than 4 cm. Low morbidity and disease free survival were similar to the data for radical nephrectomy. With the aim of maximum renal conservation, newer mini invasive procedures such as cryoablation and radiofrequency destruction of tumors have been proposed. Our experience with radiofrequency destruction is described below for 167 tumors in 123 patients. Although the short-term outcome is satisfactory; it is difficult to judge the longer-term efficacy of these relatively rarely used newer techniques. While efforts are made to achieve early diagnosis thanks to modern imaging techniques and while conservative surgery appears to be the current strategy in the multidisciplinary management of tumours, there is still a large place for radical nephrectomy by open surgery or more often via video-assisted laparoscopic surgical techniques.

Renal cancer accounts for 3% of all cancers; even in 2007 the diagnosis is often too late requiring a radical nephrectomy with an overall mediocre prognosis of 70% at 5 years. Nowadays, thanks to considerable improvement in imaging technique, 60% at least of tumors are early discovered on ultrasound examination; often of moderate size and less than 4 cms in diameter, which enables a more conservative approach to treatment. 740 radical nephrectomy were carried out in NECKER Hospital between 1985 and 2000; the results were similar to those in the literature; mediocre, with 85% survival at 5 years when the tumour was confined to the kidney (grades 1 and 2); 17% in the presence of lymph node involvment. Of the 722 conservative procedures carried out between 1987 and 2008, only 386 patients operated between 1987 and 2005 are being considered here. Although follow up is limited, the results are encouraging In Keeping with the literature, our results confirm the value of conservative surgery for early tumors with diameter of less than 4 cm. Low morbidity and disease free survival were similar to the data for radical nephrectomy With the aim of maximum renal conservation, newer mini invasive procedures such as cryoablation and radiofrequency destruction of tumors have been proposed. Our experience with radiofrequency destruction is described below for 167 tumors in 123 patients. Although the short-term outcome is satisfactory, it is difficult to judge the longer-term efficacy of these relatively rarely used newer techniques. While efforts are made to achieve early diagnosis thanks to modern imaging techniques and while conservative surgery appears to be the current strategy in the multidisciplinary management of tumours, there is still a large place for radical nephrectomy by open surgery or more often via video-assisted laparoscopic surgical techniques.

OBJECTIVETo prospectively assess the value of frozen section examination during conservative surgery for renal cell carcinoma (RCC) in exclusively elective indications and to evaluate the reality of safety margins.MATERIAL AND METHODSFrom 1997 to 2001, 220 conservative procedures for RCC were performed in our department, including 104 elective lumpectomies, 61 of which were studied prospectively. The mean age of these 61 patients was 59.4 years (range: 34.2 to 78.5). The mean tumour diameter was 32 mm (range: 12 to 50). Tumours were peripheral in 51 cases and in a juxtahilar position in 10 cases. Resection margins were evaluated macroscopically by the surgeon, and the specimen was systematically sent for frozen section examination. Incomplete margins, i.e. negative but with no safety margin, were distinguished from positive margins on the final histological examination. The thickness of the safety margins was measured on the cortical and deep extremities of the operative specimen. The mean follow-up was 78.5 months (range: 52 to 101).RESULTSHistological types of RCC comprised conventional clear cell (n = 42), tubulopapillary (n = 17) and chromophobe (n = 2), stage pT1 (n = 57) and pT2 (n = 4), and grade 1 (n = 16), 2 (n = 35) and 3 (n = 10). No positive margins were detected. The mean thickness of the safety margin was 7 mm peripherally and 2 mm in depth with no correlation between these two values. Surgeons concluded on the presence of 51 complete margins and 10 incomplete margins versus 53 and 8 on histological examination, respectively. Frozen section examination never modified the course of the operation. All patients were alive and recurrence free at last follow-up.CONCLUSIONMacroscopic evaluation of resection margins by the surgeon is precise and usually avoids the need for frozen section. However when the margins are considered to be incomplete by the surgeon, frozen section examination is mandatory to avoid positive margins, which must remain the main objective of conservative surgery.

