[Cosmetic surgery of the male genitalia]. / Chirurgie cosmétique de l'appareil génital masculin.

OBJECTIVES: To describe the indications and results of techniques to change the appearance of the penis for aesthetic reasons. Provide recommendations concerning cosmetic surgery of the male genitalia. MATERIAL AND METHODS: We have selected from Medline Database, articles published between 1990 and 2011. Forty articles have been selected excluding papers reporting populations less than five cases per type of procedure. RESULTS: There is no consensus on the size below which it is justifiable to accept or attempt to modify the size of the penis. Length of the penis in maximal tension less than 9.5 cm or 10 cm in erection can be considered as an acceptable limit, in a patient who suffers from it. The assessment of men asking for penile enlargement must include a psychosexological or psychiatric evaluation, looking for a dysmorphophobia or another psychiatric condition. Penile extenders under medical control must be the first-line treatment option for patient seeking penile lenghtening procedure when justified. In case of failure, three techniques can be used alone or in combination: penile lengthening by section of the suspensory ligaments and suprapubic skin advancement, lipectomy of Mons pubis and scrotal webbing section. The results are modest, the rate of complications significant and satisfaction low. Girth enlargement techniques by injection of autologous fat give inconsistent aesthetic results and satisfaction rates are low. All other techniques remain experimental. CONCLUSIONS: Cosmetic surgery of the penis is associated with a high risk of forensic exposure and surgery should be only proposed after a multidisciplinary consensus, followed by a time of reflection given to the patient after full disclosure. Applications for the purpose of reconstruction surgery after trauma or consequences of cancer treatment are justified.

[A case of hepatitis C virus possible transmission following a transrectal ultrasound guided prostate biopsy]. / Un cas de possible transmission du virus de l'hépatite C au décours d'une biopsie transrectale échoguidée de prostate.

The prostate biopsy is a current and well-codified act. To date, there have been no reported risks of viral transmission between patients linked to contaminated ultrasound probe. We report the case of a patient having contracted the virus of hepatitis C after transrectal prostate biopsy during an individual screening of prostate cancer.

[Pathophysiology and management of Peyronie's disease in adult patients: an update]. / Physiopathologie et prise en charge de la maladie de La Peyronie.

Peyronie's disease (PD) is due to a fibrotic plaque forms in the tunica albuginea layer of the penis. It is responsible of penile pain, angulation, and erectile dysfunction. Even though the aetiology remains unknown, the knowledge of the pathophysiology has evolved in recent years. Recent studies indicate that PD has prevalence of 3 to 9% in adult men. During the initial acute phase (6 to 18 months), the condition may progress, stabilize or regress in 20%. Therefore, a conservative treatment approach has been advocated. An initial discussion about evaluation, information, and reassurance is necessary in most cases. The most commonly employed oral therapies include tocopherol (vitamin E), and para-aminobenzoate (Potaba), which have failed to demonstrate efficiency. Intralesional injection therapies with interferon alpha-2B, verapamil are frequently used as a first-line treatment modality, and can provide an improvement in decreasing penile pain and penile curvature. Current literature has shown that extracorporeal shock wave lithotripsy was only active on the pain. Regarding penile curvature, there are discrepancies in the published series. The surgical approach is restricted to men unresponsive to nonoperative therapies (i.e., 10% of patients). In such cases, plication, grafting or even penile prosthesis implantation are conceivable management options.

[Oncologic and functional outcomes after robot-assisted laparoscopic radical prostatectomy]. / Résultats carcinologiques et fonctionnels de la prostatectomie totale laparoscopique robot-assistée.

The current gold standard treatment for localized prostate cancer remains open radical prostatectomy. From 1992, several teams have tried to explore less invasive surgical access. The first robotically assisted laparoscopic prostatectomy (RALP) case was reported in 2000. Enhancement of the ergonomics and optimization of the surgical vision provided by the robotic interface, are some reasons that explain the worldwide widespread of RALP. Although this procedure accounted for the vast majority of radical prostatectomies performed in United States, its diffusion is still limited in Europe. The cost for robot purchase and maintenance are obvious limiting factors for its expansion. According to the literature, the operating time and the blood loss are, once the learning curve is completed, similar to those of open or laparoscopic procedures. Hospital stay and time before bladder catheter removal are shorter compared to other approaches. Intermediate oncological and functional outcomes do not show difference with the open or laparoscopic results. Given that these data are encouraging, the limited follow-up with RALP do not allow to draw any definitive statement in comparison with conventional techniques.

[Results of nephron-sparing surgery for renal cell carcinoma of more than 4 cm in diameter]. / Résultats de la néphrectomie partielle pour les carcinomes à cellules rénales de plus de 4cm.

