[Upper urinary tract: physiology, pathophysiology of obstructions and function assessment]. / Voie excrétrice supérieure: physiologie, physiopathologie des obstructions et explorations fonctionnelles.

The urine is transported from the renal papilla to the bladder through the upper urinary tract which allows this transport to be safe and comfortable, i.e., without any risk or pain for the kidney. This active transport depends on the smooth muscle contractile properties. The upper urinary tract is totally autonomous; this feature allows the preservation of its function after renal transplantation. However, despite its accessory role, the autonomous nervous system can modulate its activity. Upper urinary tract obstruction involves adaptative mechanisms which are different depending on the type (acute, chronic, acquired or congenital) of obstruction. Functional evaluations of the upper urinary tract are aimed at identify the urine transport conditions and the relationship between obstruction and clinical conditions such as hydronephrosis, pain or impaired renal function.

Clinical and urodynamic repercussions after TVT procedure and how to diminish patient complaints.

OBJECTIVES: Analysis of changes in voiding patterns after sub-urethral TVT procedure: urodynamic variations and clinical repercussions. METHODS: 112 women included in an ethics committee protocol (CCPPRB ) with a mean follow-up of 22 months underwent complete urodynamic testing before and after TVT procedure and filled in pre- and post-operative questionnaires. RESULTS: Analysis of the questionnaires showed that two clinical symptoms were predominant post-operatively: dysuria and micturitional urge. The urodynamic profiles showed that TVT banding led to infravesical obstruction but not to significant detrusor overactivity. CONCLUSION: Our results show that clinical changes induced by the TVT procedure were due to infravesical obstruction, and that there was no progression of detrusor overactivity. We suggest two ways to avoid, or diminish, this post-operative obstruction, or to detect patients at risk from obstruction: training for women who use their abdominal muscles for voiding rather than their detrusor, or pre-operative screening of hypotonic bladders.

Long-term use of tamsulosin to treat lower urinary tract symptoms/benign prostatic hyperplasia.

PURPOSE: The long-term efficacy and safety of 0.4 mg. tamsulosin once daily were assessed in patients with lower urinary tract symptoms/benign prostatic hyperplasia treated for up to 4 years. MATERIALS AND METHODS: A total of 516 patients were enrolled from 2 European open label studies that were extensions of 3 double-blind controlled studies. RESULTS: Significant improvement in maximum urine flow and total Boyarsky symptom score during the controlled trials was sustained throughout the extension study for up to 4 years in patients who remained on therapy. The increase in mean maximum urine flow from baseline was 1.2 to 2.2 ml. per second (p <0.001) and it remained 11.5 to 12 ml. per second during followup. Total Boyarsky symptom score was decreased from baseline by 4.1 to 4.7 points (p <0.001). The incidence of treatment responders, defined as a 25% or greater decrease in total symptom score, remained stable throughout the 4-year period. Increasing the dose of tamsulosin from 0.4 to 0.8 mg. seemed to have no substantial additional benefit. During the 4 years of treatment 26% of patients had side effects that were considered possibly or probably drug related. However, only 5% of patients discontinued treatment because of drug related side effects. No clinically significant changes in blood pressure or pulse rate occurred during the study. CONCLUSIONS: Long-term treatment with tamsulosin is safe and well tolerated in patients with lower urinary tract symptoms/benign prostatic hyperplasia. Improved efficacy was sustained during 4 years of followup.

[Lumbar pain and hydrocalyx]. / Douleurs lombaires et hydrocalice.

The authors report the case of a patient presenting with disabling left lumbar pain. Complementary investigations confirmed the diagnosis of isolated hydrocalyx with no organic cause. Surgical treatment was conservative with caliceal plasty. The authors discuss the diagnostic and therapeutic management by analogy between this type of hydrocalyx and Fraley's syndrome.

[Accuracy of pressure measurements obtained with a new rectal balloon catheter]. / Exactitude des mesures de pression obtenues par une nouvelle sonde rectale à ballonnet à air.

