Positive surgical margins (PSMs) in men undergoing radical prostatectomy (RP) for prostate cancer... more Positive surgical margins (PSMs) in men undergoing radical prostatectomy (RP) for prostate cancer are associated with an increased risk of biochemical recurrence. This study evaluated the long-term (>10 year) impact of PSMs on biochemical recurrence after RP in adjuvant treatment-naïve pT2-pT4 N0 men and determined predictors of prostate-specific antigen (PSA) failure. The institutional registry of 1276 patients who underwent RP at Henri Mondor Hospital from 1988 to 2001 was reviewed, identifying 403 patients with regular follow-up at the time of analysis. The study included 108 patients with PSMs who did not receive neoadjuvant or adjuvant therapy before PSA relapse. Median follow-up was 12.2 years. PSA failure was defined by a PSA rising by more than 0.2 ng/ml and biochemical recurrence-free survival (RFS) was estimated using the Kaplan-Meier method. Cox proportional hazard regression models were used to analyse clinicopathological variables associated with biochemical recurrence. Biochemical recurrence 10 years after RP was 33.5% for patients regardless of the margin status. The 10-year biochemical RFS was 73% in men with negative margins compared to 49% in the case of PSM (p < 0.001). In multivariate analysis, margin status was a significantly predictive for PSA failure (hazard ratio 1.46, p = 0.04). After stratification by pathological stage, margin status was significantly predictive for biochemical RFS in pT2 (p < 0.001) and pT3a (p < 0.001), whereas the impact of PSM did not reach significance in pT3b (p = 0.16). After 10-year follow-up, PSMs remain an independent risk factor of biochemical RFS after RP with less relevant impact in pT3b disease. Randomized prospective trials are needed to determine the place of adjuvant versus delayed radiotherapy.
From 2000, the robot-assisted laparoscopic approach has been developed for the management of uret... more From 2000, the robot-assisted laparoscopic approach has been developed for the management of ureteropelvic junction obstruction (UJO) with equivalent outcomes to conventional laparoscopic access regarding functional results. This system has simplified the suturing and has improved the precision of operative technique. The main surgical steps of the transperitoneal laparoscopic robot-assisted pyeloplasty are as follows: four or five port arrangement; initial dissection and early identification of the ureteropelvic junction; renal pelvis section; transection of the ureter and preparation of a spatula; continuous posterior suture; confection of a handle racket suture; placement of a double J stent; ending of the anastomosis. Outcomes after robotic and pure laparoscopic pyeloplasties are equivalent nowadays. Despite the financial cost, it seems easier and technically feasible and accessible for surgeons accustomed to the laparoscopic techniques and even beginners to learn the robotic technique if the system is available in their institution with success rate (radiologic and clinical) almost similar with those obtain with open techniques.
To study the prognostic value of extent, number, and location of positive surgical margins (PSM).... more To study the prognostic value of extent, number, and location of positive surgical margins (PSM). A total of 1,504 consecutive adjuvant treatment naive and node-negative radical prostatectomy men were included in a prospective database including extent, number, and location of PSM. Mean follow-up was 33 months. Endpoint was biochemical progression-free (bPFS) survival. The impact of margin status and characteristics was assessed in time-dependent analyses using Cox regression and Kaplan-Meier methods. PSM was reported in 26.7 % of patients. The predominant PSM locations were apex and posterior locations. Median PSM length was 4.0 mm. The 2-year bPFS was 73.7 % in PSM patients as compared to 93.0 % in NSM patients (p < 0.001). The rate and extent of PSM increased significantly with pathologic stage (p < 0.001). The extent of PSM length was linearly correlated with bPFS (p = 0.017, coefficient: -0.122). In univariable analysis, extent and number of PSM were significantly linked to outcomes. None of PSM subclassifications significantly influenced the bPFS rates in the subgroup of pT2 disease patients. Conversely, stratification by PSM location (apex vs. other locations, p = 0.008), by PSM number (p = 0.006), and by PSM length (p < 0.001) showed significant differences in pT3-4 cancer patients. In that subgroup, PSM length also added to bPFS prediction using PSM status only in multivariable models (p = 0.005). PSM subclassifications do not improve the biochemical recurrence prediction in organ-confined disease. In non-organ-confined disease, PSM length (≥3 mm), multifocality (≥3 sites), and apical location are significantly linked to poorer outcomes and could justify a more aggressive adjuvant treatment approach.
