[Ovarian stimulation with gonadotrophins in patients with polycystic ovary syndrome]. / Stimulation ovarienne sous gonadotrophines chez des patientes atteintes de syndrome des ovaires polykystiques.

OBJECTIVES: The main objective of this study was to describe the ovulation rate in patients with polycystic ovary syndrome, treated with ovulation induction/intra-uterine insemination and follitropin alfa by gonadotrophins at a second attempt. METHODS: An observational, national and multicentre study was carried out: 51 French physicians (endocrinologists, gynaecologists) participated. Eligible patients were followed according to the usual clinical practices. The primary endpoint was the number of ovulations (spontaneous or triggered). Quality of life evaluation (by FertiQoL), compliance, and patient satisfaction were secondary endpoints. RESULTS: A total of 202 patients (mean age: 29.9 years; mean infertility: 2.9 years) were included: 78.4% met the Rotterdam definition. The ovulation rate was 93.3% (95% confidence interval [89.8; 96.8]%). At 12 weeks of gestation, 38 patients had an ongoing pregnancy. A difference of 10 points of the mean total FertiQoL score was observed between the two attempts. No patient reported missing injection. More than 9 in 10 patients said they were satisfied to very satisfied with the use of the pen injector for administration of follitropin alfa. Eight patients (4.0%) had hyperstimulation leading to cycle cancellation, and two patients (1.1%) reported ovarian hyperstimulation syndrome. CONCLUSIONS: At the second cycle of follitropin alfa stimulation, a high rate of ovulations, satisfactory compliance and tolerance profile associated with a change in quality of life were reported.

[Catatonia de novo, report on a case: immediate vital prognosis and psychiatric prognosis in longer term]. / Catatonie de novo, à propos d'un cas: pronostic vital immédiat et pronostic psychiatrique à plus long terme.

We report on the case of a 20 year old woman with no previous psychiatric history, who displayed a first episode of catatonia with acute onset. Symptoms started plainly with sudden general impairment, intense asthenia, headache, abdominal pain and confusion. After 48 hours, the patient was first admitted to an emergency unit and transferred to an internal medicine ward afterwards. She kept confused. Her behaviour was bizarre with permanent swinging of pelvis, mannerism, answers off the point and increasingly poor. The general clinical examination was normal, except for the presence of a regular tachycardia (120 bpm). The paraclinical investigations also showed normal: biology, EEG, CT Scan, lumbar puncture. Confusion persisted. The patient remained stuporous, with fixed gazing and listening-like attitudes. She managed to eat and move with the help of nurses but remained bedridden. The neurological examination showed hypokinaesia, extended hypotonia, sweating, urinary incontinence, bilateral sharp reflexes with no Babinski's sign and an inexhaustible nasoorbicular reflex. The patient was mute and contrary, actively closed her eyes, but responded occasionally to simple instructions. For short moments, she suddenly engaged in inappropriate behaviors (wandering around) while connecting back to her environment answering the telephone and talking to her parents. The patient's temperature rose twice in the first days but with no specific etiology found. During the first 8 days of hospitalization, an antipsychotic treatment was administered: haloperidol 10 mg per os daily and cyamemazine 37.5 mg i.m. daily. Despite these medications, the patient worsened and was transferred to our psychiatric unit in order to manage this catatonic picture with rapid onset for which no organic etiology was found. On admission, the patient was stuporous, immobile, unresponsive to any instruction, with catalepsy, maintenance of postures, severe negativism and refusal to eat. A first treatment by benzodiazepine (clorazepate 20 mg i.v.) did not lead to any improvement. The organic investigations were completed with cerebral MRI and the ruling out of a Wilson's disease. Convulsive therapy was then decided. It proved dramatically effective from the first attempt; 4 shocks were carried out before the patient's relatives ask for her discharge from hospital. The patient revealed she had experienced low delirium during her catatonic state. The clinical picture that followed showed retardation with anxiety. She was scared with fear both for the other patients and the nursing team. She kept distant and expressed few affects. The treatment at the time of discharge was olanzapine 10 mg per os. She was discharged with a diagnosis of catatonia but with no specific psychiatric etiological diagnosis associated. She discontinued her follow-up a few weeks later. After one year, we had no information about her. Catatonia has now become rare but remains a problem for clinicians. We reviewed data concerning short term vital prognosis and psychiatric long term prognosis in catatonia. Lethal catatonia is associated with acute onset, both marked psychomotor and neurovegetative symptoms. In the light of literature, there is no proband clinical criterion during the episode that is of relevant diagnostic value to ascertain the psychiatric etiology.

