Management of high-grade papillary Ta or T1 bladder cancer after restaging transurethral resection: A retrospective study comparing Bacillus Calmette-Guerin therapy upfront versus a third resection.

PURPOSE: Performing restaging transurethral bladder resection (reTURB) for high-risk non-muscle invasive bladder cancer (NMIBC) reduces the risk of recurrence and tumour understaging. Management of residual high-grade papillary Ta or T1 after reTURB has changed this last 10years in international recommendations. This study aimed to compare the recurrence free survival according to the different management procedures performed. MATERIALS AND METHODS: Patients who underwent reTURB for initial high-risk NMIBC between 2011 and 2020 were included. Patients with residual high-grade papillary Ta or T1 tumour after reTURB were divided into two groups: BCG instillations upfront versus BCG following a third-look resection (3TURB). Patient and tumour characteristics, BCG instillations, recurrence-free survival were retrospectively analysed. RESULTS: A total of 162 high-risk patients were included. Sixty-one (37.7%) had residual high-grade papillary Ta or T1 at reTURB: 35 (21.6%) had BCG instillations upfront, 18 (11.2%) had a 3TURB and 8 (5%) had other management. The mean follow-up was 34.2weeks±20.2. Recurrence-free survival was significantly better in patients who underwent BCG instillations upfront (P<0.0043). Recurrence after BCG therapy following reTURB was significantly lower in patients with no residual NMIBC at 6 (92.5% vs. 72.4%, P<0.004) and 12months (85% vs. 67.3%, P<0.03). CONCLUSIONS: The efficacy of intravesical BCG is compromised in case of residual tumour following TURB. The role of a 3TURB following a positive reTURB is not yet determined. This study has confirmed that residual tumor following reTURB is a negative predictive factor but could not demonstrate the value of a 3TURB compared to upfront BCG.

[Vesicovaginal fistula]. / Fistules vésicovaginales.

Urinary fistula to the vagina has been described since the beginning of the written record. In developed nations, these fistulas are usually unfortunate complications of gynecologic or other pelvic surgery and radiotherapy. Historically, birth trauma accounted for most vesicovaginal fistulas, and it remains the major cause of urinary fistulas in many underdeveloped nations. Once a vesicovaginal fistula is suspected, a thorough vaginal examination should be performed to identify its size and location, especially in relation to the trigone and eliminate a ureterovaginal fistula which can be associated in up to 10% of cases. Numerous methods for the treatment of vesicovaginal fistulae have been described. Abdominal, and vaginal approaches are used for the repair of vesicovaginal fistulae. The approach selected is dependent on many factors, but is probably best determined by the experience and training of the surgeon. The techniques of the vaginal approach involve tension-free closure of the fistula with or without excision of the tract, creation of an anterior vaginal wall flap and appropriate use of vascularized interposition grafts. The abdominal approach may be used to treat all types of vesicovaginal fistulae and is the preferred approach when concomittant ureteral reimplantation is required. Postoperative care is similar for both vaginal and abdominal vesicovaginal fistula repair. Adequate uninterrupted bladder drainage is the most critical aspect of postoperative management. A voiding cystourethrogram is performed at 10 postoperative days to confirm closure of the fistula.

Incidence and risk factors of bacteriuria after transurethral resection of the prostate.

INTRODUCTION: Postoperative bacteriuria is a frequent event after transurethral resection of the prostate, despite the use of prophylactic antibiotics. Certain risk factors have been clearly established (preoperative urinary catheter or bacteriuria, operating time), while others remain uncertain. MATERIALS AND METHODS: We conducted a prospective study in five urology centers, including non-catheterized patients with sterile preoperative urine undergoing transurethral resection of the prostate for benign prostatic hyperplasia. All received antibiotic prophylaxis with cefamandole. The incidence of bacteriuria and its risk factors were investigated. RESULTS: The postoperative bacteriuria rate was 26% (26/101), with 8% on removal of the catheter, 14% between the 7th and 10th postoperative days and 5% 1 month postoperatively. Factors associated with bacteriuria on univariate analysis were: operating time, disconnection of the closed urine drainage system and postoperative catheterization > or =3 days. Two variables were associated on multivariate analysis (logistic regression): operating time >52 min (odds ratio 9.0, 95% confidence interval 2.1-39.0) and disconnection of the closed urine drainage system (odds ratio 26.3, 95% confidence interval 6.1; 6.1-113). CONCLUSIONS: The postoperative bacteriuria rate after transurethral resection of the prostate was high in this study, raising the question of the choice and/or duration of prophylactic antibiotics. Prevention of postoperative bacteriuria must be based on careful hemostasis, prevention of postoperative catheter disconnections, and limitation of the duration of postoperative catheterization.