To date, radical nephrectomy (RN) remains the gold standard treatment for renal cell carcinoma (RCC) larger than 4 cm. However, from the early 1990's, improvements in surgical techniques have lead to the development of nephron-sparing surgery (NSS) for small renal tumours of less than 4 cm in diameter. This surgical procedure avoids nephronic waste with an acceptable morbidity and similar oncological outcomes compared to radical surgery. Recent large published series did not show any difference between NSS and RN in terms of oncological safety. Specific and disease-free five-year survival rates (82% to 97.3% and 81% to 97.3%, respectively) have confirmed the safety of NSS. Regarding laparoscopic NSS, the technique is still under evaluation and only mid-term outcomes are available so far. However, these studies are still limited and longer follow-up is needed before any definitive statement can be made. Current guidelines recommend NSS only in case of RCC of less than 4 cm in diameter in elective indications. In daily practice however, surgical teams are pushing back the limit above the threshold of 4 cm. More and more surgeons are either considering anatomical location or technical expected difficulties rather than just the tumour size. NSS leads to higher risk of bleeding, especially in case of tumours larger than 4 cm. Therefore, it is absolutely necessary to investigate thoroughly the vascularization of the tumour to avoid such complications with exhaustive and accurate preoperative imaging.

[Long-term results of laparoscopic sacral colpopexy for high-grade cystoceles]. / Résultats à long terme de la promontofixation laparoscopique dans les cystocèles de haut grade.

PURPOSE: To evaluate long-term functional and anatomical results of laparoscopic-sacral colpopexy (LSC) for the treatment of high-grade cystoceles. MATERIAL: Between 1997 and 2005, 43 women with symptomatic cystoceles of high grade (grade 3 or 4), isolated or not, were treated by LSC. All patients were seen at three months, six months and then yearly during follow-up. Each visit included an interrogatory searching for functional urinary symptoms or sexual and digestive symptoms. A clinical examination, always performed by the same operator, searched for an anatomical recurrence, which was defined by an anterior prolapse of stage greater or equals to 2. In addition, a uroflowmetry was performed systematically. Prognostic factors for cystocele recurrence were established by univariate analysis. RESULTS: With a mean follow-up of 4.1 years (2-10.1), the rate of correction of cystocele was 84%. Seven women had an anterior recurrence and were as follows: stage 2 (n=5), stage 3 (n=1) and stage 4 (n=1) associated with urinary-functional symptoms in three cases, with sexual problems in three cases or with rectal symptoms in two cases. In case of isolated cure of cystocele, we found no recurrence during follow-up. Mean uroflowmetry was 24+/-9ml/s. Nine women (21%) had dysuria associated with cystocele recurrence in four cases. Four patients had a pollakiuria (n=1), an urgenturia (n=1) or a stress-urinary incontinence (n=2) without anatomical recurrence. In a case, chronic-pelvic pain was revealing erosion of the tape into the bladder wall. No significant factor was associated with cystocele recurrence. CONCLUSION: LSC offered a viable and long-lasting correction of high-grade cystoceles, mostly when they are isolated. Anatomical recurrence was mainly revealed by the occurrence of functional symptoms. In case of atypical urinary symptoms, a cystoscopy has to be done to look for an erosion into the bladder wall.

Neurogenic bladder management and cutaneous non-continent ileal conduit.

STUDY DESIGN: Prospective monocentric follow-up study. OBJECTIVES: To assess the results of cutaneous non-continent diversion for neurogenic bladder management. SETTINGS: Department of Urology (Pitié-Salpétrière Hospital), Department of Neurological Rehabilitation (Raymond Poincaré Hospital), Assistance Publique-Hopitaux de Paris, University Paris VI and V. METHODS: We reviewed the charts of 33 consecutive patients (19 women, 14 men), operated between 1979 and 1999. Twenty-one patients had spinal cord injury (SCI), four had multiple sclerosis, three had various forms of myelitis and five had central neurological diseases. Diversion was indicated for upper urinary tract protection (17), perineal dryness (14) and/or functional or social reasons (20). Before the operation, 20 of the 33 patients (60.6%) presented urologic complications related to bladder management, including triggered micturition, indwelling catheter or intermittent catheterization: urethrocutaneous fistula (4), complicated enterocystoplasty (2), watering pot perineum and severe decubitus ulcerations (14). Ileal conduit (also named ileoureterostomy) was performed alone for 19 patients (57.6%), and in combination with simultaneous cystectomy in 14 patients. We reviewed patient outcome and early and late complications. RESULTS: Mean follow-up was 48 months (1 to 20 years). All problems related to catheters or incontinence had resolved. There were no deaths or early re-operations. Twelve patients (12 out of 33, 36%) had one or more peri-operative complication, including ileus (1), uretero-ileal anastomosis leak (1) and sepsis (1). During follow-up, four of the 19 patients who did not undergo cystectomy developed pyocystitis (3 secondary cystectomies performed between 6 and 56 months). All patients achieved perineal dryness. CONCLUSIONS: The ileal conduit procedure is a safe and well-tolerated procedure in neurologically impaired patients. This procedure is suitable for most neurogenic patients with refractory lower urinary tract dysfunctions.