BACKGROUND. The aim of the current study was to establish the predictive accuracy of the Kattan postoperative nomogram for nonmetastatic renal cell carcinoma (RCC) by comparing predictions with actual disease recurrence in patients who underwent surgery in a single center in France.METHODS. Between 1985 and 2000, 844 patients were treated for RCC. The following data were collated: age, symptoms, histology, tumor size, grade, TNM 1997 stage, recurrence, and progression. For each patient a prognostic score (predicted probability) for recurrence-free survival (RFS) at 5 years was calculated using the Kattan nomogram. The discriminating ability of the model was assessed by Harrell's concordance index (c-index). Bootstrapping was used to assess confidence intervals. Furthermore, survival was then estimated by the Kaplan-Meier method and Cox proportional hazards regression analysis.RESULTS. In all, 565 patients (median age, 62 years) were included. At the time of the last follow-up, 81 patients had died and 101 had experienced RCC recurrence. The c-index for RFS (Kattan nomogram) was only 0.607 (95% confidence interval [CI]: 0.576-0.635). The 5-year RFS rate and cancer-specific survival rate were 81.5% and 84.7%, respectively. Of the 4 variables included in the nomogram, only TNM stage was associated with recurrence in a multivariate analysis (Cox analysis) (P = .022).CONCLUSIONS. There was a discrepancy between predicted RFS as estimated by the Kattan nomogram and the likelihood of being recurrence-free at 5 years according to the Cox analysis in the current population of patients. However, until new dynamic models become available clinicians may still improve their predictive ability by using the current nomogram.

Objective: To study the specific features of the sporadic form of bilateral renal cell carcinoma (RCC).Material and Method: Twenty-six patients presented bilateral RCC among a total of 759 patients operated for RCC in our institution between 1985 and 1998. The mean follow-up for 23 patients (3 were lost to follow-up) was 56.5 months. Actuarial survival was estimated by the Kaplan-Meier method and comparisons between the various groups were performed with a Mann-Whitney test.Results: This series comprised 10 asynchronous tumours and 16 synchronous tumours. The mean diameter of synchronous tumours was significantly greater than that of asynchronous tumours (61 vs 33.5 mm). Histology revealed 16 clear cell carcinomas (CCC), 7 tubulopapillary carcinomas (TPC), 2 cases with CCC and TpC, and one bilateral oncocytoma. Malignant tumours were classified as stage T1-T2 (n=23) or T3 (n=2). TPC was more frequently bilateral than CCC (7.9% vs. 2.8%). Forty-four surgical operations (19 radical nephrectomies and 24 partial nephrectomies) were performed. The mean interval between two operations for asynchronous tumours was 85.2 months. Follow-up demonstrated 15 remissions and 6 deaths, including 5 deaths due to RCC, one local recurrence and one local recurrence with metastases. One-year specific survival was 96% and 5-year survival was 74%. Age, gender, histological type and the asynchronous or synchronous mode did not induce any significant difference on survival.Conclusion: The surgical approach must therefore be resolutely conservative in view of the good 5-year survival rate and the low local recurrence and metastasis rates.

Objectif: Evaluer de faaon prospective l'utilite de l'examen extemporane lors d'interventions conservatrices pour carcinome a cellules renales (RCC) dans des indications exclusivement electives et evaluer la realite des marges de securite. Materiel et Methodes: De 1997 a 2001, 220 chirurgies conservatrices pour RCC ont ete realisees dans notre service:104 etaient des tumorectomies d'indication elective dont 61 ont ete etudiees prospectivement. L'âge moyen des 61 patients etait de 59,4 ans (34,2 a 78,5). La taille moyenne des tumeurs etait de 32 mm (12 a 50). Elles etaient peripheriques dans 51 cas et en position juxta-hilaire dans 10 cas. Les marges etaient evaluees macroscopiquement par le chirurgien, puis la piece etait systematiquement adressee en extemporane. Les marges incompletes, (negatives mais sans marge de securite), etaient distinguees des marges positives sur l'analyse histologique definitive. L'epaisseur des marges de securite etait mesuree au niveau des extremites corticales et profondes de la piece operatoire. Le suivi moyen etait de 78,5 mois (52 a 101). Resultats: Les types histologiques de RCC etaient conventionnels a cellules claires (n=42), tubulo-papillaires (n=17) et chromophobes (n=2), de stade pTl (n=57) et pT2 (n=4), et de grade 1 (n=16), 2 (n=35) et 3 (n=10). Aucune marge n'etait positive. L'epaisseur moyenne de la marge de securite etait de 7mm en peripherie et de 2mm en profondeur sans correlation entre ces deux valeurs. Les chirurgiens ont conclu a la presence de 51 marges completes et 10 marges incompletes contre respectivement 53 et 8 en examen histologique. L'examen extemporane n'a jamais modifie le cours de l'intervention. Tous les patients etaient vivants et indemnes de recidive au dernier controle. Conclusion: L'evaluation macroscopique des marges par le chirurgien est precise et permet le plus souvent d'eviter une analyse extemporanee inutile. Neanmoins, en cas de marges jugees incompletes par le chirurgien, l'examen extemporane est imperatif afin d'eviter les marges positives, ce qui doit rester le principal objectif de la chirurgie conservatrice.

