[Carcinologic and anatomical basis of urethral preservation during cystectomy with substitution in women].
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Cystectomy↗
Biomedical subjects
Alexandre de la Taille
Publications and source records attributed to Alexandre de la Taille.
[Protocadherin-PC discovery and its implication in prostate cancer progression].
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Animals↗
Comparison of early oncologic results of laparoscopic radical prostatectomy by extraperitoneal versus transperitoneal approach.
PURPOSE: Compare the early oncological results of laparoscopic radical prostatectomy performed by either an extraperitoneal or a transperitoneal approach. METHODS: 330 consecutive men underwent laparoscopic radical prostatectomy for localized prostate cancer, the first 165 by transperitoneal approach, and the last 165 by extraperitoneal approach. Clinical stage, serum PSA, Gleason score of biopsy were recorded, as well as operating time, surgical and medical complications, blood loss, length of hospital stay and catheterization time. The weight of the specimen, pathological stage (1997 TNM classification) and status of the surgical margins were noted. The Fisher test as well as the chi2-test were used for statistical analysis. Differences were considered significant when p < 0.05. RESULTS: There were no significant differences between the two groups in terms of preoperative characteristics except for Gleason score of the biopsies which was higher in the extraperitoneal group (p < 0.0001). The operating time was longer with the transperitoneal approach (248.5 min vs. 220.0 min, p < 0.0001). There was no difference in transfusion rate (1.2% vs. 5.4%, transperitoneal vs. extraperitoneal, respectively, p = 0.6). There was no difference in hospital stay, medical and surgical complications. Respectively, in the transperitoneal and extraperitoneal groups, there were 108 and 88 pT2 tumors. There were no differences in terms of positive surgical margins between the two groups, 23% and 29.7% (p = 0.21) overall, 13.0% and 17.0% (p = 0.42) in pT2 tumors and 43.6% and 44.7% (p = 0.99) in pT3 tumors. CONCLUSIONS: Extraperitoneal approach offers the same early oncological results as transperitoneal approach with a shorter operative time.
Humans↗
Docetaxel and zoledronic acid in patients with metastatic hormone-refractory prostate cancer.
OBJECTIVE: To evaluate the safety and efficacy of combined docetaxel-zoledronic acid treatment in patients with metastatic hormone-refractory prostate cancer (HRPC), as bisphosphonates are reported have a synergistic antitumoral effect when combined with taxanes. PATIENTS AND METHODS: Between January 2001 and June 2003, 14 patients with HRPC were treated; their mean (range) age was 71 (57-86) years and mean prostate-specific antigen (PSA) level 202 (6-489) ng/mL. Five patients had had previous chemotherapy (cyclophosphamide in two, mitoxantrone-prednisolone in three). The response criteria were the Karnofsky performance status, a positive response in mean daily analgesic consumption (defined as a decrease by more than half), decreased serum PSA (by more than half) at 8 weeks, blood transfusion, bone scan at 6 months, skeletal-related events and survival. RESULTS: Patients received a mean (range) of 7.3 (6-10) cycles of therapy; there was no reported drug-related toxicity and all patients stayed at home for their treatment. Only three patients required a blood transfusion and no bone fractures were reported. At 2 months, six patients requiring analgesic drugs decreased their consumption by more than half (anti-inflammatory, paracetamol, narcotics) and eight had a reduction in PSA by more than half; of these eight with a PSA response at 2 months, six had biochemical progression with a mean delay of 6.2 (3-11) months. At 6 months, five patients had disease progression on bone scan. Nine patients had chemo-naïve hormone-refractory prostate cancer; three had biochemical progression at 2 months and two of these had progression on their bone scan. Two patients died at 7 and 15 months of follow-up; the mean follow-up was 10.2 (6-15) months. Using Kaplan-Meier plots, biochemical progression-free survivals were five of 14 at 6 months and two of 14 at 12 months; overall survival was 12 of 14 at 6 and 12 months. CONCLUSION: Docetaxel-zoledronic acid therapy is safe and decreased the serum PSA by more than half at 2 months in more than half the patients. Prospective randomized trials are needed to assess this new approach.
Aged↗
[Do urologists apply benign prostatic hyperplasia clinical practice guidelines? Survey on the complementary investigation request modalities in France].