Urodynamic monitoring during percutaneous sacral nerve neurostimulation in patients with neurogenic detrusor hyperreflexia.

The purpose of this study was to assess urodynamics parameter changes induced by acute sacral neurostimulation (SNS) in spinal cord injury (SCI) patients with neurogenic detrusor hyperreflexia. Fourteen SCI patients with urge incontinence owing to a hyperreflexive bladder were prospectively evaluated. Neurostimulation was performed on the root that obtained the best motor response (10 Hz, 210 microseconds) and amplitude ranges of >0 to 10 V. The urodynamics study was done in the prone position. Four cystometries were recorded before (two), during (one), and 10 minutes after stimulation (one). Maximal bladder capacity (MBC) (volume to first leakage), bladder volume at first uninhibited contraction (BV(1stC)), and maximal detrusor pressure during uninhibited contractions (P(det)max) were compared. Left S3 foramen was the most commonly used (9/14). Mean amplitude of stimulation was 4.5 V (range, 0.5-8.5 V). Statistically significant differences (Mann-Whitney U-test) were found for MBC, BV(1stC), and P(det)max with mean variations of +206.8 mL (+107%, P < 0.001), +151.5 mL (+98%, P < 0.01), and -23.4 cm H2O (-27%, P < 0.05), respectively. Patient gender and SCI level did not reveal any difference. Patients who reached a MBC of up to 400 mL (+278.2 mL, +129%, n = 10) with SNS had statistically significant improvement of BV(1stC) (+210.2 mL, +125%, P < 0.01) and P(det)max (-33.3 cm H2O, -38%, P < 0.01). Acute temporary SNS in SCI patients has a profound effect on key urodynamics parameters. These neurologically impaired patients with detrusor hyperreflexia may be appropriate candidates for implantable SNS.

[High intensity focused ultrasound (HIFU) in urology]. / Les ultrasons focalisés de haute intensité (UFHI) en urologie.

INTRODUCTION: Focused ultrasound is now well known to urologists in the context of its validated application in extracorporeal lithotripsy. High Intensity Focused Ultrasound (HIFU) represents a potential therapeutic modality for tissue destruction due to its very high energy and its capacity to precisely reach a target with a very short emission time. The authors review the current state of art of HIFU in urology at a time when its indication in prostate cancer is being defined. MATERIAL AND METHOD: After a brief description of the main physical principles of ultrasound and the main data determining focussing of high energy ultrasound, the main machines available (research and clinical) are described. The published clinical literature concerning the tissue destructive action in urology is reviewed. RESULTS: HIFU has been used in urology to treat renal, vesical, prostatic (BPH and cancer), and external genital organ lesions. Purely extracorporeal machines are gradually being replaced by intracorporeal procedures, especially transrectal techniques for prostatic lesions. The quality of ultrasound detection of the target still limits the use of this minimally invasive modality. The intervening tissues are spared with a good therapeutic efficacy on the target tissues, provided optimal firing parameters are used. CONCLUSION: HIFU has a demonstrated potential in the treatment of prostate cancer and studies conducted by several teams have defined the technique and its efficacy. Other indications have been studied, but must be validated by further clinical trials. The future will probably see the design of machines adapted to a specific target tissue rather than a single multidisciplinary extracorporeal machine.

[Isolated Burch type indirect colposuspension of the bladder neck in the treatment of stress urinary incontinence in women. Long-term results]. / Colposuspensions indirectes du col vésical type Burch isolées dans le traitement de l'incontinence urinaire à l'effort de la femme. Résultats à long terme.

OBJECTIVES: Burch indirect colposuspension remains the reference surgical operation in the treatment of female urinary stress incontinence. The stability of the results is highly controversial and the causes of failure remain hypothetical. The objective of this study was to analyse the long-term results of this technique. METHODS: 100 women suffering from pure urinary stress incontinence, in whom a Burch indirect colposuspension was performed, were included in this study. These patients were reviewed with a mean follow-up of 5.2 years and a questionnaire designed to assess the results was sent to their homes. RESULTS: 64% of patients no longer suffered from incontinence. Deterioration of the results was observed up to 5 years after the operation, but subsequently remained stable. The results were operator-independent. Low sphincter pressure (< 30 cm H2O), preoperative detrusor instability, insufficient hormonal impregnation and a history of pelvic surgery were the main factors predictive of failure of this technique. CONCLUSION: This study confirms the benefit provided by this technique in almost two-thirds of patients and indicates the risk factors of failure which must be taken into account before proposing Burch indirect colposuspension to a woman suffering from urinary stress incontinence.