[Study of the Ki-67 antibody immunolabeling of renal adenocarcinomas with or without renal vein thrombosis]. / Etude de l'immuno-marquage des adénocarcinomes rénaux, avec et sans thrombose de la veine rénale, par l'anticorps Ki67.

OBJECTIVES: The objective of this study was to compare the proliferation index (immunolabelling by monoclonal antibody Ki67 - MIB-1) of renal cell carcinomas as a function of the presence or absence of renal vein thrombus. Analysis of the numbers of Ki67-positive nuclei can be used to assess the degree of aggressiveness of the cell populations of these various carcinomas (tumour without thrombus, tumour with thrombus and neoplastic thrombus). METHODS: Twenty three renal cell carcinomas with renal vein thrombus were matched for Furhman grade (1st degree), tumour volume (2nd degree) and the patient's age (3rd degree) with 23 renal cell carcinomas not presenting any vascular embolus on histology. Monoclonal antibody MIB-1 immunolabelling was performed on 69 paraffin-embedded specimens: 23 tumours with thrombosis, the 23 corresponding neoplastic thrombi and 23 tumours without vascular embolus. RESULTS: A correlation between Furhman grade and the percentage of immunolabelled nuclei was observed (mean: 2.67% for low-grade tumours and 14.34% for high-grade tumours). No labelling difference was observed between the two populations of primary tumours (with thrombus/without embolus). Primary tumours presented significantly weaker Ki67 labelling than their corresponding neoplastic thrombus (mean of 2.47% versus 10.3%, p < 0.01). CONCLUSION: This study shows that there is no difference of the proliferation index between tumours with neoplastic venous thrombus and those with no histological vascular embolus. However, a difference of proliferation index was observed between the primary tumour and its corresponding thrombus, which presented a statistically higher immunolabelling. This finding suggests that the thrombus possesses more dividing cells than the primary tumour, i.e. has a shorter doubling time.

[Erectile dysfunction after radical prostatectomy: value of preoperative programming of intracavernous injections]. / Dysfonction érectile après prostatectomie radicale: intérêt de la programmation des injections intracaverneuses avant l'intervention.

OBJECTIVES: Vasoactive drugs used for self-administered intracavernous injections are currently the reference treatments for erectile dysfunction after radical prostatectomy. The acceptability of and compliance with this treatment often limit their use. This study analysed these two parameters as a function of the type of andrological management decided before radical prostatectomy. MATERIAL AND METHOD: From January 1996 to January 1997, 45 sexually active patients, aged 52 to 69 years, requiring radical prostatectomy without preservation of the nervi erigentes, for localized prostate cancer, were included in this prospective study. Before the operation all 45 patients were informed about the high risk of erectile dysfunction following radical prostatectomy. Fifteen patients (group 1) did not receive any particular advice concerning the management of erectile dysfunction after radical prostatectomy, but were possibly referred for an andrology consultation depending on their complaints. Fifteen patients (group 2) were systematically referred for an andrology consultation three months after radical prostatectomy for information about the available treatment options. For 15 patients (group 3), the andrology consultation (3 months after the operation) had been planned before radical prostatectomy to perform a test injection of prostaglandin E1. The injections, started before the operation in this group 3, therefore constituted an integral part of the global management of prostate cancer. All these patients were followed for at least 1 year in the urology department. RESULTS: Only 7 of the 15 patients of group 1 consulted an andrologist. Five of these patients received a test intracavernous injection versus 14 in group 2 and 15 in group 3. The 5 patients of group 1 who received an intracavernous injection accepted this modality as treatment versus 8 in group 2 and 12 in group 3. After one year, 4, 5 and 9 patients in groups 1, 2 and 3, respectively, continued intracavernous injections. CONCLUSION: The management of erectile dysfunction after radical prostatectomy must start with the decision to operate. Systematic encouragement to use intracavernous injections after radical prostatectomy helps to improve access to this treatment for impotence. The acceptability, and especially the compliance, appear to be better in patients in whom intracavernous injections were integrated into the global management of their prostate cancer.