[Factors predicting of failure after conservative treatment in III-V grade renal trauma]. / Facteurs prédictifs d'échec du traitement conservateur du traumatisme rénal grade III­V.

INTRODUCTION AND OBJECTIVES: Surgical exploration of renal injury secondary to major trauma often leads to nephrectomy. The aim of this work was to identify the factors associated with the need for surgery in patients with III-V grade renal trauma who were initially managed conservatively. MATERIALS AND METHODS: We retrospectively reviewed data from patients with Grade III-V kidney injury between June 2005 and June 2015. Demographic, clinical and bio-radiological characteristics at admission and follow-up, as well as management and complications, were recorded. Patient data, including conservative treatment, was a success without recourse to nephrectomy, and those patients who needed surgery were analyzed. RESULTS: Seventy three patients were included in this study. Grade III accounted for 45%, Grade IV: 49% and Grade V: 5%. The success rate for conservative treatment was 79%: 31 patients grade III (94%), 26 grade IV (72%) and no grade V patients. hypotension at admission (P=0.04), hematoma size greater than 3.5 centimeters (P=0.002), grade V (P=0.003), anemia (P=0.04), blood transfusion (P=0.01) and worsening of lesions of the control CT lesions (P=0.001), are the factors considered as predictive of failure of conservative treatment. CONCLUSION: Conservative management is the treatment of choice in III-V grade renal trauma, and the prognostic factors found in this study make it possible to better select patients. LEVEL OF EVIDENCE: 4.

[Oncological results of a series of 93 laparoscopic radical cystectomies: 5 years of follow-up]. / Résultats oncologiques d'une série de 93 cystectomies totales laparoscopiques : 5 ans de suivi.

OBJECTIVE: To report oncological results at 5 years after laparoscopic radical cystectomy (LRC) with lymph node dissection for bladder cancer (BC). PATIENTS AND METHODS: This is a retrospective single-center study of all patients who underwent LRC for BC by the same surgeon from February 2007 to March 2016. Demographic, perioperative and oncologic data were collected. We reported overall survival rate (OS), cancer specific (CSS) and recurrence-free survival (SSR), as primary indicators of oncologycal outcomes. These survival rates were estimated according to the Kaplan-Meier method. Log-rank tests were used to explore overall survival according tumor stage, lymph node involvement and surgical margins status. RESULTS: In all, 93 patients (82 men and 11 women) underwent LRC. Mean age was 59 years. Minor complications (Clavien I-II) occurred in 24.7%. Major complications (Clavien IIIa-V) were observed in 8.6%. No patients received neoadjuvant chemotherapy. Median lymph node (LN) yield was 15 and 26.5% patients had positive LN. The positive surgical margins (SMs) rate was 5.3%. Median follow-up for the entire patients was 50 months (19-84 months). Forty-three patients (46.2%) were followed for at least 71 months. Five year RFS, CSS and OS were 67%, 85% and 79%, respectively. Non organ confined desease, positive LN and positive SMs were associated with poorer OS (P<0.039, P<0.016 and P<0.001). CONCLUSION: LRC was associated with acceptable long-term oncologic outcomes, similar to those currently reported after open cystectomy for BC. LEVEL OF EVIDENCE: 3.

[Evaluation of the learning curve of laparoscopic radical cystectomy for cancer: Morbidity and oncological results]. / Évaluation de la courbe d'apprentissage de la cystectomie radicale laparoscopique pour cancer : morbidité et résultats oncologiques.