INTRODUCTION: In an attempt to standardize clinical practice, a number of authorities (American, European, international) have published guidelines for the assessment and treatment of men with lower urinary tract symptoms (LUTS) related to BPH. In order to determine the impact of these guidelines on daily practice, we conducted a survey of the initial management of BPH by French Urologists. METHODS: A clear and simple clinical situation was defined and sent to the 796 urologists members of the Association Française d'Urologie: a 65-year-old man presenting with moderate and bothersome lower urinary tract symptoms (LUTS) suggestive of BPH. Various items concerning the choice of complementary investigations were proposed. The last question evaluated the first-line drug prescription. The replies were then analysed as a function of the type of practice and the urologist's age. RESULTS: 184 urologists answered the questionnaire. The mean age of the responding urologists was 47.5 years. 31.6% of responses were derived from hospital urologists, 52.2% from private urologists and 16.2% from urologists with a mixed practice, which corresponds to the distribution of urology practices in France. Assessment of BPH comprised clinical interview and digital rectal examination for all urologists, IPSS score for 23.3%, serum creatinine for 44.7%, dipstick urinalysis and/or urine culture for 72.7%, PSA assay for 98%, uroflowmetry for 65%, renal ultrasound for 80.8%, bladder ultrasound for 84.5%, suprapubic prostatic ultrasound for 61.8%, transrectal ultrasound for 54.2%, post-voiding residue for 89.9%, fibroscopy for 4.7% and 59.6% of urologists would have instituted medical treatment by this first visit. The initial assessment was similar regardless of the type of practice or the urologist's age (greater than or less than 45 years). Hospital urologists and urologists in mixed practice performed statistically more IPSS scores, uroflowmetry or fibroscopy and fewer bladder or renal ultrasound examinations. CONCLUSION: The management of BPH in France is globally similar among urologists regardless of their age or type of practice and does not correspond to current international and national guidelines. These guidelines, designed to limit the number of examinations in countries with ageing populations who are particularly affected by lower urinary tract symptoms, must be more widely diffused. However, this diffusion is not sufficient to ensure acceptance and application of these guidelines. It is therefore essential to conduct real practice surveys among practitioners to evaluate these guidelines, demonstrate differences and try to understand these differences.
Adult↗
[Neoplasms induced by radiotherapy for prostate cancer: report of a case of pelvic sarcoma and review of the literature].
Radiotherapy for prostate cancer can be rarely associated with the development of second cancers, primarily carcinomas and exceptionally sarcomas. The authors report a case of pelvic sarcoma presenting with pain 8 years after irradiation for prostatic carcinoma. This case is discussed in the light of a review of the literature concerning second cancers after radiotherapy for pelvic cancer.
Adenocarcinoma↗
Laparoscopic and robotic surgical training in urology.
The most important change in urology during the past decade was the development of minimally invasive surgery, particularly laparoscopy. However, the main drawback of laparoscopy is a steep learning curve, which results from the significant changes in the surgical environment. Although laparoscopy can provide important advantages for the patient, including decreased length of hospitalization, decreased analgesic requirement, and a shortened postoperative convalescence, one concern has been whether laparoscopic techniques should be learned solely in the operating room. For example, sports, music, and aviation are practiced before an actual performance is ever undertaken. In this review, the advantages and limitations of all available training modalities in minimally invasive surgery are described. Testing basic laparoscopic skills on inanimate models, becoming familiar with the principles of dissection and hemostasis on living animals, and studying surgical anatomy on cadavers should be considered as indispensable and complementary elements for laparoscopic training in the future. In addition, telementoring with the help of modern image processing and virtual reality eventually may become the basis of tomorrow's surgical instruction.
Clinical Competence↗
Location of positive surgical margins after retropubic, perineal, and laparoscopic radical prostatectomy for organ-confined prostate cancer.
