Laparoscopic pyeloplasty: comparison between retroperitoneoscopic and transperitoneal approach.

OBJECTIVE: To compare both approaches of laparoscopic pyeloplasty, transperitoneal vs retroperitoneoscopy. METHODS: A total of 65 procedures were performed in 62 patients, 36 females and 26 males. Laparoscopic pyeloplasty with Anderson Hynes technique was performed transperitoneal in 34 cases and retroperitoneal in 31 cases. Parameters studied were the operative duration, the rate of conversion to open approach, transposition of crossing vessel, complications and reintervention, results, and the duration of hospitalization. Then, overall success rate for both approaches was evaluated in the presence or absence of crossing vessels, and if transposition of crossing vessel was performed vs without. RESULTS: The overall success rate for both procedures was 85% (87% for the retroperitoneal vs 82% for the transperitoneal approach). The mean operative duration was 231.69 ± 59.97 and 194.76 ± 25.37 minutes for the retroperitoneal and transperitoneal approaches, respectively (P = .029). The rate of conversion was 19.35% (6 of 31) and 2.9% (1 of 34) for the retroperitoneal and transperitoneal approaches, respectively (P = .047). No significant statistical difference was noted between both techniques related to the age of patient, the hospital stay, and intraoperative and postoperative complications. Transposition of crossing vessel had no effect on the results (81.25% with transposition and 80% if not, P = .93). CONCLUSIONS: Retroperitoneoscopic approach is associated with longer operative time and more conversion rate than transperitoneoscopy. However, the overall outcomes of laparoscopic transperitoneal pyeloplasty vs retroperitoneoscopic were comparable.

Radical cystectomy for bladder cancer: morbidity of laparoscopic versus open surgery.

PURPOSE: We compared the morbidity and mortality of laparoscopic vs open surgery in radical cystectomy for bladder cancer. MATERIALS AND METHODS: This prospective, nonrandomized study was conducted between January 2003 and July 2007 in 68 patients (7 women and 61 men) who underwent radical cystectomy for bladder cancer. A total of 38 cystectomies were performed laparoscopically and 30 by open surgery. Mean patient age was 68.0 +/- 9.0 years. Median preoperative American Society of Anesthesiologists score was 2 (range 1 to 3) in both groups. RESULTS: Intraoperative blood loss and transfusion rate were significantly lower in the laparoscopic surgery group. Postoperatively the incidence of minor complications and mortality were also significantly lower. Postoperative opioid consumption was significantly less in the laparoscopic surgery group in amount and duration. Resumption of oral fluid and solid intake as well as return to normal bowel function were significantly more rapid in the laparoscopic surgery group, and mean hospital stay was significantly shorter. Mean patient followup was 30.5 +/- 17.2 months. CONCLUSIONS: Laparoscopic radical cystectomy for bladder cancer has a lower morbidity rate than cystectomy by open surgery. It allows more rapid resumption of oral fluid and solid intake as well as return to normal bowel function and shorter hospital stay.

Prostate cancer in renal transplant recipients.

BACKGROUND: We conducted a retrospective multi-centre study to determine the characteristics of prostate cancer in renal transplant recipients (RTR) and to analyse the relation with immunosuppressive maintenance therapies. METHODS: Patients from 19 French transplant centres diagnosed with prostate cancer at least 1 year after kidney transplantation were included in this study. Data regarding demographics, kidney transplantation, prostate cancer and immunosuppressive treatment were analysed. RESULTS: Sixty-two patients met the eligibility criteria for this study. Thirty-eight patients (61.3%) received calcineurin inhibitors (CNI) and azathioprine (AZA) with or without steroids, twenty received CNI with or without steroids (32.2%) and four received CNI and mycophenolate mofetil (6.5%). Patients with CNI and AZA immunosuppressive therapy presented more high-stage cancer (T3 and T4) when compared to patients receiving CNI alone (47.5% versus 15%, respectively, P = 0.03). A non-significant increase in lymph node invasion was found in patients receiving CNI and AZA compared to patients receiving CNI alone (21% versus 5%, P = 0.16). In the multivariate analysis, the immunosuppressive regimen with CNI and AZA was the only independent risk factor for locally advanced disease (P = 0.007). CONCLUSION: Our results showed that RTR are at risk for early occurrence and for locally advanced prostate cancer, especially when they received a CNI and AZA maintenance immunosuppressive therapy.

