[Treatment of colovesical fistula: predictive factors of the maintenance of long-term digestion continuity]. / Traitement des fistules colovésicales: facteurs prédictifs du maintien de la continuité digestive à long terme.

AIM OF THE STUDY: Colovesical fistulas (CVF) may occur in inflammatory or tumoral pelvic diseases. The aim of this study was to analyze the surgical management of patients with a CVF in order to define predictive factors of good results and long term digestive continuity. PATIENTS AND METHODS: From 1989 to 1999, this retrospective study included 37 patients, 19 men and 18 women, mean age: 69 years (range 37-93 years). Main etiologies were colonic diverticulitis (n = 22) in 60% of the patients, cancer (n = 6) in 16%, previous radiotherapy (n = 5) in 14%. Treatment was a diverting colostomy in 13 cases, a colectomy in 24 cases without diverting colostomy in 10 cases. RESULTS: Overall postoperative mortality rate was 16%. With a mean follow-up of 47 months, digestive continuity was restored in 40% of the patients (100% in ASA 1 patients, 55% in ASA 2, 19% in ASA 3 and 0% in ASA 4). CONCLUSIONS: Our study suggests that long term digestive continuity following surgical treatment of colovesical fistulas does not depend upon etiology or surgical treatment but mainly upon the patient's ASA score.

A study of the anatomic features of the duct of the urachus.

The urachus is an embryonic remnant resulting from involution of the allantoic duct and the ventral cloaca. Attaching the bladder dome to the umbilicus, this duct becomes progressively obliterated during fetal life. It may subsequently persist as different variants after birth, some regarded as normal, others as pathologic, due to incomplete closure. Six pediatric cases are reported here, and the literature on the embryology and anatomic basis of the duct is discussed. The urachus is present in nearly 100% of children at birth, with several possible shapes: tubular, fusiform or funnel. It gradually regresses and is found in only a third of adults. Its length varies from 1 to 15 cm. In our series 6 patients showed defective closure of the duct, including 3 with complete patency, 1 cyst, 1 diverticulum and 1 external sinus. Although rare, congenital pathology of the urachus requires a sound knowledge of the anatomy and embryology to distinguish normal forms from those subject to complications. It should be suspected with any lesion in the umbilical region and the appropriate treatment instituted.

[Hand-assisted laparoscopic bi-nephrectomy for refractory arterial hypertension in kidney transplantation]. / Bi-néphrectomie laparoscopique assistée manuellement pour hypertension artérielle réfractaire chez le transplanté rénal.

OBJECTIVE: The authors report their preliminary experience of a manually assisted laparoscopic bilateral nephrectomy technique for refractory hypertension in renal transplant recipients. MATERIAL AND METHODS: Between April and May 1999, 2 laparoscopic bilateral nephrectomies were performed with manual assistance using the Hand-Port. One patient was operated 4 months before renal transplantation and the other was operated 13 months after renal transplantation. Both patients presented severe hypertension refractory to several antihypertensive drugs. An 8 cm midline supra-umbilical incision and 3 trocars were necessary. One hand was introduced into the abdominal cavity via the Hand-Port at the beginning of the operation. The intra-abdominal hand assisted all phases of dissection of the kidney and control of vessels. The renal vessels and ureter were clipped. The kidneys were removed by the intra-abdominal hand through the supra-umbilical incision. RESULTS: Operating times were 200 min and 130 min. Blood loss was 220 ml. No conversion was performed. The duration of major postoperative analgesics was 3 days. Length of hospital stay was 6 days and 7 days. There were no complications. Blood pressure was controlled by bilateral nephrectomy in both cases, with significant reduction of antihypertensive therapy. One year after the operation, both patients were satisfied with the aesthetic result. CONCLUSIONS: Laparoscopic bilateral nephrectomy manually assisted by the Hand-Port is an alternative to open bilateral nephrectomy. Larger series are necessary to evaluate the morbidity of this technique.

Robotic assisted, laparoscopic pelvic lymph node dissection in humans.