To describe a standardized and easily reproducible method for fluoroscopy-guided renal access dur... more To describe a standardized and easily reproducible method for fluoroscopy-guided renal access during supine percutaneous nephrolithotomy (sPCNL). From January 2009 to January 2010, 35 patients underwent sPCNL. In 10 patients, ultrasound-guided puncture was unsuccessful. In these patients, we completed percutaneous access with a method based on fluoroscopy. We used a simple technique, adapted to sPCNL, consisting of cephalad tilting of the C-arm during puncture of the targeted calyx. We prospectively recorded the time necessary for the puncture, the success, and the complication rate of the puncture. Among the 10 study patients, the mean operative time for the puncture was 50 seconds (range 35-180). The puncture was successful after 1 attempt in 7 patients and in the remaining patients after a second or a third attempt. There were no complications related to the puncture technique. This technique is easy and reproducible for creating a fluoroscopy-guided renal access adjunctive to ultrasound during sPCNL. It may also be useful for urologists not familiar with ultrasound-guided access.
To assess the effectiveness of robot-assisted pyeloplasty in patients with clinically symptomatic... more To assess the effectiveness of robot-assisted pyeloplasty in patients with clinically symptomatic ureteropelvic junction obstruction (UPJO). We retrospectively reviewed our database for all patients who were treated for UPJO by a single surgeon using a robot-assisted procedure between 2005 and 2007. We collected the following: Patient age, clinical presentation, perioperative data, complications, length of hospital stay, and outcome. Preoperative evaluation of UPJO always included an injected renal CT scan and furosemide-mercaptoacetyltriglycine (MAG-3) renal scintigraphy. Patients were seen at 3 and 6 months after surgery and once a year thereafter. Postoperative success was defined as symptomatic response and radiographic evidence of no further obstruction. Twenty patients with a mean age of 36.8 +/- 16 years (range 15-69 yr) were included. Six (30%) patients had previously undergone endoscopic treatment. The mean operative time was 150.3 +/- 36.22 minutes (range 150-240 min). The mean follow-up was 19.9 +/- 10.03 months (range 3-37 mos). Two (10%) procedures necessitated conversion to laparoscopic procedures, and there was no conversion to laparotomy. Four (20%) patients experienced minor complications: Two urinary tract infections and two urinomas. Repeated early surgery was needed in one patient for temporary (ie, 8 days) stent placement in the case of urinoma. There was no recurrence of the UPJO, and no repeated surgery was deemed necessary during the follow-up period. The success rate was estimated to be 95%. Functional outcomes after robot-assisted procedures for alleviation of UPJO are very promising. Our data showed that the robot-assisted procedure was safe and featured negligible morbidity. Therefore, we conclude that our approach is a viable alternative to open surgery.
Extracorporeal membrane oxygenation (ECMO) improves the outcome of refractory cardiogenic shock. ... more Extracorporeal membrane oxygenation (ECMO) improves the outcome of refractory cardiogenic shock. Few studies in adult populations have specifically addressed the complications of ECMO. Abdominal compartment syndrome (ACS) has been previously described in the pediatric literature, but it has never been directly attributed to ECMO alone. The authors describe two cases of ACS directly induced by venoarterial ECMO. In one case, decompressive laparotomy restored an adequate hemodynamic status. The authors hypothesize that ECMO contributed to ACS by inducing massive fluid overload and subsequent tense ascites. In conclusion, when ECMO dysfunction or hemodynamic impairment occurs, ACS should be considered and a decompressive laparotomy should be performed.