INTRODUCTION: The objective of this work was to evaluate the impact of the laparoscopic radical cystectomy learning curve on perioperative and oncological outcomes. PATIENT AND METHODS: This is a retrospective and single-center study of all patients who underwent laparoscopic radical cystectomy for bladder cancer from February 2007 to March 2016, (93 patients) Perioperative and oncological data were collected. We used mixed statistical models to predict the number of patients needed in the learning phase. We compared the perioperative parameters of the patients in the learning phase with those of the rest of the patients. Overall survival was estimated using the Kaplan-Meier method. RESULTS: Thirty-six patients are required for the learning phase (P1). The expertise phase begins after the 36th LRC (P2). In both phases, there was no significant difference in age, ASA score, and tumor stage (P=0.237, P=0.577, P=0.998). Mean operative time was 328.3min and 262.4min in P1 and P2 (P=0.0001), mean blood loss was 333.7mL and 194.3mL in P1 and P2 respectively (P=0.0003). The rate of major complications was high in the learning phase (P=0.042). There was no significant difference in lymph node yield, positive surgical margins and overall survival (P=0.068, P=0.194, P=0.703). CONCLUSION: This learning experience was evaluated without compromising oncological results, but with a significantly higher rate of major complications. LEVEL OF EVIDENCE: 3.

[Sensitivity to change of the USP score (Urinary Symptoms Profile) after surgical treatment of benign prostatic hyperplasia (BPH)]. / Sensibilité au changement du score USP (Urinary Symptoms Profile) après traitement chirurgical de l'hypertrophie bénigne de la prostate (HBP).

OBJECTIVE: To evaluate the sensitivity to change in USP score (Urinary Symptoms Profile) after surgical treatment of benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: Prospective study collecting IPSS (International Prostatic Symptom Score) and USP scores before and 6 weeks after surgery for BPH. Sensitivity to change was assessed using effect size (ES) and mean standardized response (MSR). RESULTS: Thirty patients, mean age of 68±10 years (min: 52, max: 90) were included in this study. The mean IPSS and USP scores were 14.3 (e.t.: 5.42), 20.3 (e.t.: 5.22) and 3.53 (e.t.: 3.68), 3.43 (e.t.: 3.48) before and after surgery respectively. The overall USP score showed excellent sensitivity to change with a global value of ES and MSR of 1.986 and 2.322 respectively. CONCLUSION: The USP score has an excellent sensitivity to change. It seems to be a valid and reliable score that can be perfectly adapted to the assessment of symptoms associated with BPH, with good sensitivity to changes in the overall score, with the advantage over the IPSS of an exhaustive exploration of all urinary symptoms particularly in the field of urge urinary incontinence and stress urinary incontinence. LEVEL OF PROOF: 4.

[The local anesthesia for the prostatic biopsies echo-guided: forward-looking randomized study comparing two methods]. / L'anesthésie locale pour les biopsies prostatiques écho-guidées: étude prospective randomisée comparant deux méthodes.

INTRODUCTION: The realization of the prostatic biopsies is a painful act. The objective of our work was to compare the analgesic efficiency of the injection of the lidocaine at the level of periprostatics laterals and apical areas compared with the use of gel of lidocaine intrarectal associated with the taking of oral tramadol. PATIENTS AND METHODS: Between November 2007 and December 2009, 60 patients admitted in the service of urology of the university hospital Mohammed VI of Marrakesh for prostatic biopsies were randomized in two groups. The group 1 (30 patients) received two tablets from tramadol 50mg with 10 mL of gel of lidocaine 2% intrarectal while 30 patients of the group 2 received 10 mL from lidocaine 2% injected at the level of periprostatics laterals and apicales. The pain was estimated by a visual analog scale (AVS) at the introduction of the probe of echography (AVS 1), at the time of the biopsy (AVS 2) and 20 minutes later (AVS 3). RESULTS: There was no significant difference between both groups concerning AVS 1 means. The average score of the pain was significantly lower in the group 2 for the AVS 2 and AVS 3. CONCLUSION: The periprostatics anesthesia assured a better control of the pain at the time of the prostatic biopsy and 20 minutes later, without increase of the complications. We recommend it to decrease the pain and the discomfort related to this technique.

[Perineal-scrotal gangrene: epidemiological and therapeutic aspects. About 45 cases]. / La gangrène périnéoscrotale: profil épidémiologique et aspects thérapeutiques. À propos de 45 cas.