UNLABELLED: The accuracy of measurements performed by a balloon catheter used to record abdominal pressure during urodynamic investigations was verified on a test bench. OBJECTIVE: To study the accuracy and precision of the pressure measurements obtained with a new rectal balloon catheter (ref. 95018 Laboratoires Vermed), designed to record abdominal pressure during urodynamic assessments. The clinical value of this catheter, using air for pressure transmission, is its simplicity, as there is no contamination of the perfusion circuit or transducer, no purging of the circuit, and artefacts related to movements of the tubing are eliminated. METHOD: The catheter was placed in a pressure chamber fitted with a precise, calibrated regulation system allowing programmed pressure variations from 10 to 150 cmH2O. Pressures recorded by the test catheter were compared to reference pressures applied to the chamber. The frequency of acquisition of pressure measurements was 100 Hertz and the resolution was 10 Hertz. This model was used to study the accuracy of pressure measurements and the response times of the catheter. Measurements were performed with a volume of 2 ml of air introduced into the catheter (volume recommended by the manufacturer), and the optimal volume was investigated by inflating the catheter until the best result was obtained. The evaluation was based on calculation of the mean difference observed between the two measurements and the scatter of the differences observed. RESULTS: When the catheter was filled with 2 ml of air, pressures measured by the catheter were overestimated an average of 1.1 cmH2O (standard deviation = 1), and 95% of the differences between the two measurements were within +/- 2.15 cmH2O. The optimal air volume was found to be 1.5 ml. With this air volume, no significant difference was observed between the two measurements. The mean observed difference was 0.2 cmH2O (SD = 1.2), which means that 95% of the differences were situated within the range of +/- 2.35 cmH2O. CONCLUSION: The pressure recording method with this new catheter is validated in terms of physical parameters.

[Substitutive non-modeled uretero-ileoplasty]. / Urétéro-iléoplastie non modelée de substitution.

OBJECTIVES: To evaluate the indications and results of replacement uretero-ileoplasties performed over the last six years. MATERIAL AND METHODS: Over a period of 6 years, 8 patients underwent subtotal or total replacement uretero-ileoplasty involving a total of 9 renal units. Preoperative temporary urinary diversion was performed in each patient. The mean preoperative serum creatinine was 88 mumol/l (range: 53 to 150). Uretero-ileoplasty was performed for ureteric stricture in 7 cases (bilateral in one case and in a solitary kidney in one case), ureteric necrosis following renal transplantation without a donor ureter in one case and urothelial tumour on a solitary kidney in one case. RESULTS: The mean follow-up was 54 months. The mean operating time was 218 minutes for uretero-unilateral ileoplasties, with a mean length of hospital stay of 12 days (range: 10 to 18 days). The following complications were observed: acute urinary retention, stenosis of the ileo-vesical implantation treated by endoscopic dilatation, 2 incisional hernias after midline laparotomy, one case of stones of the ileo-vesical anastomosis, non-febrile urinary tract infections treated on an outpatient basis. The functional result was considered to be satisfactory in every case. No electrolyte disorders were observed. Mean postoperative serum creatinine was 86 mumol/l (range: 59 to 140). CONCLUSION: In this recent series with a mean follow-up of 4.5 years, replacement uretero-ileoplasty successfully treated partial or total complex ureteric lesions with a low morbidity.

Intermittent androgen suppression in the treatment of metastatic prostate cancer.

BACKGROUND: To assess the feasibility of intermittent androgen suppression in patients with metastatic prostate cancer and to quantify the improvement in the quality of life. METHODS: Forty-three patients with M1 b prostate cancer were treated by intermittent hormonal deprivation using luteinizing hormone-releasing hormone (LHRH) analogue alone (n = 11), or associated with an antiandrogen (n = 32). The prospective nonrandomized study required an initial therapy period of 12 months with a stable biological response during 6 months (PSA, testosterone). Treatment was resumed when the serum PSA value recovered to 20 ng/ml, or when local failure or new bone metastasis occurred. The assessment of quality of life was carried out using the EORTC QLQ-C30. RESULTS: The mean follow-up time was 43.7 months. After the initial 12 months of androgen suppression, one patient with a minimal disease was off-therapy with a follow-up of 18 months. For the 42 other patients, the mean off-therapy period was 6.7 months. In the second therapy period (9-12 months), 7 patients were hormono-independent and died with a mean survival time of 27 months; 35 patients were responders. The mean off-therapy length in the second cycle was short (3.8 months). After this time, androgen suppression therapy was reintroduced permanently, but 10 patients were hormono-independent. No difference was observed in the EORTC QLQ-C30 between therapy and off-therapy periods, only a rapid decrease in adverse events due to the hormonal deprivation was reported in all cases during the off-therapy period. CONCLUSIONS: Intermittent androgen suppression in patients with M1 b prostate cancer could be associated with a significant period off-therapy in the first cycle (55.8%), and with a chance of second hormone response. But in the second cycle, the off-therapy period length was short and required a careful follow-up.