Pubourethral ligaments in women: anatomical and clinical aspects.

The anatomy and histological structure of the proximal (PPUL), distal (DPUL) and intermediate (IPUL) pubourethral ligaments in women was examined to improve the understanding of their roles in female urethral physiology. An anatomical study of the pelvis was carried out in 10 adult female cadavers (60-102 years), the pelvis being removed and frozen prior to dissection. The pubourethral ligaments (PUL) were dissected in sagittal sections in seven specimens and in a frontal section in one specimen; the remaining two pelves were dissected using a hypogastric approach. The location, insertion, direction and histological structure of the ligamentous structures were studied. The PUL were identified in all 10 dissections, being paired, symmetrical, pearly-white, fibrous and resistant to stretching. The bony (parietal) insertion was variable on the posterior surface of the pubis, while the visceral insertion was located on the dorsal aspect of the proximal third of the urethra and neck of the bladder for the PPUL and on the distal third of the urethra for the DPUL. Histologically, the ligaments were composed of dense collagen fibres and bundles of axially orientated smooth muscle fibres. The PPUL was closely associated with the sphincter urogenitalis muscle, whereas the DPUL appeared to reinforce the role of the compressor urethra. It is suggested that the PUL plays an effective role in passive and active suspension of the urethra. The pubourethral ligaments are a constant anatomical entity which should be spared in urethral surgery in women in order to ensure an intact urogenital sphincter.

Assessment of morbidity and functional results in bladder replacement with Hautmann ileal neobladder after radical cystectomy: a clinical experience in 55 highly selected patients.

OBJECTIVES: To analyze the morbidity and functional results of the ileal neobladder in a series of 55 highly selected patients. The ileal neobladder is a commonly used technique for orthotopic bladder reconstruction after radical cystectomy in both sexes. Good results have been published from Ulm University, where the technique was popularized. METHODS: From February 1994 to June 2000, 55 patients (47 men and 8 women), 32 to 75 years old (mean age 58) with good performance status (American Society of Anesthesiologists score 1 and 2), underwent radical cystectomy for bladder cancer and Hautmann ileal neobladder reconstruction. Functional assessments were done at 3 months and every 6 months thereafter, with special attention to urinary continence and upper urinary tract status. RESULTS: The median follow-up was 28.8 months (range 8 to 96). One perioperative death occurred. Early complications occurred in 23.6% without repeated surgery and late complications occurred in 25.4%, with three repeated operations for occlusive syndromes. The daytime and nighttime continence rates at 3, 6, and 12 months were 59.6%, 80.8%, and 88.5% and 38.5%, 61.5%, and 78.8%, respectively. The overall continence rate in patients younger than 70 years old was 80.8%. Three patients required self-catheterization to empty their neobladder. Eleven patients died of metastatic evolution of their bladder cancer or intercurrent disease at 6 to 36 months. CONCLUSIONS: In highly selected patients, the ileal neobladder provides good functional results regarding continence with an acceptable complication rate. In this series, the results were comparable to those reported in the referent institution.

Impact of a modified apical dissection during radical retropubic prostatectomy on the occurrence of positive surgical margins: a comparative study in 212 patients.

OBJECTIVES: To assess the impact of a modified technique of apical dissection during radical retropubic prostatectomy on the occurrence of positive surgical margins (PSMs). METHODS: Between 1992 and 1998, 212 nonconsecutive patients with localized prostate cancer (57 T1, 155 T2) underwent radical retropubic prostatectomy and were divided into two groups: group 1, 85 patients who underwent surgery before January 1994; and group 2, 127 patients who underwent surgery with the modification of the apical dissection after January 1994. The modified technique consisted of a wide excision of periprostatic soft tissue at the apex, including the bilateral neurovascular bundles. The clinical data (age, prostate-specific antigen, clinical staging) and pathologic findings (pathologic staging, Gleason score, PSM rate) of the two groups were compared. RESULTS: No significant difference was found between the two groups regarding the median prostate-specific antigen level (10.8 ng/mL and 9.5 ng/mL), Gleason score, and pathologic staging. Overall, the PSM rate was 53% in group 1 and 20.5% in group 2 (P <0.001). The number of PSMs decreased 2.6-fold in group 2. The PSM rate was significantly reduced at the apex with the new technique (group 1, 33.3%; group 2, 7.7%; P = 0.008). The PSM rate expressed with the odds ratio was 4.4-fold lower for patients in group 2 than for those in group 1. CONCLUSIONS: The modified apical dissection in radical retropubic prostatectomy significantly improves the PSM rate in patients with localized T1-T2 prostate cancer.