Chyluria is a rare disease outside of parasite endemic zones. The treatment of severe forms is surgical. Reno-lymphatic disconnection is the reference procedure, with long-term success rates of 99%. This operation performed via a lumbar incision can also be performed by retroperitoneal or transperitoneal laparoscopy. The advantages of this minimally invasive incision are those classically reported in the literature.

Renal cell carcinoma of transplanted kidneys is rare. We report three such cases among 1,250 kidney grafts that were performed or followed from 1968 to 2002. A strategy to diagnose these lesions is needed because of their rarity, late detection, and therapeutic repercussions. At the least, the strategy should include annual ultrasonography of the graft throughout its lifespan. Because the risk of tumor development in another organ from the same donor is not negligible, a national registry should be established to rapidly alert graft recipients with the same donor and other transplantation centers about the risk of graft tumors.

Objective: To use Bootstrapping to estimate the Kaplan-Meier survival of sporadic forms of bilateral renal cell carcinoma (RCC).Patients and Methods : Over a period of 13 years, 759 patients were operated for RCC. 26 patients had bilateral sporadic RCC (3.4%) and 23 of them were reviewed with a median follow-up of 50 months (range: 7.8 to 143.4). The 95% confidence interval (95% CI) of Kaplan-Meier survival was estimated according to the Greenwood (Gw) normalized method and by Bootstrap percentile (B*) with B = 1000.Results: The overall 1-year and 5-year survival rates were 95.8% (95% CI Gw: [87.6-100] and B*: [92.1-96.4]) and 73.6% (95% CI Gw: [54.9-92.15] and B*: [72.3-86.5%]), respectively. Conclusion: For diseases with a low incidence, Bootstrapping can improve the precision of the Kaplan-Meier survival estimate, by providing a narrower CI. This statistical technique provides the clinician with more precise results in a study limited by a small number of patients.

PURPOSE:We identified prognostic factors of papillary renal cell carcinoma (PRCC) types 1 (PRCC1) and 2 (PRCC2).MATERIALS AND METHODS:Between 1985 and 1998, 759 patients underwent surgery for renal cell carcinoma, of whom 88 (11.6%), including 69 males and 19 females with a mean age of 61.8 years (range 21.3 to 85.9) who had PRCC. Multifocality was defined as 2 or greater tumors separated by 10 mm or greater. Small basophilic cells defined PRCC1 and large eosinophilic cells defined PRCC2. Mean followup in 79 cases was 71.1 months (range 1 to 196.6). Survival rates were calculated and statistical analyses were done.RESULTS:The 88 patients underwent radical nephrectomy (65) or conservative surgery (28, that is elective in 17 and imperative in 11). Mean tumor size was 62 mm (range 10 to 190) and 41% of lesions were multifocal, independent of PRCC size, stage, grade or type. Comparing the 56 PRCC1s (63.6%) to the 32 PRCC2s (36.4%) showed that PRCC2 grade and stage were significantly higher (p = 0.024 and 0.025, respectively). A total of 51 patients (64.6%) remained relapse-free and progression-free. Local relapses occurred only after imperative conservative surgery in 2 cases (2.5%). Of the 26 deaths 15 (4 PRCC 1 and 11 PRCC 2) were tumor associated. Mean survival was 26.6 months (range 1 to 112.5). The overall 10-year survival rate was 73% with PRCC1 and PRCC2 10-year rates of 80% and 59%, respectively (p <0.003). Univariate analysis identified stage (p <0.0001), grade (p <0.0001) and histological type (p <0.003) as prognostic factors. Multivariate analysis retained stage (p = 0.006) and grade (p = 0.004).CONCLUSIONS:PRCC multifocality was not associated with stage, grade or histological type and it seems not to be an argument against conservative surgery. Univariate analysis of PRCC prognostic factors identified stage, grade and histological type but the latter was not retained on multivariate analysis.