PURPOSE: We evaluate the feasibility and efficacy of robotic assisted, laparoscopic pelvic lymph node dissection for locally advanced prostate cancer staging. MATERIALS AND METHODS: Robotic assisted, laparoscopic pelvic lymph node dissection was performed in 10 consecutive patients with mainly T3 M0 prostatic carcinoma (robotic group). Operative, postoperative and pathological parameters were compared with the results of the last 10 patients undergoing conventional, laparoscopic pelvic lymph node dissection performed with similar indications by the same operator (laparoscopy group). RESULTS: All operations were performed according to the established protocol with no specific intraoperative or postoperative complications. No conversion was required, and no technical incidents were observed in the robotic group. Mean operating time plus or minus standard deviation for the robotic group was 125 +/- 57 minutes (range 75 to 215), significantly longer than that for the laparoscopy group, which was 60 +/- 15 minutes (p = 0.0013). In the robotic group 2 patients presented with postoperative lymphoceles revealed in 1 by deep venous thrombosis and in the second by obturator pain. In the laparoscopy group 1 patient presented with acute urinary retention. The histological results concerning the number of lymph nodes removed were similar in both groups (p = 0.5). CONCLUSIONS: We show the technical feasibility of robotic assisted, laparoscopic pelvic lymph node dissection in humans. Although the benefit of this technique has not yet been established, predictable technological improvements would suggest the development of telesurgery and an improved precision of surgical procedure.

[Biphasic sarcomatoid carcinoma of the prostate]. / Carcinome sarcomatoïde biphasique prostatique.

Sarcomatoid carcinoma of the prostate is a rare aggressive tumor, characterized by an intimate admixture of two malignant epithelial and sarcomatoid components. We report the case of a prostate tumour reputed to have a poor outcome, in a 59-year-old man. The radical prostatectomy specimen was completely involved. There were no signs of recurrence or metastasis after 15 months of follow up. The serum PSA values before and after chirurgical treatment were normal. The definition of this tumour as its histogenesis and prognosis is discussed.

[Role of complementary tests in the management of colo-vesical fistulae]. / La place des examens complémentaires dans la prise en charge des fistules colo-vésicales.

OBJECTIVE: Colo-vesical fistulas (CVF) are a complication of inflammatory or neoplastic diseases of the lesser pelvis. Although the clinical diagnosis is obvious in the presence of pneumaturia or faecaluria, a number of patients require complementary diagnostic and/or pretreatment investigations. The objective of this study was to analyse the management of these patients in order to define the place and cost-effectiveness of complementary investigations. MATERIAL AND METHODS: This retrospective study was based on 37 patients with a colo-vesical fistula, secondary to sigmoid diverticulitis in 60% of cases. RESULTS: Cystoscopy was the most cost-effective examination for the diagnosis of CVF with a sensitivity of 94%. The preoperative assessment of CVF and the underlying disease was optimally performed by a combination of cystoscopy, opaque enema and CT. CONCLUSIONS: Our study defined the place of the various examinations in the assessment of colo-vesical fistula, but the value of magnetic resonance imaging, not performed in this series, remains to be defined.

Epididymitis in children: is further investigation necessary after the first episode?

OBJECTIVE: The aim of this study was to evaluate the usefulness of investigating underlying urinary tract pathology after the first episode of acute epididymitis in children with no prior urological history, and also to assess the possible predictive factors of urological disease at the time of diagnosis. METHODS: Children with acute epididymitis were studied retrospectively over a period of 8 years. Diagnosis was made either using ultrasonography or surgical exploration. Renal ultrasonography and voiding cystourethrography were performed 1 month after epididymitis. RESULTS: These tests were carried out in 38 children who revealed 7 anomalies (18%). Only 1 patient received further surgery : endoscopic treatment of a ureterocele. We also studied 3 predictive factors: age <2 years; recurrence, and urine bacteria. None could be associated with the presence of urinary tract pathology. CONCLUSION: The authors suggest that, when there is no previous urological anomaly and absence of bacteriuria, routine screening for epididymitis should be carried out following the second episode.

Type 1-primary cutaneous meningioma of the scalp.

Type 1-primary cutaneous meningioma is a rare and often clinically unsuspected lesion of the scalp, forehead or paravertebral region which occurs at birth or during childhood. The pathogenesis of these lesions still remains uncertain. Several authors have emphasized that type 1-cutaneous meningiomas are not real tumors but sequestrated meningoceles or heterotopic meningeal nodules of the skin. Nevertheless, the search for an intracranial or intravertebral connection should be carried out. We describe the clinical and pathological features of a congenital type 1-meningioma of the vertex. No cranial defect or intracranial tumor was found. However, the cutaneous lesion was directly linked to a large cranial vein. The purpose of this study was to illustrate this rare lesion and to indicate the possible surgical risks and the pathological characteristics.