[Leiomyosarcoma of the renal vein]. / Le léiomyosarcome de la veine rénale.

The authors report a new case of leiomyosarcoma of the right renal vein, marked by a rapidly fatal course within 9 months, despite the initial absence of metastasis. This exceptional vascular tumour (only about thirty cases have been published) must be distinguished from primary renal leiomyosarcoma and retroperitoneal leiomyosarcomas involving adjacent structures. This difficult diagnosis was suggested by preoperative CT and angiography. Leiomyosarcomas of the renal vein generally have an unfavourable outcome in the medium term. The prognosis is related to the localized nature of the tumour and the risk of local and distant recurrence. Limited tumour resection is rarely sufficient and radical nephrectomy is usually necessary, possibly associated with a vascular procedure on the inferior vena cava in the case of contiguous extension.

Radical cystectomy in patients older than 75 years: assessment of morbidity and mortality.

OBJECTIVE: We have reviewed our surgical experience to assess intra- and postoperative morbidity and mortality in 25 patients 75 years old or older with invasive bladder cancer who underwent radical cystectomy and urinary diversion or bladder substitution. METHODS: Between January 1993 and February 1999, of 190 patients who underwent radical cystectomy, 23 men and 2 women were aged from 75 to 87 (median 79) years. Urinary diversion was performed in 23 cases and bladder substitution in 2. All patients had significant comorbidity and 15 patients were ASA II and 10 ASA III. RESULTS: Median operating time was 4 h. Perioperative mortality rate was 4%. Intraoperative, early and late postoperative complications occurred in 15, 16 and 6 patients, respectively. The most common early complications were pyelonephritis (32%), disorientation (20%), additional pulmonary infection (20%) and prolonged ileus (32%). No secondary procedures were necessary. The most common late complication was ureteroileal anastomotic stricture (16%). The median hospital stay and intensive care unit stay were 24 and 14 days, respectively. With a median follow-up of 14 (5-50) months the overall mortality rate was 32%. CONCLUSIONS: Radical cystectomy can be performed in elderly patients with acceptable perioperative mortality and morbidity. However, because of the high incidence of minor medical complications, hospital stay is often prolonged.

The tension-free transvaginal tape procedure in the treatment of female urinary stress incontinence: a French prospective multicentre study.

OBJECTIVE: To evaluate in a prospective multicentre study (five centres) the preliminary results regarding efficacy and morbidity of the new tension-free transvaginal tape (TVT) technique in the treatment of urinary stress incontinence (USI) in women. METHODS: From November 1996 to May 1999, 52 women of mean age 64 (range 37--91) years underwent the TVT procedure to treat isolated grade 2 or 3 USI (44 cases) or grade 1 or 2 USI associated with uterine or rectal prolapse surgery (8 cases). Twenty-nine patients (55.8%) presented recurrent USI (1--4 previous procedures). Clinical data showed urethrovesical junction hypermobility in 35 cases (67.3%), isolated intrinsic sphincter deficiency (ISD) in 17 cases (32.6%) and pelvic organ prolapse in 8 cases. Urodynamics confirmed ISD in 27 cases (51.9%) with a mean urethral closure pressure of 18.5 (range 7--25) cm H(2)O. All data were collected by surgeons on a questionnaire. RESULTS: The surgical procedure was performed under spinal cord anaesthesia in 82.7% of patients (local anaesthesia 11.5%) with a mean operation time of 30 (range 20--60) min for TVT implantation. Six bladder injuries (11.5%) were identified and the needle was repositioned. Mean hospital stay was 2.5 (range 1-7) days in the group who underwent TVT alone. Mean follow-up of continence was 15.2 (range 6--36) months: 83% of patients were dry and 17% were improved. Nine patients (17.3%) required self-catheterization for 2--10 days postoperatively. No recurrence of USI, defect healing or tape rejection were reported. CONCLUSION: TVT is a new technique for the surgical treatment of USI which is useful for recurrent cases. The advantages are simplicity, low morbidity, reproducibility and reduced operative time. These early results indicate the technique is effective in correcting incontinence and is locally well tolerated. But these are preliminary data and the long-term outcome on USI and the urethra is needed.