Perineoscrotal gangrene is an acute disease, a rare and severe affection of the perineum, whose evolution is unpredictable and rapidly extensive. The diagnosis is clinical. The paraclinical examinations allow early diagnosis and assessment of anatomical and biological repercussions. We conducted a retrospective study of 45 patients spread over six years, involving a multidisciplinary team consisting of three specialists (urologists, visceral, plastic surgeons). The average age was 52 years. The largely male dominated our series. Fournier gangrene was the most common etiology. We noted five cases of death (11%) in the acute phase, secondary to septic shock (four patients) or multiple organ failure (one patient). The evolution was favorable in 40 other patients in the series, requiring an initial management in intensive care unit, and surgical treatment. The average hospital stay was 17 days. After the acute phase, all patients underwent a surgery for skin coverage, ranging from guided healing (two patients) to musculocutaneous flap of the gracilis (six patients) via the secondary suture (four patients), the burying the testes (18 patients) and half thick skin graft, with a functional and aesthetic result was acceptable, and minimal sequelae. In our series, the most predictive prognostic factors would be the delay of care, sepsis on admission and associated diseases.

Malignant epithelioid renal angiomyolipoma involving the inferior vena cava in a patient with tuberous sclerosis.

Renal angiomyolipomas (AMLs) are mesenchymal tumors that occur either sporadically or are associated with tuberous sclerosis, and are generally considered to be benign. Malignant AML is extremely rare, and most are found to be epithelioid histopathologically. The authors report the case of a patient followed for renal AML. On CT surveillance, this lesion developed features of a malignant tumor involving the renal vein and inferior vena cava. The patient was treated by nephrectomy and tumor thrombectomy with retroperitoneal lymph node dissection. Histological examination demonstrated renal AML with a malignant epithelioid contingent. The various aspects of this histological and radiological variant are discussed.

Lymphoproliferative disorder presenting as a tumor of the renal allograft.

Post-transplant lymphoproliferative diseases (PTLDs) constitute a group of potentially life-threatening complications in solid organ transplantation, occurring in 1-2% of kidney transplant recipients. The absolute number of cases occurring at each transplant center remains small, making it difficult to assess incidence, prognosis, and treatment. We report a case of post-transplant lymphoproliferative disorder that developed in the allograft renal parenchyma 2 years after renal transplantation. This case implies that partial nephrectomy may be a safe and effective treatment protocol for renal lymphoma in allograft kidneys.

Nephron-sparing surgery for de novo renal cell carcinoma in allograft kidneys.

Renal cell carcinomas account for 4.6% of post-transplant cancers, 10% of which occur in allograft kidneys. We report three such cases among kidney grafts that were performed or followed from 1970 to 2004. In all patients, we performed a partial allograft nephrectomy after consideration of the tumor size, location, and absence of metastases and local extension. Renal function has remained stable, and there has been no sign of graft rejection, tumor recurrence or metastases. The surgery was technically feasible without exposing the patients to increased postoperative risks. The lateral, peripherally located tumor allowed excision without renal hilar dissection or entry into the collecting system. In agreement with data emerging from the literature, the present cases confirm that even in the setting of long-standing immunosuppression, de novo RCC of the kidney graft warrants a minimally invasive approach to spare patients graft loss and return to hemodialysis.

The structure and innervation of the male urethra: histological and immunohistochemical studies with three-dimensional reconstruction.

The structure of the striated urethral sphincter, the so-called rhabdosphincter, remains the subject of controversy. There are two main concepts regarding its structure: either it is a part of the urogenital diaphragm, or it extends from the base of the bladder up to the urogenital diaphragm and is an integral part of the urethra. It is also uncertain whether it possesses a somatic innervation or a mixed innervation (i.e. autonomic and somatic). The purpose of this study was to show the precise location of the nerves running to the urethra, and to try to determine their exact nature. Histology and immunohistochemistry were performed in the external urethral sphincter of ten male fetuses (114-342 mm crown-rump length, or between 14 and 40 weeks of gestation). A three-dimensional (3D) reconstruction of the urethral structure and its innervation was made from serial sections. The 3D reconstruction of the same section levels with different strains allowed us to identify the precise structure of the muscle layers (smooth and striated muscle fibres) and the nature of the nerve elements (myelinated and unmyelinated), their distributions and their relationship to the urethral wall, the prostate and the seminal vesicles. Histological and immunohistochemical 3D reconstruction of the anatomical elements of the urethral sphincter helps us to understand the 3D arrangement of the sphincter muscle layers. It also provides a better understanding of the origin and nature of the nerve elements that play a role in urinary continence.