[Kidney harvesting in living donors with manually assisted laparoscopy: technique and results]. / Prélèvement de rein chez le donneur vivant par laparoscopie assistée manuellement: technique et résultats.

OBJECTIVE: To evaluate the feasibility and complications of manually assisted laparoscopic live donor kidney harvesting. MATERIAL AND METHOD: Since June 1999, all related live donor kidney harvests have been performed by manually assisted laparoscopy. The patient is placed in the lumbotomy position and an 8 cm midline periumbilical incision is made. The assistant's hand is introduced through a watertight port (HandPort). Three trocars are used. The assistant presents the structures to be dissected and controls the ureter. The artery is clipped and the vein is stapled or clipped, depending on its diameter. The kidney is extracted via the midline incision and washed. RESULTS: Five kidney harvests were performed (three right kidneys and two left kidneys) with a mean operating time of 220 +/- 30 minutes. Conversion was necessary in one case following the intraoperative discovery of two right renal veins. Warm ischaemia lasted 5 minutes for the first patient and one to two minutes for the other four non-converted patients. Blood losses were minimal. The mean duration of major analgesia was 2.4 days and the mean length of hospital stay was 7.2 days. Complications were: bacteriuria in 2 cases and prolonged lymphorrhoea in 1 case. One transplanted kidney had to be removed because of immediate thrombosis of the recipient iliac artery. With a mean follow-up of 6 months (1 to 12 months), no ureteric or venous complications have been observed in the 4 evaluable transplanted kidneys. CONCLUSION: An intra-abdominal hand during laparoscopic live donor kidney harvesting simplifies dissection, ensures intraoperative security and allows rapid extraction of the kidney.

[Malignant neuroendocrine tumor of the bladder: an entity not to be unrecognized]. / Tumeur neuro-endocrine maligne de vessie: une entité à ne pas méconnaître.

The authors report a case of primary malignant neuroendocrine bladder tumour. This rare bladder tumour presents the morphological and immunohistochemical characteristic common to all neuroendocrine tumours observed in other organs. The urologist must recognise this histological entity, which requires multidisciplinary management.

[Intraurethral Macroplastic injections in the treatment of urinary incontinence after prostatic surgery]. / Les injections intra-urétrales de Macroplastique dans le traitement de l'incontinence urinaire après chirurgie prostatique.

OBJECTIVES: To evaluate the results and the place of a minimally invasive intraurethral injection technique designed to improve the efficacy of the urethral sphincter in urinary incontinence after prostatic surgery. MATERIALS AND METHODS: A prospective study of 26 Macroplastique injections performed in 15 patients with a mean age of 66.4 years (range: 54 to 78 years) was conducted over an 18-month period. Eleven patients received 2 injections. Prostatic surgery consisted of retropubic radical prostatectomy (9 cases), transurethral resection (4 cases) or open prostatectomy (2 cases). Three patients received pelvic irradiation. Evaluation at 1, 3 and 12 months consisted of clinical questionnaire and urodynamic assessment. RESULTS: Rapid deterioration of the initial improvement was observed (40% success at 1 month; 71% at 3 months; 33% at 6 months; 26% at 12 months). No significant influence was demonstrated for post-prostatectomy radiotherapy, the patient's age, more proximal bladder dysfunction, severity of incontinence or preoperative status. However, better results were observed when the resting urethral closure pressure remained higher than 30 cm H2O. CONCLUSION: We believe that intraurethral injections still have a place in the therapeutic armamentarium for incontinence after prostatic surgery with satisfactory initial results, which unfortunately deteriorate after 3 months. Our study confirms the value of Macroplastique compared to other substances. It is difficult to define the predictive factors of failure, but a closure pressure greater than 30 cm H2O remains essential. Finally, an interval of at least 3 months should be observed before repeating this procedure in the case of an insufficient result.

[Recurrent febrile infections of the urinary tract and diverticulum of the urachus]. / Infections multirécidivantes fébriles du tractus urinaire et diverticule de l'ouraque.

The urachus can present a partial or complete obliteration defect. If the defect is situated in its vesical extremity, it then forms a diverticulum. The authors report a case of diverticulum of the urachus in a young adult, responsible for recurrent febrile urinary tract infections since the beginning of adolescence. The diagnosis was suggested by ultrasonography and magnetic resonance imaging and confirmed by cystoscopy and histological examination. Treatment consisted of complete surgical resection via a suprapubic incision.