[Efficacy of periurethral injections of polyacrylamide hydrogel (Bulkamid(®)) and quality of life of patients with urinary incontinence due to sphincter deficiency (IUE-IS)]. / Efficacité des injections péri-urétrales de polyacrylamide hydrogel (Bulkamid(®)) et qualité de vie de patientes souffrant d'incontinence urinaire d'effort par insuffisance sphinctérienne (IUE-IS).

INTRODUCTION: This study was carried out to evaluate the efficacy of periurethral injection of polyacrylamide hydrogel (PAHG, Bulkamid(®), Ethicon) for the treatment of female stress urinary incontinence (SUI). METHODS: Single-center prospective study: periurethral injection of Bulkamid(®) was performed in 80 patients with severe urinary incontinence between June 2010 and October 2011. The evaluation of the impact on quality of life was carried out using the Patient Global Impression of Severity (PGI-S), the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) and Patient Global Impression of Improvement (PGI-I) before and after treatment. RESULTS: With a mean follow-up of 18.6 ± 5.3 months, 60% of patients had improved. For 30/74 (40%) there was no improvement and no patient had worsening of PGI-I after injection. Before surgery, 55.4% of patients considered their condition as severe (PGI-S). After injecting 21/74 (28%) and 11/74 (15%) considered it normal and severe (zero leakage). The ICIQ -SF score increased from 17 ± 2.84 before injection to 13 ± 5.52 after surgery, with a significant 30% decrease (P<0.00001). The reinjection rate was 29%. The complication rate was 16% (17/108): 11 cases of transient postoperative retention, 2 cases of cystitis, dysuria four episodes. No abscess or infection at the injection site, no specific complication to the product used. CONCLUSION: With an (PGI-I) improvement rate of 60 and 15% of patients without leakage (PGI-S/ICIQ), periurethral injection of Bulkamid(®) is an effective and safe treatment option for women with a severe urinary incontinence especially in therapeutic failure. LEVEL OF PROOF: 4.

Impact of preoperative immunonutrition on morbidity following cystectomy for bladder cancer: a case-control pilot study.

PURPOSE: To compare postoperative complications in patients with or without preoperative immunonutrition before cystectomy. METHODS: A prospective, multicenter, pilot, case-control study was conducted during 6 months. Patients with 7-day preoperative immunonutrition were prospectively included and compared with a retrospective, matched control group without immunonutrition. Early complication rates and the length of hospital stay were analyzed. The bilateral type I error was <0.05; the power was 90%. Thirty patients in each group were required. RESULTS: Thirty patients were included in each group, on a comparable basis. In the immunonutrition group, fewer postoperative complications (40 vs. 76.7%; p = 0.008), less paralytic ileus at D7 (6.6 vs. 33.3%; p = 0.02), fewer infections (23.3 vs. 60%; p = 0.008), and in particular less pyelonephritis (16.7 vs. 46.7%; p = 0.03) occurred. Clavien's grades for complications were higher in the control group (p = 0.04). Mortality, pulmonary embolism, anastomotic fistulae, and wound dehiscence were similar between two groups. The length of stay was reduced by 3 days in the immunonutrition group. CONCLUSIONS: In this pilot case-control study, immunonutrition is associated with a decrease in postoperative complications, urinary tract infections, Clavien's grade for complications, and paralytic ileus in patients undergoing cystectomy for bladder cancer. Prospective randomized placebo control studies are needed to confirm these promising results.

[Functional MRI by general radiologists in prediction of side-specific extracapsular extension after radical prostatectomy: what value in daily practice?]. / IRM fonctionnelle par des radiologues généralistes, dans la prédiction de l'extension extracapsulaire lobe spécifique après prostatectomie radicale : quelle valeur en pratique quotidienne ?

OBJECTIVE: To evaluate the performance of functional MRI (FMRI) performed by general radiologists (GR) in detection of side-specific extracapsular extension (SSECE) prostate cancer (PCa). METHODS: We retrospectively analyzed 79 patients who underwent FMRI with pelvic phased array coil before radical prostatectomy (RP) performed at University Hospital (UH) of Nîmes. Twelve GR (including three from UH) interpreted the images during their daily practice. FMRI results were dichotomized as positive or negative and confronted to pathological reports for SSECE and side-specific seminal vesicle invasion (SSSVI), with calculation of diagnostic values. The influence of interval between biopsy and FMRI, diffusion-weighted sequence (DWS) and intensity of FMRI, on the diagnostic performance were assessed by Fisher's exact test. RESULTS: A SSECE and a SSSVI were observed at FMRI and pathology respectively on 14 (8.8%) and 38 (24.1%) prostate lobes, and on six (3.8%) and seven (4.4%) prostate lobes. The sensitivity, specificity, positive and negative predictive values of FMRI for SSECE were respectively 24%, 96%, 64% and 80%; and for SSSVI were 14%, 97%, 17% and 96% respectively. The time between biopsy and FMRI, intensity of FMRI and DWS, did not influence the sensitivity and specificity of fMRI at Fisher test. CONCLUSION: This study found that preoperative prostate FMRI performed by GR has good specificity but poor sensitivity in predicting SSECE on pathological reports.