OBJECTIVES:To report the results of conservative surgery for the treatment of hereditary renal cell carcinoma (RCC) and to define its place with respect to new less invasive treatment options.MATERIAL AND METHOD:Over a period of 14 years, 30 women and 26 men were operated for one or several hereditary RCC, either by radical nephrectomy or nephron-sparing excision, via a lumbar or subcostal incision, when the diameter of at least one RCC was greater than 2.5 cm.RESULTS:92 operations were performed: 62 local excisions and 30 nephrectomies. The TNM stage was: 75 pT1, 14 pT2, 3 pT3b; 4 N+; 3 M+. 26 patients (46%) were operated at least twice. Two or more RCC were resected in 43 cases (47%). In the case of nephron-sparing surgery, mean blood loss was 175 +/- 231.7 cc (range: 50-1300 cc); mean pedicle clamping time (97% of cases) was 32 +/- 10.4 min (range: 10-50 min); mean preoperative serum creatinine was 85 +/- 18 micromol/L (range: 52-150 micromol/L) and mean postoperative serum creatinine was 105 +/- 80 micromol/L (range: 59-576 micromol/L); the calculated tumour recurrence rate was 24% at 5 years and 80% at 8 years; overall 5-year survival was 100% and overall 10-year survival was 67%. The median follow-up was 55.9 months.CONCLUSION:When hereditary RCCs are situated between 2.5 cm and 6 cm in diameter, nephron-sparing surgery is the reference treatment. Modern imaging and genetic screening should allow early detection of increasingly smaller RCCs. In the future, less invasive treatment options could replace surveillance for RCCs less than 2 cm and eventually reduce the indications for local excision.

OBJECTIVES:To determine whether coloepiploic mobilization (CEM) is indicated to reduce the incidence of iatrogenic splenectomy during left radical nephrectomy for renal cell carcinoma. The incidence of iatrogenic splenectomy during a left nephrectomy is estimated to be between 1.4% and 24%. In a recent study, we reported that the incidence of iatrogenic splenectomy was 8% during a left nephrectomy performed for renal cell carcinoma through a transperitoneal anterior subcostal incision. METHODS:A left radical nephrectomy was performed in 233 consecutive patients for renal cell carcinoma through a transperitoneal anterior subcostal incision with a CEM procedure in which the left colonic flexure was completely detached from the epiploa. Perioperative and postoperative complications, including splenic injury, were noted in a database. The mean patient age was 51.3 years (range 21.3 to 90.2). The mean tumor size was 58 mm (range 15 to 230). RESULTS:An iatrogenic splenectomy was required in 3 patients, and in 1 patient, a splenic injury was treated conservatively. The incidence of iatrogenic splenectomy accompanying left radical nephrectomy was 1.3%. The mean operative time was 120 minutes (range 80 to 240). The mean time to normal gut motility was 3.4 days (range 2 to 11) and to discharge from the hospital it was 9.3 days (range 6 to 19). Regarding CEM, we did not observe any significant abdominal complications. CONCLUSIONS:The incidence of iatrogenic splenectomy during a left radical nephrectomy through a transperitoneal anterior subcostal incision may be reduced by performing the technique of CEM.

La nephrectomie elargie doit-elle demeurer la regle, meme en cas de tumeur renale localisee pour laquelle il est souvent difficile d'affirmer par l'imagerie le caractere malin. Une approche conservatrice visa vis de ces petites tumeurs commence a se developper.