Cancer Primitif de l'Uretre

Objective: We report six cases of primitive cancer of the urethra out of a total of 1109 cases of urologic cancers hospitalized during a period of 12 years. Patients and Methods: From 1990 to 2001 six patients (four males; two females) were hospitalized for cancer of the urethra. The tumors were analyzed according to the classification of Grabstald. All the patients were explored by retrograde urethrocystography showing an irregular image of the urethra and at times opacifying the sinus ways. Urethrocystoscopy showed the site of the tumor and its aspect and allowed for diagnostic biopsies. In five cases it revealed an epidermoid cancer and an adenocarcinoma in one case. The treatment used depended on the stage of the disease and the general condition of the patients. Two patients underwent radical pelvectomy without any adjuvant treatment. Two patients with disseminated disease received palliative treatment by radiotherapy. The two remaining patients having refused surgical treatment were also treated by radiotherapy alone. Results: Overall; the average rate of survival was 17.5 months (3 to 60 months). The best results were achieved with surgical treatment. Two of the patients referred to the oncologist for palliative radiotherapy died within 3 and 6 months; respectively. One patient treated by radiotherapy alone after having refused surgical treatment presented 6 months later with a long post-radiation stenosis of the urethra. Since the patient still refused surgical treatment; he was treated by final cystostomy. The last patient also treated by exclusive radiotherapy is being followed up by the radiologists. Conclusion: Primitive cancer of the urethra is rare. Its semiology is not very specific which explains the frequently delayed diagnosis. It is the meticulous examination of the urethra which allows the diagnosis. The treatment of choice is surgery and/or radiotherapy

[Carcinomatous degeneration on augmentation ileocystoplasty for tuberculous bladder]. / Dégénérescence carcinomateuse sur iléocystoplastie d'agrandissement pour vessie tuberculeuse.

The development of cancer on the ileal graft after augmentation ileocystoplasty for benign bladder disease is a little known complication. The authors report a case of squamous cell carcinoma in the ileal bladder occurring 37 years after augmentation ileocystoplasty for tuberculous bladder, in a 68-year old patient. Carcinomatous degeneration is usually occurs more than ten years after cystoplasty. Patients treated by this operation must be submitted to annual cystoscopy combined with guided biopsies at the slightest doubt. This surveillance should be started between the 5th and the 10th postoperative year.

Factors influencing adrenal metastasis in renal cell carcinoma.

OBJECTIVES: We determine the incidence and characteristics of adrenal involvement in localized and advanced renal cell carcinoma, and evaluate the role of adrenalectomy as part of radical nephrectomy. MATERIAL AND METHODS: From 1993 to 1999, 210 patients with renal cell carcinoma (RCC), (139 men and 71 women, mean age 60.8 years, range 12-96) underwent radical nephrectomy with associated adrenalectomy. Patients were divided into two subgroups of 106 with localized (stage T1-2 tumor, groupl) and 104 with advanced (stage T3-4N01M01, group2) renal cell carcinoma. A retrospective review of preoperative computerized tomography (CT) of the abdomen was performed. Radiographic findings were subsequently compared to postoperative histopathological results to assess the predictive value of tumor characteristics and imaging in determining adrenal metastasis. RESULTS: Of the 210 patients, 15 (7.1%) had adrenal involvement. Tumor stage correlated with probability of adrenal spread, with T3-4 and T1-2 accounting for 13.4% and 0.9% of cases, respectively (p < 0.001). Upper pole intrarenal RCC most likely to spread was local extension to the adrenal gland, representing 53.3% of adrenal involvement. In contrast, multifocal, lower pole and mid region RCC tumors metastasized hematogenously, representing 21.4%, 7%, and 14% of adrenal metastasis, respectively. The relationship between intrarenal tumor size (mean 7.8 cm, range 4 to 21) and adrenal involvement was not statistically significant. Preoperative CT demonstrated 97.7% specificity, 98.4% negative predictive value, 87% sensitivity and 80% positive value for adrenal involvement by RCC. CONCLUSIONS: Ipsilateral adrenalectomy should only be performed if a lesion is seen preoperatively on CT scan or if gross disease is seen at the time of nephrectomy. The prognosis is poor for RCC with ipsilateral involvement even with complete removal. Because of this poor prognosis we believe that adrenal involvement should constitute a separate stage category.