[Conservative management of renal haemangioma: value of a synergistic combination of flexible ureteroscopy and CT angiography]. / Traitement conservateur d'un hémangiome rénal: intérêt de la synergie urétéroscopie souple et artériotomodensitométrie.

Renal haemangioma (RH) is a rare congenital vascular lesion that is frequently responsible for macroscopic haematuria. This lesion is difficult to diagnose preoperatively despite progress in imaging techniques. These diagnostic difficulties account for the high rate of radical treatment (nephrectomy or nephro-ureterectomy) due to a suspicion of renal carcinoma or upper urinary tract tumour. However, conservative diagnostic and therapeutic management can be performed by a combination of CT angiography, flexible ureteroscopy and selective embolization.

Uterus, fallopian tube, ovary and vagina-sparing laparoscopic cystectomy: technical description and results.

OBJECTIVES: The purpose of our study was to demonstrate, describe, and assess the results of the technique of laparoscopic cystectomy sparing the uterus, fallopian tubes, ovaries, and vagina. PATIENTS AND METHODS: Between July 2004 and December 2005, 13 women with neurogenic vesical dysfunction (mean age: 53.3+/-13.0 yr) underwent laparoscopic cystectomy sparing the uterus, fallopian tubes, ovaries, and vagina. A noncontinent transileal Bricker diversion was performed extracorporeally in each case. Parameters studied were the pre-, peri- and postoperative data. RESULTS: Mean duration of the operation was 325+/-36 min, and mean blood loss was 323.1+/-246.3 ml. No conversion was required. One perioperative complication was observed: a tear in a branch of the right hypogastric vein, which was sutured under laparoscopy. One patient was transfused during surgery (2 units of blood). No early or late postoperative complications were observed. One patient required transfusion of 2 units of red blood cell concentrate on the first day after surgery. None of the patients required opiate analgesia in the postoperative period. The analgesic regimen used was paracetamol and nefopam in all cases. The pain score on an analogic visual scale was less than 4 in all cases. Resumption of transit was not delayed in any of the patients. Mean hospital stay was 11.6+/-1.9 d. Over an average follow-up of 7.4+/-5.4 mo, none of the patients developed late complications. Before surgery, 77% of the women were sexually active; 80% of them were sexually active 4 mo after the surgery. CONCLUSIONS: Laparoscopic cystectomy sparing the uterus, fallopian tubes, ovaries, and vagina is feasible. This operation has low morbidity and requires only a limited stay in hospital.

Perihepatitis and perinephric abscess due to Mycoplasma hominis in a kidney transplant patient.

Mycoplasma hominis has been incriminated in several genital and extragenital infections. Here, we report the first case of perihepatitis associated with a perinephric abscess in a woman who had received a kidney transplant. Four months after the transplant, the patient was admitted for perirenal allograft pain, fever, and elevated inflammatory parameters and liver enzyme levels. A renal ultrasonography found a collection of fluid. Results of blood and urine analyses were within normal limits. Fluid aspiration of the peritoneal cavity was performed, and the results of cultures for bacteria and fungi were negative. The patient was treated by surgical lavage of the peritoneal cavity. Her fever resolved 5 days later. Two months after surgical lavage of the peritoneal cavity, her liver enzyme levels returned to the normal range. Three months after surgical lavage, cultures of the perinephric fluid showed Mycoplasma hominis. We conclude that in patients who present with perinephric fluid suspected of being infected, bacteriologic analysis of the fluid (from surgical lavage of the peritoneal cavity) should be performed. Antibiotics active against intracellular bacteria should be administered.

[Laparoscopic live donor nephrectomy: surgical technique and results]. / Preélèvement laparoscopique du rein de donneur vivant: résultats et aspects chirurgicaux.