OBJECTIVES: To evaluate and compare the location of positive surgical margins after retropubic, perineal, and laparoscopic radical prostatectomy for organ-confined prostate cancer (pT2). METHODS: From 1988 to 2001, 538 patients underwent radical prostatectomy for clinically localized prostate cancer. Patient age at surgery, clinical stage, preoperative prostate-specific antigen, and Gleason score of positive biopsies were noted. Postoperatively, specimen weight, final Gleason score, and capsular, seminal vesicle, and lymph node status, as well as tumor volume, were studied. The incidence and location of positive margins and the pathologic stage were noted according to the surgical approach. RESULTS: A total of 371 patients (69.5%) had organ-confined tumors. Of the 371 patients, 116 underwent the retropubic, 86 the perineal, and 169 the laparoscopic approach, and positive surgical margins were noted in 22 (18.9%), 12 (13.9%), and 32 (18.9%) patients, respectively. Positive surgical margins were reported in 72 specimen locations, 32 (44.4%) at the apex, 17 (23.6%) at the bladder neck, and 29 (31.9%) posterolaterally. The distribution for the retropubic, perineal, and laparoscopic approaches was apex in 50%, 33.3%, and 44.4%, bladder neck in 29.1%, 41.7%, and 13.9%, and posterolaterally in 20.8%, 25%, and 41.6%, respectively. CONCLUSIONS: In our series, each approach had a specific high-risk location of positive margins: the apex for the retropubic, the bladder neck for the perineal, and posterolaterally for the laparoscopic approach. Improvements in the surgical techniques should take these specific locations under consideration to decrease the incidence of positive surgical margins.
Adenocarcinoma↗
Assessment of surgical technique and perioperative morbidity associated with extraperitoneal versus transperitoneal laparoscopic radical prostatectomy.
OBJECTIVES: To compare the perioperative morbidity and surgical technique of the two main variants of laparoscopic radical prostatectomy: the more often used transperitoneal approach with primary dissection of the plane posterior to the seminal vesicles (TP-LRP) and a purely extraperitoneal approach (EP-LRP). METHODS: Our initial 20 consecutive patients who underwent EP-LRP and the last 20 consecutive patients who underwent TP-LRP were included in this retrospective study. The two groups were well matched for age, American Society of Anesthesiologists score, body mass index, prostate-specific antigen level, and Gleason score. The mean time for completion of the individual laparoscopic steps was assessed for both approaches. RESULTS: With EP-LRP, the mean operative time was shorter (169.6 minutes versus 224.2 minutes, P <0.001) and patients resumed a full diet earlier (mean 1.6 days versus 2.6 days, P = 0.002). The mean total dose and duration of morphine administration were higher in the TP-LRP group, but the difference was not statistically significant (6.0 mg versus 12.8 mg and 0.5 day versus 0.9 day, respectively). The catheter time was nearly identical in the two groups (mean 5.3 days with TP-LRP and 4.2 days with EP-LRP). The incidence of positive margins was not affected by the surgical approach. CONCLUSIONS: These preliminary results suggest that the initial posterior dissection associated with TP-LRP is less efficacious than direct access of the prevesical space during EP-LRP. Measures of perioperative morbidity were at least equivalent, if not superior, for the EP-LRP technique. These findings, together with the significant decrease in operative time with EP-LRP, appear sufficiently important to abandon the transperitoneal technique.
Aged↗
Prospective evaluation of a 21-sample needle biopsy procedure designed to improve the prostate cancer detection rate.
OBJECTIVES: To evaluate prospectively the diagnostic yield of a 21-sample ultrasound-guided needle biopsy procedure for prostate cancer in patients with elevated serum prostate-specific antigen and/or abnormal digital rectal examination findings. METHODS: Between December 2000 and May 2002, 303 patients underwent 21-sample needle biopsy under local anesthesia, comprising sextant biopsies at a 45 degrees angle, 3 biopsies in each peripheral zone at an 80 degrees angle, 3 biopsies in each transition zone (TZ), and 3 biopsies in the midline peripheral zone. Morbidity was assessed clinically. A short questionnaire was filled out by 90 consecutive patients. RESULTS: The cancer detection rate using 6 biopsy samples (sextant biopsies only), 12 samples (sextant plus lateral biopsies), 18 samples (sextant plus lateral plus TZ biopsies), and 21 samples (sextant plus lateral plus TZ, plus midline biopsies) was 22.7%, 28.3%, 30.7%, and 31.3%, respectively. The 21-sample procedure statistically improved the cancer detection rate by 37.9% relative to the 6-sample procedure. The improvement was most marked in patients with a prostate volume of more than 40 cm(3) (48.3%), patients with Stage T1c prostate disease (44.9%), patients undergoing repeat biopsy (66.2%), and patients with prostate-specific antigen levels greater than 10 ng/mL (38.5%). Adverse effects were infrequent (3%), consisting of prostatitis in 3 patients, acute urinary retention in 6 patients, and rectal bleeding requiring hospitalization in 1 patient taking aspirin. Using the questionnaire, 84% of patients reported macroscopic hematuria for an average of 3.4 days and hematospermia for 12.8 days, and 45% reported minor rectal bleeding lasting 1.1 days. The mean pain score, with a visual analog scale ranging between 0 (no pain) and 10 (intense pain), was 4.56. CONCLUSIONS: A 21-sample needle biopsy procedure increased the prostate cancer detection rate relative to a 6-sample procedure, without increasing morbidity. Patients with elevated prostate-specific antigen values should undergo sextant biopsies and at least 6 additional biopsies in the peripheral zone and 6 in the TZ.