[Primary carcinoid tumor and horseshoe kidney: potential association]. / Tumeur carcinoïde primitive et rein en fer à cheval: une association possible.

The authors present the ninth case of primary carcinoid tumour arising in a horseshoe kidney. The diagnosis and treatment were delayed due to the benign cystic appearance of the initial lesion. This exceptional association must be kept in mind, as horseshoe kidney is associated with an increased risk of malignant tumours, especially for carcinoid tumours. The minimally aggressive nature of these tumours generally allows limited surgical resection.

Urological complications of laparoscopic surgery: experience with 350 procedures at a single center.

PURPOSE: We assessed our experience with urological complications of laparoscopic surgery in regard to incidence, etiology, treatment and possible prevention. MATERIALS AND METHODS: A total of 350 laparoscopic procedures were performed at our institution between June 1993 and December 1999 in 206 men and 139 women. These procedures included pelvic lymph node dissection in 102, bladder neck suspension in 99, adrenalectomy in 54, varicocelectomy in 23, pyeloplasty in 22, nephrectomy in 20, treatment of benign renal pathologies, including cyst, diverticula and calculi, in 13, genitourinary prolapse repair in 11 and miscellaneous procedures in 6 patients. Complications were evaluated according to the procedure attempted and were listed by incidence and etiology. RESULTS: A total of 19 (5.4%) complications occurred in our series. The associated mortality rate was 0.3% and conversion rate was 1.1%. Most intraoperative complications (2.6%) were vascular (4) and visceral injuries (5), while postoperative complications (2.8%) were predominantly thromboembolism (3) and wound infection (2) at trocar sites. The complication rate decreased from 9% for the first 100 to 4% for the subsequent 250 procedures. CONCLUSIONS: Critical documentation of complications of laparoscopic surgery is important for further development of the technique and information for urologists in training. Most of our serious complications should be preventable with better mastery of the different procedural steps. However, laparoscopy must be regarded as major surgery with a significant learning curve.

Retroperitoneal laparoscopic versus open pyeloplasty with a minimal incision: comparison of two surgical approaches.

OBJECTIVES: To compare the complications, hospital stay, and functional results of retroperitoneal laparoscopic (RL) pyeloplasty versus open pyeloplasty (OP) with a minimal subcostal incision. METHODS: From October 1997 to January 2000, 53 consecutive nonrandomized patients underwent 26 RL pyeloplasties, of which 1 was bilateral (group 1), and 28 OP (group 2). The decision between the two techniques depended on the patient's anesthetic ability to tolerate RL, previous ureteropelvic junction surgery, associated renal pathologic findings, and the surgeon's laparoscopic experience. Subjective outcomes as to postoperative pain and convalescence and objective findings on intravenous urography were assessed at 3 months postoperatively in both groups. RESULTS: The mean operating time (165 versus 145 minutes) and mean blood loss (92 versus 84 mL) were similar in both groups. No intraoperative complications occurred in either group; in group 1, 1 patient required open conversion. Postoperative complications occurred in 11.5% of group 1 and 14.3% of group 2. The mean hospital stay was 4.5 days for group 1 and 5.5 days for group 2. At 3 months, 23 patients (92%) in group 1 and 25 (89.2%) in group 2 were pain-free or improved. Intravenous urography showed a patent ureteropelvic junction in all cases and improvement of hydronephrosis in 88.5% of group 1 and 89.3% of group 2. CONCLUSIONS: The incidence of complications, hospital stay, and functional results were equivalent for RL pyeloplasty and OP with a minimal incision, but the return to painless activity was more rapid with laparoscopy in younger patients.

Congenital bilateral absence of the vas deferens: clinical characteristics, biological parameters, cystic fibrosis transmembrane conductance regulator gene mutations, and implications for genetic counseling.