OBJECTIVE: To report the results of laparoscopic live donor nephrectomy (LLDN) and to describe our technique. MATERIAL AND METHODS: We retrospectively reviewed 47 laparoscopic live donor nephrectomies performed between January 1999 and July 2005. Several parameters were studied: donor clinical characteristics, intraoperative and postoperative complications, operating time and warm ischaemia time. This series comprised 26 women (55.31%) and 21 men (44.68%) with a mean age of 48 +/- 20 years. Donor nephrectomy was mainly performed on the left kidney (85.37%). It was performed by lumbar endoscopy in the first 20 cases and by laparoscopy in 27 cases. Kidney extraction was performed via an incision between two trocar orifices for the first cases and via an iliac incision for the last 18 cases. RESULTS: The mean operating time was 189 min with a mean blood loss of 127 ml. Warm ischemia time was 6 minutes. Open conversion was required in two cases: renal vein injury in one case and an obese donor with difficulties of dissection in the other case. Surgical revision was required in only one case (haemoperitoneum secondary to genital vein injury). A trocar orifice abscess was observed in one case and prolonged ileus was reported in 2 cases. In the recipient, a urinary anastomotic fistula was observed secondary to ischaemic necrosis of the distal segment of the ureter. Late complications were essentially vascular (19.14%). A right renal graft was lost due to an error of compatibility. Mean serum creatinine was 132 +/- 6.5 micromol/l at 3 months for the other recipients. CONCLUSION: Our experience confirms the feasibility and efficacy of laparoscopic live donor nephrectomy. Intraoperative and postoperative complications and the conversion rate were low. Renal function was rapidly restored in the recipient. The morbidity of this technique is low, but there is a high risk of vascular complications at the beginning of the operator's experience.

[Linguistic validation of the "Brief Index of Sexual Functioning for Women"]. / Validation linguistique du "Brief Index of Sexual Functioning for Women". Application a l'etude de la sexualité dans une population de 93 femmes franaaises.

UNLABELLED: Application to the study of sexuality in a population of 93 French women. OBJECTIVES: This study was designed to linguistically validate the French version of the BISF-W (Brief Index of Sexual Functioning for Women) which provides a quantitative and qualitative assessment of female sexuality according to 7 dimensions. This version was then used to study the impact of recognized factors of sexual dysfunction on a control population. MATERIAL AND METHOD: The BISF-W a self-administered quality of life questionnaire developed by Rosen, was translated and linguistically validated. This questionnaire comprises 22 questions in 7 dimensions investigating all aspects of female sexuality: D1 (desire), D2 (arousal), D3 (frequency of sexual activity), D4 (receptiveness), 05 (pleasure, orgasm), D6 (relational satisfaction), D7 (problems affecting sexuality), Composite Score (CS) D1+D2+D3+D4+D5+D6+07. The French version was administered to a study population of 93 women: 49 derived from gynaecology or urology departments and 44 derived from the general population. We calculated and compared the scores of the various dimensions of the BISF-W according to factors able to modify sexuality, such as menopause, age or parity. RESULTS: The results of our study show an alteration of the various dimensions of sexuality in elderly patients (D2, D5, D6, CS; p<0.05) or postmenopausal patients (D2, D5, D6, CS, p<0.05) and in multiparous women. CONCLUSION: The French version of the BISF-W gives results in line with the literature and demonstrates changes of sexuality as a function of the above mentioned variables.

Impact of mycophenolic acid dose modifications on renal function after kidney transplantation.

OBJECTIVE: Mycophenolic acid dose modifications after renal transplantation seem to adversely affect renal allograft outcome. The aim of this retrospective study was to examine the effect of mycophenolic acid dose modifications on renal function 1 year after transplantation and to determine the factors predictive of those dose modifications within the first year after renal transplantation. PATIENTS AND METHODS: All 130 patients at our institution who were treated de novo between January 2002 and April 2003 with either a mycophenolate mofetil-based or an enteric-coated mycophenolate sodium-based therapy and who had a functioning renal allograft 1 month after transplantation were included in this study. RESULTS: Fifty-seven patients (43.8%) underwent a dose modification during the first year after transplantation. One, 3, 6, and 12 months after transplantation, renal function was significantly improved in the patients who did not receive a dose modification. A mycophenolic acid dose that 1 year after transplantation was less than the initial dose received just after transplantation was an independent factor associated with deteriorating renal function. Sirolimus immunosuppression, Cytomegalovirus infection, and pretransplant lymphocyte counts were independent factors associated with mycophenolic acid dose modifications within the first year after kidney transplantation. CONCLUSIONS: Modification of the mycophenolic acid dose may adversely affect renal function 1 year after transplantation.