[Surgery of varicocele: results concerning sperm motility and morphology]. / Chirurgie de la varicocèle: résultats sur la mobilité et la morphologie des spermatozoïdes.

STUDY OBJECTIVE: This study evaluated the changes induced by surgical treatment of varicocele on the classical parameter of the sperm count as well as the parameters of Kruger's classification. MATERIAL AND METHODS: Comparative analysis of sperm concentration, mobility and head morphology was performed on the sperm counts obtained before and 6 months after surgery in 159 infertile patients with clinical left varicocele, suspected of being the only aetiological factor for infertility. RESULTS: Sperm mobility and the percentage of spermatozoa with normal head morphology were significantly increased after treatment. The percentage of spermatozoa with normal morphology was only slightly improved, due to the absence of improvement of flagellar and intermediate segment abnormalities. Fifty-nine term pregnancies were obtained after treatment, corresponding to 41.1% of treated patients. CONCLUSION: Treatment of varicocele in infertile patients can improve sperm count and morphology parameters, particularly abnormalities of the head according to Kruger's strict criteria. The number of pregnancies observed argues in favour of the treatment of varicocele, when it constitutes the only aetiological factor for infertility.

[Skin graft urethroplasty]. / Urétroplastie par greffe cutanée.

OBJECTIVES: To evaluate the results of skin graft urethroplasty (SGU) in the management of urethral stricture. MATERIAL AND METHODS: Twenty eight patients, with a mean age of 54 years, treated by SGU were reviewed with a mean follow-up of 24.5 months (range: 1-66). The first-line material skin graft material was the foreskin or, in its absence, the penile skin or skin of the arm was used. RESULTS: This study demonstrated a satisfactory result (no clinical signs, maximum flow rate > or = 15 ml/s, no need for salvage surgery) in 67.9% of cases. Although the early complication rate was low, 8 stenoses were observed during subsequent follow-up; 3 of which required open surgical revision. The other relapses were treated by internal urethrotomy or hetero- or autodilatations. This study showed that urine sterility at the time of surgery was a decisive factor. CONCLUSION: The preferential indication for this type of urethroplasty remains a bulbar urethral stricture with sterile urine. However, the aetiology and length of the stricture are not discriminant factors.

[IgA deficiency and multiple Staphylococcus aureus perirenal abscesses. A case report]. / Déficit en IgA et abcès péri-rénaux multiples à Staphylococcus aureus. A propos d'une observation.

The authors report the case of a patient with IgA deficiency who presented with a low-grade renal abscess. Due to the atypical nature of the clinical features and imaging, the diagnosis was not established prior to surgery. Despite radical surgery, the abscess recurred several weeks later. In the light of this case, the authors discuss the various possible diagnoses that must be considered in the presence of these types of images and the therapeutic approach during initial management. They discuss the various immune deficiencies to be investigated in a particular infectious context.

The urodynamic effects of intravenous opioids and ketoprofen in humans.

UNLABELLED: We used a double-blind design to study urodynamic changes induced by mu-agonists (fentanyl, morphine), a partial mu-agonist antagonist (buprenorphine), a putative mu-antagonist, kappa-agonist (nalbuphine), and ketoprofen, an injectable nonsteroidal antiinflammatory drug. Men (20-55 yr old) were randomly assigned to receive one of the following i.v. before anesthesia for endoscopic extraction of a ureteral stone: 10 mg of morphine, 0.3 mg of buprenorphine, 0.35 mg of fentanyl, 20 mg of nalbuphine, 100 mg of ketoprofen, or 10 mL of 0.9% sodium chloride. The urodynamic study consisted of cystometry followed by urethral pressure profile. Measurements were taken before the i.v. infusion of drugs and 15 min thereafter. Statistical comparisons were performed by using analysis of variance with repeated measurements (P < 0.05). Ketoprofen and saline did not induce any urodynamic changes. Opioids altered bladder sensations, and the residual volume after voiding increased, except after morphine. Detrusor contraction decreased only after the administration of fentanyl and buprenorphine. Some patients could not micturate after receiving morphine, fentanyl, and buprenorphine. Compliance and urethral pressures did not change with any drug. This study suggests that ketoprofen and nalbuphine are useful analgesics in terms of their urodynamics. IMPLICATIONS: We compared the urodynamic effects of opioids and ketoprofen used as analgesics in surgical patients. In contrast to ketoprofen, opioids altered urodynamics. The opioid nalbuphine had no effect on detrusor contraction. This study suggests that ketoprofen and nalbuphine are useful analgesics in terms of their urodynamics.