Real indications for adrenalectomy in renal cell carcinoma.

OBJECTIVES: We determined the incidence and characteristics of adrenal involvement in localized and advanced renal cell carcinoma, and evaluated the role of adrenalectomy as part of radical nephrectomy. PATIENTS AND METHODS: From 1993 to 1999, 210 patients with renal cell carcinoma (RCC) (139 men and 71 women, mean age 60.8 years, range 12-96 years) underwent radical nephrectomy with associated adrenalectomy. Patients were divided into two subgroups of 106 with localized (stage T1-2 tumor, group 1) and 104 with advanced (stage T3-4N01M01, group 2) renal cell carcinoma. A retrospective review of preoperative computerized tomography (CT) of the abdomen was performed. Radiographic findings were subsequently compared with postoperative histopathological results to assess the predictive value of tumor characteristics and imaging in determining adrenal metastasis. RESULTS: Of the 210 patients, 15 (7.1%) had adrenal involvement. Tumor stage correlated with probability of adrenal spread, with T3-4 and T1-2 accounting for 13.4% and 0.9% of cases, respectively (p < 0.001). Upper pole intrarenal RCC most likely to spread was local extension to the adrenal gland, representing 53.3% of adrenal involvement. In contrast, multifocal, lower pole and mid region RCC tumors metastasized hematogenously, representing 21.4%, 7%, and 14% of adrenal metastasis, respectively. The relationship between intrarenal tumor size (mean 7.8 cm, range 4-21) and adrenal involvement was not statistically significant. Preoperative CT demonstrated 97.7% specificity, 98.4% negative predictive value, 87% sensitivity and 80% positive value for adrenal involvement by RCC. CONCLUSIONS: Ipsilateral adrenalectomy should only be performed if a lesion is seen preoperatively on CT scan or if gross disease is seen at the time of nephrectomy. The prognosis is poor for RCC with ipsilateral involvement even with complete removal. Because of this poor prognosis we believe that adrenal involvement should constitute a separate stage category.

Solitary contralateral adrenal metastasis after nephrectomy for renal cell carcinoma.

Malignant involvement of the contralateral adrenal gland in cases of renal cell carcinoma is extremely rare. Solitary metachronous metastatic involvement of the contralateral adrenal gland from renal cell carcinoma is rarely diagnosed during life. In fact, clinical signs and symptoms of adrenal insufficiency are rare in these patients. We report a case of renal cell carcinoma with solitary metachronous contralateral adrenal metastasis occurring 9 years after radical nephrectomy.

[Spontaneous subcapsular renal hematoma: diagnosis and treatment. Two case reports]. / Hématomes spontanés de la loge rénale: diagnostic et traitement. A propos de deux cas.

Spontaneous perirenal haematomas essentially raise the problem of the aetiological diagnosis, but can sometimes be inadequate. Arteriography is useful when CT scan is negative or in the case of vascular disease. The therapeutic attitude, nephrectomy or conservative treatment remains controversial, but in view of the frequency of renal neoplastic lesions, the authors recommend nephrectomy at the slightest doubt concerning renal integrity. When no case be found, the assessment must be completed postoperatively with long-term, close surveillance, due to the risk of an undiagnosed neoplastic lesion. The authors report two recent cases and try to propose a diagnostic and therapeutic strategy based on the aetiology.