[Prospective study of iliac extraction of the kidney after laparoscopic nephrectomy]. / Extraction du rein par voie iliaque après néphrectomie laparoscopique.

INTRODUCTION: Various routes are used to extract the operative specimen during laparoscopic nephrectomy. The main points are compliance with rules of cancer surgery, when applicable, and minimum wall destruction. The objective of this study was to prospectively evaluate the low iliac approach. MATERIAL AND METHOD: Prospective follow-up of 23 laparoscopic nephrectomies (17 tumours and 6 living donor kidney harvestings) in which the kidney was extracted via a low iliac incision measuring 5 to 7 cm. RESULTS: The mean operating time was 188 +/- 50 min with a mean blood loss of 112 +/- 126 ml. The mean duration of the incision was 10 minutes. In the case of a tumour the mean weight of the operative specimen was 571 +/- 127 g in and the mean diameter of the mass was 5.7 +/- 1.9 cm. All grafted kidneys functioned normally. No surgical conversion was necessary. The mean follow-up was 9.6 +/- 1.2 months. No late postoperative complications were observed. CONCLUSION: Radical nephrectomy or living donor kidney harvesting can be performed via laparoscopy with extraction of the operative specimen via a low iliac incision. This incision ensures extraction of very large specimens while preserving the aesthetic and functional advantages of laparoscopy with no increased cancer risk. They are simple to perform and easily reproducible via a transperitoneal or retroperitoneal approach. Absence of muscle section maintains the integrity of the abdominal wall. No postoperative incisional hernia has been observed.

Three-dimensional conformal radiotherapy for localized prostate cancer in kidney transplant recipients.

BACKGROUND: This is the first report of graft function and prostate cancer control in renal transplant recipients subjected to modern conformal radiotherapy. METHODS: Eight kidney transplant recipients were treated with three-dimensional conformal radiotherapy. All patients but one were subjected to transitory hormonal deprivation. A three-dimensional radiotherapy-planning system (Pinnacle, Philips Medical System, Bothell, WA) was used to delineate anatomic contours on pretreatment computed tomography and for dose computation. The clinical target volume encompassed the prostate and was expanded with a 10-mm wide margin in all directions to obtain the planning target volume. The irradiation technique consisted of a nine-field arrangement delivering 70 Gy in 2-Gy fractions, with 18-MV photon beams. Biochemical recurrence was defined as two consecutive increases in prostate-specific antigen (>1.5 ng/mL). Graft function was monitored by creatinine clearance. Excretory profiles were assessed by furosemide-stimulated diethylenetriaminepentaacetic acid renography. All patients were subjected to hip magnetic resonance imaging to assess for avascular hip necrosis. RESULTS: After a mean follow-up of 28 months, two patients showed isolated biochemical recurrence and six patients remained free of recurrence. In seven patients with functional allografts, the creatinine clearance was unimpaired by treatment. However, significant obstruction of the terminal ureter was revealed in two patients by furosemide-stimulated diethylenetriaminepentaacetic acid renograms. The doses delivered to the uretero-neocystostomy were calculated to range from less than 20 Gy to more than 45 Gy depending on bladder repletion. CONCLUSIONS: Adequate cancer control was achieved at the expense of infraclinical ureteral obstruction. The doses delivered to the uretero-neocystostomy may be reduced by having a full bladder at the time of irradiation. No avascular hip necrosis was observed.

[Laparoscopic cystoprostatectomy, initial experience: 13 patients]. / Cysto-prostatectomie laparoscopique, expérience initiale à propos de 13 cas.