Positive surgical margins (PSMs) in men undergoing radical prostatectomy (RP) for prostate cancer... more Positive surgical margins (PSMs) in men undergoing radical prostatectomy (RP) for prostate cancer are associated with an increased risk of biochemical recurrence. This study evaluated the long-term (>10 year) impact of PSMs on biochemical recurrence after RP in adjuvant treatment-naïve pT2-pT4 N0 men and determined predictors of prostate-specific antigen (PSA) failure. The institutional registry of 1276 patients who underwent RP at Henri Mondor Hospital from 1988 to 2001 was reviewed, identifying 403 patients with regular follow-up at the time of analysis. The study included 108 patients with PSMs who did not receive neoadjuvant or adjuvant therapy before PSA relapse. Median follow-up was 12.2 years. PSA failure was defined by a PSA rising by more than 0.2 ng/ml and biochemical recurrence-free survival (RFS) was estimated using the Kaplan-Meier method. Cox proportional hazard regression models were used to analyse clinicopathological variables associated with biochemical recurrence. Biochemical recurrence 10 years after RP was 33.5% for patients regardless of the margin status. The 10-year biochemical RFS was 73% in men with negative margins compared to 49% in the case of PSM (p < 0.001). In multivariate analysis, margin status was a significantly predictive for PSA failure (hazard ratio 1.46, p = 0.04). After stratification by pathological stage, margin status was significantly predictive for biochemical RFS in pT2 (p < 0.001) and pT3a (p < 0.001), whereas the impact of PSM did not reach significance in pT3b (p = 0.16). After 10-year follow-up, PSMs remain an independent risk factor of biochemical RFS after RP with less relevant impact in pT3b disease. Randomized prospective trials are needed to determine the place of adjuvant versus delayed radiotherapy.
From 2000, the robot-assisted laparoscopic approach has been developed for the management of uret... more From 2000, the robot-assisted laparoscopic approach has been developed for the management of ureteropelvic junction obstruction (UJO) with equivalent outcomes to conventional laparoscopic access regarding functional results. This system has simplified the suturing and has improved the precision of operative technique. The main surgical steps of the transperitoneal laparoscopic robot-assisted pyeloplasty are as follows: four or five port arrangement; initial dissection and early identification of the ureteropelvic junction; renal pelvis section; transection of the ureter and preparation of a spatula; continuous posterior suture; confection of a handle racket suture; placement of a double J stent; ending of the anastomosis. Outcomes after robotic and pure laparoscopic pyeloplasties are equivalent nowadays. Despite the financial cost, it seems easier and technically feasible and accessible for surgeons accustomed to the laparoscopic techniques and even beginners to learn the robotic technique if the system is available in their institution with success rate (radiologic and clinical) almost similar with those obtain with open techniques.
To study the prognostic value of extent, number, and location of positive surgical margins (PSM).... more To study the prognostic value of extent, number, and location of positive surgical margins (PSM). A total of 1,504 consecutive adjuvant treatment naive and node-negative radical prostatectomy men were included in a prospective database including extent, number, and location of PSM. Mean follow-up was 33 months. Endpoint was biochemical progression-free (bPFS) survival. The impact of margin status and characteristics was assessed in time-dependent analyses using Cox regression and Kaplan-Meier methods. PSM was reported in 26.7 % of patients. The predominant PSM locations were apex and posterior locations. Median PSM length was 4.0 mm. The 2-year bPFS was 73.7 % in PSM patients as compared to 93.0 % in NSM patients (p < 0.001). The rate and extent of PSM increased significantly with pathologic stage (p < 0.001). The extent of PSM length was linearly correlated with bPFS (p = 0.017, coefficient: -0.122). In univariable analysis, extent and number of PSM were significantly linked to outcomes. None of PSM subclassifications significantly influenced the bPFS rates in the subgroup of pT2 disease patients. Conversely, stratification by PSM location (apex vs. other locations, p = 0.008), by PSM number (p = 0.006), and by PSM length (p < 0.001) showed significant differences in pT3-4 cancer patients. In that subgroup, PSM length also added to bPFS prediction using PSM status only in multivariable models (p = 0.005). PSM subclassifications do not improve the biochemical recurrence prediction in organ-confined disease. In non-organ-confined disease, PSM length (≥3 mm), multifocality (≥3 sites), and apical location are significantly linked to poorer outcomes and could justify a more aggressive adjuvant treatment approach.