Influence of preoperative hydronephrosis on the outcome of urothelial carcinoma of the upper urinary tract after nephroureterectomy: the results from a multi-institutional French cohort.

OBJECTIVES: Recent publications have assessed the prognostic significance of hydronephrosis in the outcome of upper tract urothelial carcinoma (UUT-UC). Our study sought to determine the prognostic impact of hydronephrosis on UUT-UC survival and its relationship to the clinicopathological features. MATERIALS AND METHODS: A retrospective, multi-institutional French study was conducted on 401 patients who underwent radical nephroureterectomy for non-metastatic UUT-UC. Hydronephrotic status was determined using preoperative imaging reports. Univariate and multivariate analyses were conducted to identify factors associated with survival. RESULTS: Preoperative hydronephrosis was present in 74 patients. Median follow-up was 26 months. Hydronephrosis was associated only with ureteral localisation (p < 0.001). No difference was observed in 5-year cancer-specific survival (CSS) between the hydronephrosis group (80.1 %) and the no hydronephrosis group (83.6 %) (p > 0.05). Only age (p = 0.02) and pT stage (p = 0.01) were independent predictors of CSS. Hydronephrosis was not a significant predictor of CSS in the univariate and multivariate analyses (p = 0.87 and p = 0.66). No significant difference was observed for 5-year metastasis-free survival (MFS) between the hydronephrosis group (69.8 % ± 6.6 %) and the no hydronephrosis group (80.5 % ± 3 %) (p = 0.052). Hydronephrosis was not a significant predictor of MFS in the univariate and multivariate analyses (p = 0.16 and p = 0.36). Multifocality (p = 0.02), pT stage (p < 0.001) and positive surgical margins (p = 0.02) were independent predictors of MFS. For the pelvic tumours subgroup, hydronephrosis was an independent predictor of MFS (p = 0.01) but not CSS (p = 0.86). CONCLUSION: Preoperative hydronephrosis was not associated with survival. However, among tumours presenting with hydronephrosis, pelvicalyceal tumours appear to have a worse prognosis than ureteral tumours.

[Interest of flexible videocystoscopy in blue light (+Hexvix(®)) in consultation for the diagnosis of vesical tumor]. / Intérêt de la vidéocystoscopie souple en lumière bleue (+Hexvix(®)) en consultation pour le diagnostic des tumeurs de vessie.

OBJECTIVES: Estimate the feasibility and the results of the realization in consultation of a flexible videocystoscopy in blue light preceded by an instillation of Hexvix(®) (GE Healthcare) for the initial diagnosis or the surveillance of vesicals tumors (VT). The objective of this study was to compare the number of hurts seen in white light and in blue light, and to estimate in which percentage of case the use of the Hexvix(®) in consultation modified the care. PATIENTS AND METHODS: Thirty consecutive patients (26 men and four women) were estimated prospectively by vesical videofibroscopy in blue light (Wolf's PD videofibroscope) realized 1 hour after an endovesical instillation of Hexvix(®). All the examinations were realized in external consultation under local anesthetic by xylocaine gel: 23 (76.6%) patients within the framework of a surveillance of VT and seven (23.4%) for the diagnosis of a hematuria with normal echography. When a suspect hurt or a VT was discovered, the patients benefited from an endoscopic resection under anesthesia with new cystoscopy in blue light. RESULTS: Suspect hurts were revealed in 10 out of 30 patients, five in white and blue light, five in blue light only. Among the five only visible hurts in blue light, three were urothelial tumors (any pTa of bottom-rank, less of 5 mm) and two non-specific hurts. No CIS's hurt was revealed during this study. The fibroscopy in blue light allowed to diagnose invisible hurts in white light in three patients (10%) and has modified the care of five patients (16.7%). The duration of the cystoscopy was on average of 9.5 minutes. The tolerance of the examination was good and no complication arose. CONCLUSION: The use of the flexible videocystoscopy in blue light +Hexvix(®) has allowed to improve the rate of detection of VT. Except CIS's hurts, this improvement was bound to the diagnosis of little aggressive small-sized VT. The indications must be specified by studies of bigger scale and a medical economic evaluation.

[Anticoagulant therapy complicated by ureteric haematoma: A case report]. / Hématome urétéral compliquant un traitement anticoagulant : à propos d'un cas.