OBJECTIVE: To evaluate relationships between the phenotypic and genotypic characteristics of patients with congenital bilateral absence of the vas deferens (CBAVD). DESIGN: Retrospective study. SETTING: A university hospital urology-andrology department. PATIENT(S): Forty-one men with CBAVD. INTERVENTION(S): CBAVD was diagnosed during surgical and/or ultrasound exploration of the vasa deferentia (VD) (n = 39), or on the basis of impalpable scrotal VD (n = 2). MAIN OUTCOME MEASURE(S): History, clinical and seminal characteristics, and cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations including IVS-8 polyT analysis. RESULT(S): A palpable scrotal vas deferens was present as a fibrous cord or nonpermeable duct in 13% of patients undergoing surgical exploration. Seminal vesicles were bilaterally absent in 28% of patients. No CFTR gene mutation or 5T allele was detected in 24.5% of the patients. Two CBAVD patients with renal agenesis carried a CFTR gene mutation (DeltaF508/5T-9T and R117G/7T-9T). CBAVD patients who have both a semen volume of < or =1.0 mL and a semen pH of < 7.0 have a significantly higher risk of severe CFTR gene mutation (OR = 9.12 [95% CI = 1.81-49.50]). CONCLUSION(S): A palpable scrotal vas deferens was found in 13% of CBAVD patients. Semen volume of < or =1.0 mL and semen pH of < 7.0 in CBAVD patients were associated with a higher risk of severe CFTR gene mutations. Patients with CBAVD and renal agenesis should be screened for CFTR gene mutations before assisted reproductive techniques are used.

[Assessment of urinary continence in Hautmann neobladder]. / Evaluation de la continence urinaire dans la néovessie de Hautmann.

OBJECTIVE: The Hautmann neobladder is a bladder replacement technique frequently proposed after total cystectomy for bladder cancer. The objective of this prospective study was to evaluate the patients' urinary continence after this operation, based on clinical and urodynamic data. MATERIALS AND METHODS: The functional assessment was based on 26 patients from a series of 45 consecutive Hautmann bladder replacements performed between February 1994 and May 1999. These 26 nonselected patients (21 men and 5 women) with a mean age of 56 years (range: 38-68) accepted the principle of functional assessment of continence at visits held 1, 3, 6 and 12 months postoperatively including clinical interview, urodynamic studies and fibroscopy. Only one patient presented with preoperative stress incontinence. The mean follow-up of these 26 patients was 22 months (range: 10-60). Three patients, including two women, died from progression of their bladder tumour at the 12th, 20th and 32nd postoperative months. RESULTS: Urodynamic studies showed a mean maximum capacity of the ileal reservoir of 420 ml (range: 316-571), a maximum filling pressure of 15 cmH2O (range: 2-24) and a maximum urethral closure pressure of 49 cmH2O (range: 31-74). According to the evaluation criteria used, the satisfactory continence rates, as assessed by the patients were 62%, 77%, 84.6% during the day and 42%, 615%, 77% at night, at 3, 6 and 12 months, respectively. CONCLUSION: The Hautmann neobladder ensures satisfactory diurnal and nocturnal urinary continence in more than 75% of cases after the 6th postoperative month. Continence is an evolving parameter especially during the first postoperative year. The selection of patients in good general condition and motivated for management of their new urinary situation remains an essential prerequisite to obtain a good functional result.

[Repair of female urinary incontinence with prolene "TVT": preliminary results of a multicenter and prospective survey]. / Cure d'incontinence urinaire féminine par bandelette de prolène "TVT": résultats préliminaires d'une enquête multicentrique et prospective.

OBJECTIVES: A multicentre, prospective study (6 private centres, 1 general hospital and 1 teaching hospital) was conducted to evaluate the perioperative morbidity and short-term functional results of the TVT procedure in the treatment of the female urinary stress incontinence. PATIENTS AND METHODS: From November 1996 to September 1999, 120 patients with a mean age of 65.2 years (range: 37-91) were operated according to the tension-free vaginal tape (TVT) technique for isolated urinary stress incontinence (stage 2 or 3) in 94 cases and associated with pelvic tone disorder in 26 cases. 59 patients (49.2%) presented recurrence of urinary incontinence that had already been operated between 1 and 4 times. Physical examination demonstrated hypermobility of the urethra in 73 cases (60.8%), isolated clinical sphincter incompetence in 47 cases (39.2%) and pelvic tone disorders in 31 cases. Urodynamic studies, performed in 113 patients, demonstrated sphincter incompetence in 65 cases (57.5%) with a mean maximum urethral closure pressure of 18 cmH2O (range: 5-29). RESULTS: The operation, performed under spinal anaesthesia in 97 cases (80.8%), general anaesthesia in 16 cases (13.3%) and local anaesthesia in 7 cases (5.8%) lasted an average of 28.7 min (range: 15-60) for insertion of the TVT. Perioperative complications consisted of twelve bladder injuries (10%) and two pelvic haematomas (1.7%). No cases of infection, erosion or migration of the tape were reported. In the group of 94 patients operated exclusively by TVT, the mean hospital stay was 2.6 days (range: 1-7). Twelve patients (10%) required self-catheterization for 2 to 30 days. With a mean follow-up of 15.2 months (range: 36-6), continence was restored in 104 patients, corresponding to a cure rate of 86.7%. A marked improvement was obtained in 11 cases (9.2%) and five cases (4.2%) were considered to be failures. CONCLUSION: The TVT procedure is a new approach to the treatment of female urinary stress incontinence. Its advantages are its simplicity, the rapidity of the technical procedure and the short-term efficacy on continence. A longer follow-up is essential to assess to the functional outcome and the long-term urethral tolerance.