Monsieur Z, 65 ans, diabetique insulinorequerant, tabagique a 45 paquets-annee, avec un antecedent de pancreatite chronique d'origine ethylique, est hospitalise pour un abces du scrotum et une fievre a 40 °C. Il presentait depuis un mois des signes d'hyperglycemie (polyuropolydypsie, amaigrissement, asthenie) alors qu'il etait traite par deux injections quotidiennes d'une insuline semi-lente (34 unites le matin, 30 unites le soir). Il avait ete admis en urgence quatre jours auparavant (en medecine interne), pour une douleur scrotale bilaterale, une rougeur et une inflammation avec une hyperleucocytose (17 000/mm3) a polynucleaires neutrophiles (90 %). Le diagnostic d'orchite bilaterale a ete evoque et un traitement par oxacilline a ete administre. Dans les 48 heures qui ont suivi, on a note une majoration des signes locaux avec une augmentation de l'inflammation et des douleurs et l'apparition en surface d'une zone cutanee lustree. La temperature etait a 39-40 °C et l'hyperleucocytose a 19 800/mm3. L'antibiotherapie a ete modifiee, associant une cephalosporine de 3e generation et une fluoroquinolone par voie veineuse. Devant l'aggravation des signes, le patient a ete adresse 24 heures plus tard en urologie. A l'arrivee, l'examen a revele des lesions interessant la totalite du scrotum avec douleurs, rougeurs, suintements nauseabonds perlant en gouttelettes, sphaceles, crepitations neigeuses et zone cutanee necrotique de 4 cm (figure 1). La fievre montait a 39,8 °C sans signes de choc mais on notait des marbrures aux membres inferieurs ; il n'y avait pas de signes digestifs, l'abdomen etait souple et la region anale normale. L'hyperleucocytose etait a a 25 600/mm3. Des prelevements a visee bacteriologique ont ete effectues : hemocultures, mise en culture de peau scrotale, prelevement de liquide suintant sur milieu aerobie et anaerobie (injection sous-cutanee de 1 ml de serum physiologique puis aspiration immediate et mise en culture). Ils mettront en evidence une flore multiple associant Escherichia coli, streptocoques, Bacteroides, staphylocoques et Clostridium difficile. Les principaux parametres biologiques sont indiques dans le tableau. Le patient est opere en urgence par debridement chirurgical (figure 2) de tous les plans cutanes et sous-cutanes, de la base de la verge a la base de l'anus avec excision tres large des tissus necroses et douteux, abrasion des berges, lavage a la betadine diluee, drainage du champ par des lames ondulees de type Delbet et pansement au tulle gras. Les testicules sont enfouis dans la region inguinale. La vessie est drainee par catheter sus-pubien. Une colostomie iliaque de derivation est effectuee par voie sous-costale gauche. L'examen anatomopathologique de la piece operatoire confirme la presence de larges zones sous-cutanees abcedees et necrotiques avec destruction de l'architecture, dissociation des faisceaux de collagene et musculaire, et infiltration des lobules adipeux sans thrombose vasculaire. Le revetement epidermique est pratiquement toujours respecte sauf en regard de quelques zones ulcerees qui correspondent aux zones de necrose cutanee (figure 3). Le patient est suivi en reanimation chirurgicale avec une triple antibiotherapie a large spectre (cephalosporine de 3e generation + fluoroquinolone + metronidazole) et correction des troubles metaboliques. Le pansement est fait tous les jours sous anesthesie generale au bloc operatoire avec excision systematique des tissus atones et douteux, abrasion et parage des berges, lavage et pansement. Au 8e jour, les berges sont toniques et propres et le pansement est alors fait sans anesthesie au lit du patient. On realise, au 30e jour, des greffes de peau libre en filet prelevee sur la face interne des cuisses au dermatome. Le patient sort de reanimation a la 12e semaine. Des complications ont emaille l'evolution : une encephalite virale, une cholecystite alithiasique, une pneumopathie et un ulcere gastro-duodenal. Le retablissement de la continuite digestive est realise a 4 mois par incision elective. Le patient est revu en bonne forme 2 mois plus tard (figure 4).