Bleeding of the ureteral wall during an anticoagulant treatment is a rare complication. We report the case of a 57-year-old white woman presented with macroscopic haematuria and lumbar pain with an overdose of anticoagulant treatment. Computed tomographic scan revealed the bleeding of the ureteral wall. Clinical improvement was excellent after correction of the haemostasis disorder.

No involvement of nitric oxide in the limitation of beta-adrenergic inotropic responsiveness during ischemia.

We tested whether or not endogenous nitric oxide (NO) attenuates beta-adrenergic inotropic responsiveness during normoperfusion or moderate myocardial ischemia. In 13 anesthetized pigs with a cannulated left anterior descending (LAD) coronary artery, the maximal contractile responses to intracoronary dobutamine and calcium were assessed during normoperfusion and at the end of a 90-min period of moderate ischemia (50% reduction in coronary arterial inflow) without (group 1, n = 6) and with (group 2, n = 7) prior inhibition of NO synthesis [30 mg/kg iv N(omega)-nitro-L-arginine (L-NNA)]. Contractile function was assessed by a regional work index (sonomicrometry, micromanometry, mm. mmHg). In groups 1 and 2 during normoperfusion, the maximal increase of the work index was greater with calcium than with dobutamine. At the end of ischemia in group 1, the baseline work index was decreased by approximately 50%, and the subsequent maximal increase of the work index with dobutamine, but not with calcium, was reduced compared with normoperfusion. In group 2 during normoperfusion, L-NNA did not alter the maximal increases of the work index with dobutamine or calcium. At the end of ischemia, the baseline work index was reduced by 64%, and the subsequent maximal increases of the work index with both dobutamine and calcium were reduced compared with normoperfusion; however, the response to calcium was still greater than that to dobutamine. We conclude that endogenous NO does not limit beta-adrenergic inotropic responsiveness in normoperfused or moderately ischemic porcine myocardium.

Progressive loss of perfusion-contraction matching during sustained moderate ischemia in pigs.

It is unclear whether perfusion-contraction matching (PCM) is maintained during prolonged myocardial ischemia. In 27 anesthetized pigs, left anterior descending coronary arterial inflow was reduced to decrease an anterior work index (WI) at 5 min of hypoperfusion by 40% and then maintained at this level for 12 or 24 h. With 12 h of hypoperfusion, the myocardium remained viable in 6 of 7 pigs (with triphenyltetrazolium chloride; TTC) and with 24 h of hypoperfusion in 5 of 11 pigs (TTC, histology). The reduction in WI to 62 +/- 4 and 62 +/- 3% of baseline in the two groups was matched to the reduction of transmural blood flow (TBF; microspheres) at 5 min of hypoperfusion, averaging 59 +/- 4 and 60 +/- 2% of baseline. With prolonged hypoperfusion, WI decreased to 30 +/- 5% at 12 h and 18 +/- 3% at 24 h; TBF remained unchanged (53 +/- 4 and 54 +/- 4%). The added calcium concentration required for the half-maximal increase in WI increased from 121 +/- 25 microg/ml blood at baseline to 192 +/- 26 microg/ml blood at 12 h of hypoperfusion. Thus, with hypoperfusion for 24 h, PCM is progressively lost, and calcium responsiveness is reduced.

Role of endogenous opioids in ischemic preconditioning but not in short-term hibernation in pigs.

Endogenous opioids are involved in ischemic preconditioning (IP) in several species. Whether or not opioids are important for IP and short-term myocardial hibernation (STMH) in pigs is currently unknown. In 34 enflurane-anesthetized pigs, the left anterior descending coronary artery was flow constantly perfused. Subendocardial blood flow (Endo), infarct size (IS; percent area at risk), and the free energy change of ATP hydrolysis (DeltaG) were determined. After 90-min severe ischemia and 120-min reperfusion, IS averaged 28.3 +/- 5.4% (means +/- SE) (n = 8; Endo: 0.047 +/- 0.009 ml. min(-1) x g(-1)). IP by 10-min ischemia and 15-min reperfusion reduced IS to 9.9 +/- 3.8% (P < 0.05, n = 8; Endo: 0.044 +/- 0.009 ml. min(-1) x g(-1)). After naloxone (1 mg/kg iv followed by 2 microg x kg(-1) x min(-1)), IS averaged 25.8 +/- 7.0% (n = 6; Endo: 0.039 +/- 0.008 ml x min(-1) x g(-1)) without and 24.7 +/- 4.7% (n = 6; Endo: 0.044 +/- 0.006 ml x min(-1) x g(-1)) with IP. At 5-min moderate ischemia in the presence of naloxone, Endo decreased from 0.90 +/- 0.07 to 0.28 +/- 0.03 ml x min(-1) x g(-1)and DeltaG decreased from -58.6 +/- 1.0 to -52.6 +/- 0.4 kJ/mol. Prolongation of ischemia to 90 min did not alter Endo, but DeltaG recovered toward control values (57.7 +/- 1.1 kJ/mol), and the myocardium remained viable. These responses are identical to those of nonnaloxone-treated pigs. Endogenous opioids are involved in IP but not in STMH in pigs.