Aged↗
Operative management of rectal injuries during laparoscopic radical prostatectomy.
OBJECTIVES: To present our experience in the management of rectal injuries during laparoscopic radical prostatectomy. METHODS: All patients underwent bowel preparation and received perioperative antibiotics. If rectal injury was suspected, digital rectal examination was performed, aided by bubbling air into the rectum if required. When the diagnosis was confirmed, the hole was closed in two layers of absorbable sutures. A fat flap was developed from the omentum (in the transperitoneal approach) or the perirectal fat (in the extraperitoneal approach) and placed on the suture line. Anal dilation was performed. After surgery, broad-spectrum antibiotics and a low-residue diet were prescribed. RESULTS: Of 300 patients who underwent surgery between May 1998 and June 2002, 6 (2%) had a rectal injury. The first patient had received neoadjuvant hormonal therapy. Five cases were in the transperitoneal approach and were closed using omental fat and 1 was in the extraperitoneal approach with a perirectal fat flap. The first patient presented with a rectourethral fistula and was treated with catheterization for 1 month and a diverting colostomy. The others were detected intraoperatively and were treated laparoscopically. In the second patient, a diverting colostomy was performed at the end of surgery using a separate incision. Patients resumed oral intake within 2 to 7 days and were discharged from the hospital between 6 and 18 days postoperatively. No wound infection was noted. CONCLUSIONS: Rectal injuries during laparoscopic radical prostatectomy can be identified and managed intraoperatively without requiring conversion. Double-layered closure reinforced by a fat flap resulted in an uneventful recovery.
Colostomy↗
Positive surgical margins in laparoscopic radical prostatectomy: the impact of apical dissection, bladder neck remodeling and nerve preservation.
PURPOSE: We assess the incidence and location of positive surgical margins in a consecutive series of patients who underwent laparoscopic radical prostatectomy. MATERIALS AND METHODS: Between May 1998 and September 2001, 235 men underwent laparoscopic radical prostatectomy at our institution. During this period modifications were made in the technique. We stopped preserving the puboprostatic ligaments during 1999 and stopped preserving the bladder neck during 2000. We compared the incidence of apical and bladder neck margins before and after these changes in surgical technique. Nerve sparing status was documented by the surgeon at the end of the operation and its effect on the incidence of lateral positive margins was evaluated. To concentrate on the surgically induced margins this study focused on pT2 cases. RESULTS: There were 169 pT2 cases and 32 (18.9%) positive margin locations. A constant decrease was noted in the overall incidence of positive margins but, while apical margins were the most abundant in 1998, posterolateral margins were most abundant in 2001. Avoiding bladder neck preservation eliminated positive bladder neck margins in 2001. The overall incidence of positive lateral surgical margins in pT2 cases treated with a nerve sparing procedure was 8.4%. CONCLUSIONS: The experience gained in this procedure led to a decrease in the incidence of positive margins. Wide resection of the bladder neck and cutting the puboprostatic ligaments decreased bladder neck and apical positive margins. Nerve preservation did not increase the incidence of positive margins. These technical modifications may improve the outcome of laparoscopic radical prostatectomy.
Aged↗
A simplified 5-step model for training laparoscopic urethrovesical anastomosis.