[Testicular tumor in renal and pancreatic transplantation]. / Tumeur du testicule en transplantation rénale et pancréatique.

The authors report the case of a 49-year-old, insulin-dependent diabetic man treated by double kidney-pancreas transplantation. A T3, N3, M0 testicular tumour was discovered at the 8th month and treated by inguinal orchidectomy and 2 courses of chemotherapy. Immunosuppressant treatment was decreased without any consequences for the transplants. Seven years later, the patient was cured but still treated by haemodialysis for chronic rejection of the renal transplant. The pancreatic transplant was still functional and the patient is waiting for a second renal transplantation.

Outcome of patients with an implanted artificial anal sphincter for severe faecal incontinence. A single institution report.

Implantation of an artificial sphincter is an alternative treatment for patients with severe faecal incontinence. This prospective study from one institution has evaluated the results from 13. Preoperative and postoperative incontinence scores, anal manometry, and quality of life were evaluated in 13 patients who had undergone implantation of an artificial sphincter over a 7-year period. Two patients were definitive failures. One developed acute total colitis after 5 years of satisfactory function, and a second had discomfort and demanded removal of an otherwise functioning device. After a median follow-up of 30 (range 5-76) months, 11 patients had an activated and functional device. These included 6 with a urinary AMS 800 and 5 with the newly designed anal ABS. The mean incontinence score decreased from 17 to 4, and quality of life improved markedly. Two of the 11 patients had undergone successful reimplantation, one following rupture of the cuff and the second following ulceration of the control pump through the labia. In no case was infection or erosion of the anal canal a cause of failure. While the cause of incontinence and age did not affect outcome, psychological reaction had a significant impact. The artificial anal sphincter may have a role to play in severe faecal incontinence.

[Female urinary incontinence. Which assessments? Which treatment?]. / Incontinence urinaire de la femme. Quel bilan? Quel traitement?

Urinary incontinence, corresponding to the definition of involuntary urine leaks, due to alteration of the physiological mechanisms of continence, experienced as discomfort in everyday life affects approximately 10% of the female population. The main predisposing factors are age, child-birth (particularly the first), recurrent urinary tract infections, and obesity. Pathophysiologically, urine leak occurs when the forces of expulsion resulting from abdominal straining or detrusor contraction, exceed the physiological (urethral sphincter device) and pathological (obstruction) continence forces. These two mechanisms correspond to two types of incontinence, stress and urge incontinence, which are primarily diagnosed on the basis of the clinical interview, which must also strive to evaluate the volume of urine leaks, the circumstances inducing incontinence, and associated urinary symptoms such as dysuria and frequency. Clinical examination, in women in the gynaecological position, demonstrates incontinence on coughing and control of incontinence by supporting the bladder neck (Bonney's manoeuvre); it also evaluates vulval trophicity and the quality of perineal musculature; it analyses the components of possible vaginal prolapse. The objective of complementary investigations is not to confirm the data of the clinical interview and clinical examination, but to complete them by providing additional elements. Radiological examinations have largely been replaced by urodynamic examinations, able to detect detrusor instability and evaluate the quality of sphincter tone, which largely determines the success of surgery. Surgery remains the reference treatment for stress incontinence with a success rate of almost 90%; the main mechanism consists of supporting the bladder neck, allowing it to close during efforts increasing the abdominal pressure. Perineo-sphincter rehabilitation must be tried first, although its results are less lasting. Currently, the only effective medical treatment is anticholinergic drugs in urge incontinence.

Comparative analysis of MiB1 and p53 expression in human bladder tumors and their correlation with cancer progression.

Expression of p53 and MiB1, markers of tumor proliferation, was evaluated in human bladder tumors, and correlated with ploidy and cancer progression in 83 consecutive patients. Transurethral resection of a newly diagnosed bladder tumor was performed in 73 cases, and systematic bladder biopsies were performed in 10 cases after bacillus Calmette-Guerin (BCG) treatment. p53 and MiB1 expression were performed by an immunohistochemical technique and the ploidy was determined on a frozen fragment of the tumor. p53 expression was correlated in relation to grade, stage and combination of grade and stage. MiB1 expression was correlated with cytological grade, and a significant difference was demonstrated between pT0 and pTa, pTa, and pT1, pTa and pT2 tumors but not between pT1 and > or = pT2 tumors. A discordance was observed for the comparison of p53 and MiB1 values, stage by stage, suggesting that these two techniques are independent of each other. A larger proportion of aneuploid tumors were positive for p53 and MiB1 (64.8 vs. 86.5%, respectively), but p53 and MiB1 immunostaining were not better indicators than ploidy alone to predict cancer progression.