To describe a standardized and easily reproducible method for fluoroscopy-guided renal access dur... more To describe a standardized and easily reproducible method for fluoroscopy-guided renal access during supine percutaneous nephrolithotomy (sPCNL). From January 2009 to January 2010, 35 patients underwent sPCNL. In 10 patients, ultrasound-guided puncture was unsuccessful. In these patients, we completed percutaneous access with a method based on fluoroscopy. We used a simple technique, adapted to sPCNL, consisting of cephalad tilting of the C-arm during puncture of the targeted calyx. We prospectively recorded the time necessary for the puncture, the success, and the complication rate of the puncture. Among the 10 study patients, the mean operative time for the puncture was 50 seconds (range 35-180). The puncture was successful after 1 attempt in 7 patients and in the remaining patients after a second or a third attempt. There were no complications related to the puncture technique. This technique is easy and reproducible for creating a fluoroscopy-guided renal access adjunctive to ultrasound during sPCNL. It may also be useful for urologists not familiar with ultrasound-guided access.
To assess the effectiveness of robot-assisted pyeloplasty in patients with clinically symptomatic... more To assess the effectiveness of robot-assisted pyeloplasty in patients with clinically symptomatic ureteropelvic junction obstruction (UPJO). We retrospectively reviewed our database for all patients who were treated for UPJO by a single surgeon using a robot-assisted procedure between 2005 and 2007. We collected the following: Patient age, clinical presentation, perioperative data, complications, length of hospital stay, and outcome. Preoperative evaluation of UPJO always included an injected renal CT scan and furosemide-mercaptoacetyltriglycine (MAG-3) renal scintigraphy. Patients were seen at 3 and 6 months after surgery and once a year thereafter. Postoperative success was defined as symptomatic response and radiographic evidence of no further obstruction. Twenty patients with a mean age of 36.8 +/- 16 years (range 15-69 yr) were included. Six (30%) patients had previously undergone endoscopic treatment. The mean operative time was 150.3 +/- 36.22 minutes (range 150-240 min). The mean follow-up was 19.9 +/- 10.03 months (range 3-37 mos). Two (10%) procedures necessitated conversion to laparoscopic procedures, and there was no conversion to laparotomy. Four (20%) patients experienced minor complications: Two urinary tract infections and two urinomas. Repeated early surgery was needed in one patient for temporary (ie, 8 days) stent placement in the case of urinoma. There was no recurrence of the UPJO, and no repeated surgery was deemed necessary during the follow-up period. The success rate was estimated to be 95%. Functional outcomes after robot-assisted procedures for alleviation of UPJO are very promising. Our data showed that the robot-assisted procedure was safe and featured negligible morbidity. Therefore, we conclude that our approach is a viable alternative to open surgery.
Extracorporeal membrane oxygenation (ECMO) improves the outcome of refractory cardiogenic shock. ... more Extracorporeal membrane oxygenation (ECMO) improves the outcome of refractory cardiogenic shock. Few studies in adult populations have specifically addressed the complications of ECMO. Abdominal compartment syndrome (ACS) has been previously described in the pediatric literature, but it has never been directly attributed to ECMO alone. The authors describe two cases of ACS directly induced by venoarterial ECMO. In one case, decompressive laparotomy restored an adequate hemodynamic status. The authors hypothesize that ECMO contributed to ACS by inducing massive fluid overload and subsequent tense ascites. In conclusion, when ECMO dysfunction or hemodynamic impairment occurs, ACS should be considered and a decompressive laparotomy should be performed.
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Papers by Julie Rode