PURPOSE: We developed a training model and program aimed at improving the skills of urologists with no previous experience in laparoscopy to perform a running suture urethrovesical anastomosis as is done during laparoscopic radical prostatectomy. MATERIALS AND METHODS: Our program is performed on a pelvic trainer with a videolaparoscopic unit and consists of passage of a ligature, intracorporal knotting, intracorporal suturing, linear anastomosis and circular running suture anastomosis. The trainees performed the first 3 tasks during the initial lessons and then advanced to the 2 final tasks. At the end of each lesson time was recorded and progression curve was plotted for each participant for each task. The end point of the study was participant ability to perform an accurate circular anastomosis. Logarithmic regression analysis was used to assess the significance of progression. RESULTS: All 10 urologists who participated in this study showed a rapid and significant decrease in the time required to perform the first 3 tasks accurately. The participants were able to perform a linear anastomosis after 3 to 5 lessons and an accurate circular anastomosis after 5 to 10 lessons. CONCLUSIONS: By using this model and dividing a complicated surgical step to simplified tasks, we were able to improve trainee performance significantly in a short time. A training program for basic and advanced laparoscopic skills should be incorporated into the syllabus of urologists-in-training and available to those who wish to gain experience in laparoscopic surgery.
Anastomosis, Surgical↗
Beta-catenin-related anomalies in apoptosis-resistant and hormone-refractory prostate cancer cells.
PURPOSE: beta-Catenin is a critical end component of the wnt signaling pathway that regulates cell growth, apoptosis, and migratory behavior in response to intercellular adhesion molecules. The aim of this study was to evaluate abnormalities of beta-catenin protein expression, subcellular localization, and activity in an in vitro model of acquired apoptosis-resistance in cultured PC cells and in primary human prostate cancers (PrCa). EXPERIMENTAL DESIGN: Apoptosis-resistant human prostate cancer cell line variants were derived from parental LNCaP cells by repeated brief exposure to apoptotic stimuli. The derivative and parental cells were analyzed for beta-catenin expression and intracellular localization using cell fractionation and Western blotting procedures. Endogenous transcriptional activity from the TCF/LEF-1 response element was also studied in these variants after transfection with a beta-catenin sensitive reporter plasmid. Finally, beta-catenin protein expression and intracellular localization were evaluated on 212 patients [122 localized PrCa and 90 hormone-refractory (HRPC) PrCa specimens by immunohistochemistry]. RESULTS: Western blot analysis showed that the intracellular partitioning of beta-catenin was shifted from the membrane fraction in parental cells to the cytoplasmic/nuclear fractions of the apoptosis-resistant cell lines. Coordinately, transcriptional activity from a TCF/LEF-promoted reporter plasmid was increased significantly in the apoptosis-resistant lines. In the primary prostate tumors analyzed, cytoplasmic and/or nuclear beta-catenin expression was correlated statistically with the HRPC status and Gleason score. In the group of localized PrCa, abnormal beta-catenin expression tended to be associated with a higher Gleason score and with pT3 disease. No mutation was found in patients with HRPC and abnormal beta-catenin expression. CONCLUSION: These data suggest that anomalies of beta-catenin expression occur in PrCa and that these anomalies are associated with disease progression, especially to the therapeutic-resistant state.
Adult↗
[Simple nephrectomy with retroperitoneal laparoscopy].
OBJECTIVE: Nephrectomy was one of the very first urological procedures to be performed by laparoscopy. The objective of this study was to evaluate the results of retroperitoneal laparoscopic simple nephrectomy. METHODS: From 1995 to 2002, 88 retroperitoneal laparoscopic simple nephrectomies were performed in 87 patients with a mean age of 45.3 years (range: 18 to 77 years). The intraoperative and postoperative complications, conversion rate, blood loss, operating time and length of hospital stay were studied for each patient. RESULTS: The mean operating time was 114 min (range: 35 to 280 min), mean blood loss was 97.6 ml (range: 0 to 300 ml), there were 3 conversions (3.4%) and the mean length of hospital stay was 4.7 days (range: 2 to 13 days). The main postoperative complications were 2 cases of haematoma and one abscess of the nephrectomy site requiring surgical revision and 3 intraoperative thromboses of arteriovenous fistulas in 3 patients with polycystic kidney disease. CONCLUSION: Due to its low morbidity, laparoscopic simple nephrectomy has probably become the, reference technique for all indications for nephrectomy for benign disease.