Enhanced reduction of myocardial infarct size by combined ACE inhibition and AT(1)-receptor antagonism.

The effects of the angiotensin-converting-enzyme inhibitor (ACEI) ramiprilat, the angiotensin II type 1 receptor antagonist (AT(1)A) candesartan, and the combination of both drugs on infarct size (IS) resulting from regional myocardial ischaemia were studied in pigs. Both ACEI and AT(1)A reduce myocardial IS by a bradykinin-mediated process. It is unclear, however, whether the combination of ACEI and AT(1)A produces a more pronounced IS reduction than each of these drugs alone. Forty-six enflurane-anaesthetized pigs underwent 90 min low-flow ischaemia and 120 min reperfusion. Systemic haemodynamics (micromanometer), subendocardial blood flow (ENDO, microspheres) and IS (TTC-staining) were determined. The decreases in left ventricular peak pressure by ACEI (by 9+/-2 (s.e. mean) mmHg), AT(1)A (by 11+/-2 mmHg) or their combination (by 18+/-3 mmHg, P<0.05 vs ACEI and AT(1)A, respectively) were readjusted by aortic constriction prior to ischaemia. With placebo (n=10), IS averaged 20.0+/-3.3% of the area at risk. IS was reduced to 9.8+/-2.6% with ramiprilat (n=10) and 10.6+/-3.1% with candesartan (n=10). Combined ramiprilat and candesartan (n=10) reduced IS to 6.7+/-2.1%. Blockade of the bradykinin-B(2)-receptor with icatibant prior to ACEI and AT(1)A completely abolished the reduction of IS (n=6, 22.8+/-6.1%). The relationship between IS and ischaemic ENDO with placebo was shifted downwards by each ACEI and AT(1)A and further shifted downwards with their combination (P<0.05 vs all groups); icatibant again abolished such downward shift. The combination of ACEI and AT(1)A enhances the reduction of IS following ischaemia/reperfusion compared to a monotherapy by either drug alone; this effect is mediated by bradykinin.

No involvement of endogenous nitric oxide in classical ischemic preconditioning in swine.

Endogenous nitric oxide (NO) is involved in the protection by classical ischemic preconditioning (IP) against ischemia-induced arrhythmias in anesthetized dogs. Furthermore, NO triggers and mediates protection against infarction and stunning in delayed IP in conscious rabbits. Up to now it is unclear whether or not endogenous NO is also involved in the protection against infarction by classical IP in vivo. In 45 enflurane-anesthetized swine, severe left anterior descending coronary artery hypoperfusion for 90 min followed by 2 h of reperfusion resulted in an infarct size (IS, triphenyl tetrazolium chloride-staining) of 20.5+/-5.4% (S.E.M.) of the area at risk. Inhibition of NO synthase by l -nitro arginine (l -NA, 30 mg/kg i.v.) increased left ventricular (LV) peak pressure from 93+/-3 to 120+/-1 mmHg (P<0.05), but did not alter IS (22.4+/-5. 6%). With aortic constriction to match the increase in LV peak pressure with l -NA, IS was unchanged (18.1+/-5.1%). IP by 10 min ischemia and 15 min reperfusion preceding the 90 min target ischemia reduced IS to 2.0+/-0.8% (P<0.05 v. non-preconditioned groups). This reduction of IS by IP was not affected by l -NA (1.3+/-0.9%, P<0.05 v. non-preconditioned groups). Area at risk and myocardial blood flow (microspheres) during ischemia were not different among groups. Relationships between IS and subendocardial blood flow with l -NA or aortic constriction, respectively, were not different from that with placebo, but were significantly shifted downwards by IP with and without l -NA. Thus, endogenous NO does not alter infarct size development per se and is not involved in the protection against infarction by classical IP in pigs in vivo.

[Double gastric and thyroid localization of MALT lymphoma with lymphocytic thyroiditis]. / Double localisation d'un lymphome du MALT avec atteinte gastrique et thyroïdienne sur une thyroïdite lymphocytaire.

Case report of a 82 year old man, with double localisation of low grad MALT lymphoma. The first one is in the thyroid gland, with a lymphocytic thyroiditis background; the second one gastric, is revealed by fibroscopy performed after thyroidectomy. The fact that gastric lymphoma could be a primary or secondary entity is discussed.