[Injuries of the renal pedicle: is renal revascularization justified?]. / Traumatismes du pédicule rénal: la revascularisation rénale est-elle justifiée?

OBJECTIVE: Renal trauma with pedicle lesions may require emergency vascular repair, a surveillance in a surgical unit or immediate or secondary nephrectomy. The objective of this study was to evaluate these various treatment modalities. MATERIAL AND METHODS: 28 patients presenting with renal pedicle trauma, treated in two urological centres between 1985 and 1995 were reviewed. All cases of trauma were investigated by intravenous urography, CT and/or arteriography. 16 patients had associated intra-abdominal lesions. RESULTS: 7 patients underwent vascular repair after a mean interval of 4.8 hours. There were 5 nephrectomies and 2 functional kidneys, including 1 with hypertension. 13 patients underwent first-line nephrectomy: 4 performed as an emergency for haemodynamic instability, and 9 performed as a deferred emergency for silent kidney or secondary haemodynamic disorders. The mean time to diagnosis was 20 hours. No complication was observed in this group. Non-surgical management was decided in 8 patients. The mean time to diagnosis was 7.5 hours. One death was observed in this group, due to associated cerebral lesions. 3 patients subsequently underwent late nephrectomy for severe hypertension and 4 had a persistent silent kidney without sequelae. Overall: 21 nephrectomies, 2 functional kidneys (1 patient was hypertensive), 4 silent kidneys without hypertension and one death were observed. CONCLUSION: In cases of renal pedicle trauma seen after the 4th hour, the severity of ischaemic lesions and renal sequelae and the small number of kidneys saved despite revascularization surgery argue in favour of immediately elective nephrectomy.

[Inguinal lymphadenectomy in cancer of the penis: surgical techniques and indications]. / Lymphadénectomie inguinale dans le cancer du pénis: techniques chirurgicales et indications.

Lymph node invasion is one of the major prognostic factors of cancer of the penis. However, as it is difficult to evaluate clinically and by means of complementary investigations, inguinal or even ilioinguinal lymph node dissection is still indicated. As this surgery carries a certain morbidity (necrosis of skin edges, infection, lymphorrhoea and subsequent lymphoedema), the indications are presented according to the presence or absence of palpable inguinal lymph nodes and the stage of the primary tumour. Various surgical techniques are proposed: Superficial and deep inguinal lymph node dissection in the case of mobile and palpable inguinal nodes, simplified and superficial inguinal lymph node dissection in the absence of palpable inguinal nodes and in the case of invasive primary tumour.

Comparison of tamsulosin with alfuzosin in the treatment of patients with lower urinary tract symptoms suggestive of bladder outlet obstruction (symptomatic benign prostatic hyperplasia). The European Tamsulosin Study Group.

OBJECTIVE: To compare the efficacy and tolerability of the alpha 1 A-subtype selective drug tamsulosin with the nonsubtype-selective agent alfuzosin in the treatment of patients with lower urinary tract symptoms (LUTS) suggestive of bladder outlet obstruction (BOO), often termed symptomatic benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: The study comprised 256 patients with benign prostatic enlargement and LUTS suggestive of BOO (symptomatic BPH) who received tamsulosin 0.4 mg once daily or alfuzosin 2.5 mg three times daily during 12 weeks of treatment. The response was assessed by measurements of maximum urinary flow rate (Qmax), a symptom score (Boyarsky) and blood pressure at regular intervals. RESULTS: Tamsulosin and alfuzosin produced comparable improvements in Qmax and total Boyarsky symptom score. Both treatments were well tolerated with respect to adverse events. Tamsulosin had no statistically significant effect on blood pressure compared with baseline but alfuzosin induced a significant reduction in both standing and supine blood pressure, compared with baseline (P < 0.05). CONCLUSION: Tamsulosin is the first adrenoceptor antagonist that is selective for the alpha 1 A-subtype; this specificity may explain its lack of effect on blood pressure compared with alfuzosin, an agent that is not receptor subtype specific. Moreover, this finding may partly explain why tamsulosin, in contrast to other currently available alpha 1-adrenoceptor antagonists, can be administered without dose titration. Another advantage compared with alfuzosin (and prazosin) is the once-daily dosing regimen of tamsulosin.