Adolescent↗
Patient reported sexual function following laparoscopic radical prostatectomy.
PURPOSE: We evaluated the sexual function of patients who underwent laparoscopic radical prostatectomy. We assessed the effect of unilateral or bilateral preservation of the neurovascular bundle on the ability to achieve erections and have sexual intercourse postoperatively. MATERIAL AND METHODS: Between May 1998 and September 2001, 232 men underwent laparoscopic radical prostatectomy for localized prostate cancer at our institution. Sexual function questionnaires were given to the patients preoperatively. The study included 143 patients who were potent preoperatively. After the procedure the surgeon noted whether he performed unilateral, bilateral or no nerve sparing. Sexual function questionnaires were collected at 1, 3, 6 and 12 months after surgery. RESULTS: Of the 143 patients, 100, 80, 48 and 26 responded to the questionnaire at 1, 3, 6 and 12 months respectively. Of the nonnerve sparing group 11.7%, 11.1%, 16.6% and 30%, of the unilateral nerve sparing group 20%, 35%, 41.6% and 50% and of the bilateral nerve sparing group 32.5%, 41.1%, 29.1% and 87.5% respectively reported spontaneous erections 1, 3, 6 and 12 months after surgery, respectively. The overall incidence of positive lateral surgical margins in pT2 cases treated with a nerve sparing procedure was 8.4%. CONCLUSIONS: The overall rate of patients who had erections preoperatively and maintained erections after surgery (53.8%) is comparable to the results for open surgery. Patients with bilateral preservation did better than those with unilateral preservation. Our preliminary results show a promising rate of potency at 1 year after laparoscopic radical prostatectomy.
Aged↗
Radical prostatectomy by the retropubic, perineal and laparoscopic approach: 12 years of experience in one center.
OBJECTIVES: We retrospectively evaluated the oncological outcome of radical prostatectomy performed by the retropubic, perineal and laparoscopic approaches. METHODS: From 1988 to 2000, 401 patients underwent radical prostatectomy for localized prostate cancer by the retropubic, perineal or laparoscopic approach. Age, clinical stage, preoperative PSA and Gleason score of positive biopsies were noted. Operating time, complication rate, transfusion rate, length of hospital stay, catheterization time and pathological results were reviewed. Kaplan-Meier analysis was used to evaluate the likelihood of biochemical recurrence (PSA > or =0.2 ng/ml). RESULTS: There were no significant differences between the three groups regarding preoperative characteristics, except for PSA (21.4 ng/ml, 13.2 ng/ml, and 11.6 ng/ml for the retropubic, perineal, and laparoscopic approach, p<0.05) and the frequency of stage T1c tumors (31.7%, 47.1% and 63.5%, respectively, p<0.05). The operating time was significantly longer in the laparoscopic approach (285 min) compared to the retropubic and perineal techniques (197 min and 178 min, respectively). The retropubic approach was associated with a higher transfusion rate (26.2% versus 15.9% and 2.9% with the perineal and laparoscopic approaches), longer bladder catheterization time (15.9 days versus 11.7 days and 6.8 days, respectively), and longer hospital stay (15.2 days versus 8.5 days and 7.4 days, respectively) (p<0.05 for each). With the retropubic, perineal and laparoscopic approaches, medical complication rates were 8.3%, 4.2% and 5.1%, and surgical complication rates were 16.5%, 12.7% and 13.1%, respectively. The rates of pathological stage pT2 tumors were 62.1%, 72.2% and 75.9%, in the retropubic, perineal and laparoscopic groups, respectively. Positive surgical margins in pT2 tumors were noted in 19%, 14% and 22%, respectively. The actuarial 3-year recurrence-free survival rates were not significantly different between the three techniques (75%, 85.2% and 84.1%, respectively; 91.7%, 95.8% and 90.4% among patients with organ-confined tumors). CONCLUSION: Despite changes in patient selection criteria over time, and the relatively short follow-up, this study showed no significant difference in oncologic outcome between the retropubic, perineal and laparoscopic approaches to radical prostatectomy.
Aged↗