[Kock's pouch: experience and clinical course in 31 patients]. / La poche de Kock: expérience et évolution chez 31 patients.

OBJECTIVES: To analyse the morbidity and functional results of Kock's continent urinary diversion performed since 1992 in cystectomized patients in whom the urethra could not be used. MATERIAL AND METHODS: From March 1992 to June 1998, 31 Kock's pouches were performed by 2 surgeons on a group of patients with a mean age of 54 years. Henriet's technique was used in 23 patients until 1996, and was then modified the last 8 patients in order to create a continent valve. The diversion was performed after cystectomy for bladder or gynaecological tumour in 23 cases and 1 urinary tract reconstruction in 8 cases (neurogenic bladder, destroyed urethra, conversion of Bricker diversion). RESULTS: With a mean follow-up of 42 months (12 to 84), the perioperative mortality was 3.4% and immediate complications were 26%, justifying reoperation in 6.4%. Late complications predominantly consisted of disinvagination of the valve with a reoperation rate of 13%. No surgical revision for newly modified antireflux valves has been performed since 1996. The continence rate of the system, evaluated between 3 and 6 months, was 90%. CONCLUSION: Kock's pouch is a delicate operation, clearly associated with a high morbidity in this series, as in the literature, although the results improved with experience. Indications must be confined to patients in good general condition, motivated for self-catheterization (ATS) and in whom the urethra cannot be used for bladder replacement.

Retroperitoneal laparoscopic adrenalectomy: clinical experience in 52 procedures.

OBJECTIVES: Laparoscopic adrenalectomy has become an effective option for removal of small adrenal tumors. The aim of this prospective study was to evaluate the retroperitoneal approach with regard to intraoperative complications, morbidity, and length of hospital stay. METHODS: Between September 1996 and October 1999, we performed 52 laparoscopic adrenalectomies (31 left, 21 right) for benign lesions by a retroperitoneal approach in 44 patients (27 women, 17 men) with a mean age of 46.9 years (range 17 to 74). The average adrenal tumor size was 32 mm (range 10 to 63). All procedures required four trocars and a mean operative time of 135 minutes (range 75 to 240). RESULTS: There was no mortality, conversion rate to open surgery was 1.9%, and estimated blood loss was 80 mL (range 30 to 200). With a mean follow-up of 16 months, morbidity was 17.2%, which included intraoperative complications (5. 7%) with two vascular injuries, and postoperative complications (11. 5%) with wound infections, deep hematoma, and parietal dehiscence. Average length of hospital stay was 5 days with a mean analgesic consumption of 2 days (range 1 to 5). CONCLUSIONS: The retroperitoneal approach in laparoscopic adrenalectomy appears to be a minimally invasive and safe therapeutic option that may become the standard for unilateral or bilateral adrenal tumors not larger than 7 cm. However, a learning curve in laparoscopy is indispensable before starting this type of procedure.

[Pfannenstiel short horizontal laparotomy in retropubic radical prostatectomy]. / La laparotomie horizontale courte selon Pfannenstiel dans la prostatectomie radicale rétropubienne.