From July 2003 to February 2004, 13 laparoscopic radical cysto-prostatectomies have been achieved in our department. The technique is describe, the ablation of the bladder and prostate is done through a pure laparoscopic approach when the reconstruction is done trough a small incision under the umbilicus. The uretro-neobladder anastomoses are performed under laparoscopy after re-integration of the bladder. All procedures have been successfully achieved; the mean operative time is 400 minutes, 320 for the cutaneous diversions and 450 for the Camey 2 procedures. Blood loss were 390 ml, blood transfusion was d for only one patient. No major complication was observed, the mean hospital stay was 14.2 days (+3.5). In our experience laparoscopic radical cystectomy is a safe option, associated with shorter hospital stays and gentler postoperative recovery.

[Symptomatic vesicoureteral reflux in kidney transplantation: results of endoscopic injections of teflon and predictive factors for success]. / Reflux vésico-urétéral symptomatique chez le transplanté rénal: résultats des injections endoscopiques de téflon et facteurs prédictifs de succès.

OBJECTIVES: Evaluation of the results of endoscopic Teflon injections for the treatment of symptomatic vesicoureteric reflux in renal transplant recipients and identification of prognostic factors. POPULATION AND METHODS: Between June 1997 and January 2002, out of a series of 408 renal transplant recipients, 15 patients (8 males, 7 females) with a mean age of 41.9 years were treated for symptomatic vesicoureteric reflux on the transplanted kidney by endoscopic Teflon injection. This treatment was indicated due to the presence of febrile or afebrile infections, possibly associated with deterioration of renal function. Reflux was demonstrated by retrograde cystography. The results of endoscopic treatment were evaluated by cystography at 3 months, and by clinical and laboratory examinations thereafter. RESULTS: The mean interval between renal transplantation and endoscopic treatment was 64.2 +/- 64.7 months. With a mean follow-up of 25 +/- 16.7 months, we observed a 53.3% success rate (8 patients), 13.3% of patients (2 patients) were improved and 33.3% of procedures were considered to be failures (5 patients). A lower number of preoperative infections, reflux < or = grade III and the absence of impaired renal function are predictive factors for the success of endoscopic treatment. The only complication was one case of renal colic due to meatal stenosis at 3 months, which responded favourably to endoscopic treatment alone. CONCLUSION: Endoscopic treatment of symptomatic vesicoureteric reflux on a transplanted kidney by Teflon injection is effective in two-thirds of cases. Due to the low morbidity of this minimally invasive procedure, this treatment should be proposed as first-line management for all cases of symptomatic vesicoureteric reflux on a transplanted kidney.

[Retroperitoneal laparoscopic nephrectomy fo polycystic kidney: preliminary results]. / La néphrectomie laparoscopique rétropéritonéale pour polykystose rénale: résultats préliminaires.

OBJECTIVES: To evaluate the morbidity and mortality of retroperitoneal laparoscopic nephrectomy for polycystic kidney. MATERIAL AND METHODS: Between June 2000 and March 2002, seven retroperitoneal laparoscopic nephrectomies for polycystic kidney were performed in six patients (three men, three women) with a mean age of 52.8 years. All patients presented end-stage renal failure treated by haemodialysis in five cases and by renal transplantation in one case. The ASA score was 2 in four cases and 3 in two cases. The indication for surgery was preparation for renal transplantation, episodes of macroscopic haematuria and pain in three cases, hypertension poorly controlled by medical treatment in two cases, preparation for renal transplantation in one case and pain associated with restrictive respiratory syndrome due to compression in one case. RESULTS: The mean operating time was 4 hours 35 minutes, and the mean blood loss was 400 ml. There were no intraoperative or perioperative deaths. An early postoperative complication occurred in two cases. The mean hospital stay was 11 days, with a mean stay of 2.4 days in the postoperative intensive care unit. No late complications were observed with a mean follow-up of 14 months. Preoperative pain, episodes of haematuria, hypertension and signs of compression resolved in each case. CONCLUSION: Laparoscopic nephrectomy for polycystic kidney is a technique that can be performed via a retroperitoneal approach without manual assistance and with low morbidity.