[Role of dental panorama in identification procedures]. / Rôle du panoramique dentaire lors des procédures d'identification.

Identifying the bodies of victims of terrorism or major catastrophies is a difficult task. When the regular procedures of forensic medicine are insufficient, either because the bodies have become putrefied or were burned, the coroner often has to rely on dental identification. The precision of the different dental records written during the life of the victim is not always adequate. Panoramic dental radiography is the only regularly updated and truly reliable identification card. Films taken earlier can be compared to films of the unidentified body. This method could concern members of the armed forces serving abroad as well as airline personnel. The radiogram would be taken at the same time as chest films during medical check-ups. This document would provide a reliable basis for legal identification when needed.

[Urologic surgery and risks of complaints in medical responsibility]. / Chirurgie urologique et risques de plaintes en responsibilité médicale.

The card-index study of specialized insurance companies allowed the analysis of 82 cases concerning urological surgical procedures. Forty-two cases went to the Civil Court, 10 to the Penal Court and 5 to the Administrative Tribunal, while 5 cases were simply declared to insurance companies without judiciary consequences. Sixty-two cases concerned private plaintiffs surgeons and 34 cases concerned non specialist urologic surgeons. Sixteen plaintiffs were compensated, 9 after a conciliatory agreement and 7 after trial. There were no penal condemnations (one case on the waiting list). Impotence was the most frequent cause for complaint which was compensated. Next, came incontinence generally secondary to endoscopic resection. Retrospectively, 19 cases seemed to be unwarranted due to the dishonesty of patients (3 patients were prosecuted for unwarranted procedures). On the other hand, 32 cases seemed to be due to a lack of information given to the patients themselves or to their families, either before of after the incriminated act. The risk of prosecution is relatively low in urology. It could be decreased by careful management of the medical chart, by rapid analysis of complications and by a constant effort to inform the patient and his family.

[Urology facing the courts. The basis of professional responsibility]. / L'urologue face aux tribunaux. Fondements de la responsabilité professionnelle.

The liability of the urologist can be involved according to 3 procedures: The civil procedure is that of the Tribunal de Grande Instance (High Court) then the Cour d'Appel (Court of Appeal). Financial compensations are claimed from the surgeon for not respecting the medical contact. This contract is tacit, oral and carries obligations for the surgeon. The administrative procedure is that of the Tribunal Administratif (Administrative Court) then the Conseil d'Etat (Council of State). This only concerns the salaried surgeon in his salaried activities. The penal procedure is that of the Tribunal Correctionnel (Criminal Court) then the Cour d'Appel (Court of Appeal). The surgeon is then charged with a crime, usually unintensional injuries or through negligence. Although the harlm is easy to prove, the reality of the fault of the surgeon and the relation between fault and damage are far less so. It is the plaintiff (Civil Course, Administrative Cours) or the State Prosecutor (Penal Course) who must prove the fault and causality by the help of an expert's report. So, the responsibility of the surgeon can be committed. However, the development of the insurance system has allowed more widespread compensation without any fault found on the surgeon's part and increasingly frequent conciliatory procedures.

[The medicolegal identification of victims of major disasters]. / Identification médico-légale des victimes des grandes catastrophes.

The medical identification of victims of major catastrophes is based upon a strict methodological approach at the actual site of the catastrophe when victims are found and in mortuaries. In the majority of cases, police identification can be pronounced. It is only in much more difficult cases where there are calcination or putrefaction processes that medicolegal identification is requested. This identification is based upon the results of medicolegal autopsy itself and on examination of the dental system which remains of capital importance. In the absence of data which can be used to compare the dental system of the victim with this of missing it is possible using single teeth to assess dental age and determine blood group, thereby providing the legal authorities with a group of additional arguments which can be used for presumptive identification.

[Medicolegal identification by the dental system]. / Identification médico-légale par le système dentaire.

Bodies found in acts of war or natural disasters are sometimes impossible to identify for police or legal purposes, notably because of calcination or putrefaction. Teeth, which are particularly resistant to destruction by fire, bacteria or other agents, can be used to evaluate the victim's dental age by the Gustafson method with a margin of error of plus or minus 4,6 years. Blood group has also been established with more than 85% concordant results by determination of the A. B. O antigens which are present in dental tissue and pulp. These techniques were tested on 257 teeth from subjects of known dental age and blood group. They provide additional evidence of the identity of deceased persons.