OBJECTIVE: To evaluate the feasibility of the Pfannenstiel short horizontal laparotomy to perform retropubic radical prostatectomy and its consequences on postoperative analgesic consumption. MATERIALS AND METHODS: From December 1998 to February 2000, 62 radical prostatectomies were performed via a short horizontal suprapubic incision. The mean length of the incision in the lower abdominal fold was 10.2 cm (range: 8 to 14 cm). The mean duration of radical prostatectomy was 130 minutes (range: 90 to 210 min). Double drainage (retropubic and subaponeurotic) was systematically maintained for an average of 48 hours. Postoperative narcotic analgesic consumption, and the modalities and duration of prescription were compared between 30 patients operated by this technique and 30 patients previously operated via a midline infraumbilical incision. RESULTS: The abdominal wall opening and closing time was about 20 minutes. The operation was always performed via this incision, allowing excellent exposure of lymph node areas and the prostate. Postoperative complications related to this incision consisted of a single subaponeurotic haematoma, which was not drained. The mean dosage and duration of postoperative analgesic consumption decreased by 44% compared to the reference group. Postoperative assessment of the abdominal wall showed almost complete disappearance of the scar at 3 months and no secondary wound dehiscence. CONCLUSION: The Pfannenstiel short horizontal laparotomy is a simple and reproducible technique for retropubic radical prostatectomy. This feasibility study was accompanied by a reduction of postoperative analgesic consumption in the study group.

[Renal adenocarcinoma with retrohepatic vena cava thrombus: role of extracorporeal circulation in a retrospective series of 10 cases]. / L'adénocarcinome rénal avec thrombus cave rétro-hépatique: place de la circulation extra-corporelle sur une série rétrospective de 10 cas.

INTRODUCTION: Renal cell carcinoma is accompanied by tumour thrombus in the inferior vena cava (IVC) in 4 to 10% of cases. Since the use of cardiopulmonary bypass (CPB), surgery for extensive thrombus has been improved by reduction of blood loss, facilitating complete resection of the kidney and thrombus and possible repair of the inferior vena cava. OBJECTIVES: To analyse a retrospective series of 10 cases and to compare the complications of CPB and conventional surgery by direct clamping. MATERIAL AND METHODS: From February 1985 to December 1997, 413 patients were operated for renal cancer, including 23 (5.6%) patients with tumour thrombus in the inferior vena cava. Ten of these 23 cases of inferior vena caval thrombus were retrohepatic. Group I (5 patients) was operated under CPB and profound hypothermia at 16 degrees C (mean duration of bypass: 30 min). Group II (5 patients) was operated by conventional surgery (CS) (mean clamp time: 12 min). RESULTS: No difference in terms of intraoperative complications was observed between the two groups, but 2 deaths occurred in group II due to respiratory decompensation, 1 and 2 weeks postoperatively. CONCLUSION: The level of the thrombus in the inferior vena cava determines the mode of vascular management. The presence of invasion of the inferior vena cava wall is difficult to predict because of the poor sensitivity of radiological examinations. CPB did not induce any excess morbidity in this series. The use of CPB in renal cancers with retrohepatic thrombus facilitates the resection procedure and allows inferior vena cava reconstruction in a bloodless environment.

[Large-cell calcifying Sertoli cell tumors: apropos of a case and review of the literature]. / Les tumeurs calcifiées à grandes cellules de Sertoli: à propos d'un cas et revue de la littérature.

The authors report the case of a 22-year-old man presenting with a tumour of the lower pole of the left testis, present for 4 months, which proved to be a calcified Sertoli large cell tumour, an extremely rare group of sex cord tumours of the testis presenting specific clinical and histological features. These tumours are usually benign, occur during the first two decades of life and can be associated with dysplastic complexes or endocrinopathies (Carney's complex, Peutz-Jeghers syndrome). They present either in the form of bilateral, multifocal tumours in the context of a pathological association, or in the unilateral form, without association. Several malignant forms with metastases have been described. Conventional treatment is transinguinal radical orchidectomy.

[Value of free PSA/total PSA ratio in therapeutic decisions in the case of a single positive biopsy of the prostate]. / Intérêt dans la décision thérapeutique du rapport PSA libre/PSA total en cas de biopsie de prostate unipositive.

OBJECTIVES: Study of the value of the free PSA/total PSA ratio in the therapeutic decision concerning prostatic adenocarcinoma, in the case of a single positive biopsy. MATERIAL AND METHODS: The free PSA/total PAS ratio was calculated on serum samples derived from 37 patients with clinically localized prostatic carcinoma and only one positive biopsy, in whom radical prostatectomy was performed. RESULTS: The free PSA/total PSA ratio appeared to be independent of pathological stage and histological prognostic criteria (grade and score, degree of capsular effraction). CONCLUSION: In the case of a single positive biopsy, calculation of the free PSA/total PSA ratio does not appear to provide any decisional criteria in favour of radical prostatectomy.