[Ureteral replacement with non-modelled isoperistaltic ileoplasty]. / Remplacement urétéral par iléoplastie isopéristaltique non modelée.

OBJECTIVES: To study the long-term morbidity and efficacy of ureteroileoplasty in a retrospective series of 18 patients. MATERIALS AND METHODS: 12 men and 6 women with a mean age of 50 years underwent ureteroileoplasty with unilateral replacement in 15 patients and bilateral replacement in 3 patients. A total of 21 units renoureteral units were repaired by this technique. The pelvic ureter was replaced in 16 renoureteral units, the lumbar ureter was replaced in 1 case and the entire ureter was replaced in 4 cases. The commonest ureteral lesions were strictures secondary to ureteroscopy or ureterolithotomy (40%). All patients had normal renal function, except for one patient with serum creatinine of 224 mumol/l. RESULTS: With a mean follow-up of 25 months (range: 3 to 64 months) all ureteroileoplasties were patent with no major morbidity. Only the patient with preoperative renal failure developed hyperchloraemic acidosis with deterioration of her renal function. CONCLUSION: In the absence of renal failure, ureteroileoplasty is an operation with low morbidity achieving good medium-term results.

[Prognostic factors of renal adenocarcinoma: study of a series of 233 patients]. / Les facteurs pronostiques de l'adénocarcinome rénal: Etude d'une série de 233 patients.

OBJECTIVE: To identify certain prognostic factors of renal cell carcinoma in a retrospective series of 233 patients. PATIENTS AND METHODS: 233 patients (162 males and 71 females with a mean age of 60 years) were operated for renal cell carcinoma between January 1980 and December 1991. sith a mean follow-up of 41.7 months. Statistical analysis was performed according to the Kaplan-Meier method for survival curves, according to the Mantel-Cox model for univariate or multivariate analysis and according to Student's t test and Chi-square test for comparison of quantitative and qualitative variables. RESULTS: The operative and global mortality was 2.2% and 28%, respectively. The following prognostic factors were identified: visceral metastases (p = 0.0001), lymph node invasion (p = 0.001), symptomatic nature of the tumour (p = 0.0004), local pathological stage (p = 0.0001) and nuclear grade (p = 0.0001). Multivariate analysis showed that the first 3 factors were the most pejorative (relative risk (RR) = 6.7, 4.6, and 1.7, respectively). Venous invation, multifocal tumours, and cell type were not studied in our series. CONCLUSION: This study confirmed that metastases, lymph node invasion and symptomatic tumours were the most pejorative prognostic factors.

Prognostic value of nuclear grade of renal cell carcinoma.

BACKGROUND: The authors assessed the interest and the value of Fuhrman's nuclear grade as a possible prognostic factor for renal cell carcinoma (RCC). METHODS: An 11-year retrospective study of 190 patients with RCC treated by radical nephrectomy was performed. The distribution by grade was: Grade I, 54 patients; Grade II, 58; Grade III, 58; and Grade IV, 20. The distribution of the patients by tumor stage according to the TNM15 classification was: pT1, 56 patients; pT2, 41; pT3a, 55; pT3b, 25; pT3c + pT3d + pT4b, 5; and pT4a, 8. Significant correlations with other prognostic parameters were noted. Survival curves by grade were evaluated by the Kaplan-Meier method. RESULTS: Nuclear grade was correlated with tumor stage (P = 0.0001), synchronous metastases (P = 0.003), lymph node involvement (P = 0.0001), renal vein involvement (P = 0.0001), tumor size (P = 0.0001), and perirenal fat involvement (P = 0.001). No correlation was found between nuclear grade and tumor multicentricity (P = 0.14) and cell type (P = 0.2). Nuclear grade was an effective parameter in predicting development of distant metastases after nephrectomy. Among the 54 patients who presented with Grade I tumors, only one tumor did metastasize during the 5-year follow-up, whereas 17% of the Grade III and 30% of the Grade IV tumors metastasized. The 5-year actuarial survival rates of the patients with Grade I, II, III, and IV tumors was 76%, 72%, 51%, and 35%, respectively. The comparison of the survival curves by grade showed a statistically significant difference between the curves when Grade I and II tumors were compared with Grade III and IV tumors (P = 0.001). CONCLUSION: In this study, nuclear grade was found to have prognostic significance and seems to be an important criterion when considering the outcome of patients with RCC.

[Outcome of kidney transplants with multiple arteries]. / Evolution des transplants rénaux à artères multiples.

OBJECTIVES: To evaluate the morbidity of multiple artery renal transplants (> 1 artery) and to assess the value of this parameter as a risk factor for complications of renal transplantation in adults. METHODS: 140 renal transplants derived from brain dead donors with multiple arteries (2 arteries = 123, 3 arteries = 17) were reviewed with a mean follow-up of 3 years (6-120 months). Pedicle restoration was performed in 57 cases (end-to-side reimplantation of a polar artery = 17, composite aortic patch graft = 14, multiple procedures = 10, ligation of a polar artery = 8, arterial wound = 5, "gun barrel" anastomosis of 2 arteries = 4). Arteriography was performed systematically in 57 cases, in the absence of any signs suggestive of a vascular complication. RESULTS: 2 recipients died from a vascular complication. 40% of transplants were functional at 5 years. 10 transplantectomies were performed for a vascular complication. 14 recipients returned to dialysis because of a vascular complication. 7.5% of systematic arteriographies revealed stenosis of the transplant artery. 54 transplants developed a vascular complication: thrombosis = 19, stenosis = 25. Three-artery transplants had a vascular morbidity of 50%. "Gun-barrel" anastomoses and polar reimplantations into the main trunk had a vascular morbidity of 40%. The urological morbidity was 10%. CONCLUSION: Multiple artery renal transplants, especially 3-artery transplants and certain pedicle restorations, are associated with a high risk of vascular complications. Arterial anatomy is a selection criterion for the donor and recipient which must be taken into account in renal transplantation.

[Cystectomy followed by cecocystoplasty: functional and oncologic results. An experience of 101 cases]. / Cystectomies suivies de caecocystoplasties: résultats fonctionnels et carcinologiques. Une expérience de 101 cas.

From 1979 to 1992, 101 radical cystectomy with caecoplasty were performed by the same operator (MR). Mean age of the patients was 62 years with a sex-ratio: 10 males/1 female. The indications were: Transitional Cell Carcinoma in 89 cases, neurologic bladder in 5 cases, interstitial cystitis in 3 cases tuberculosis bladder in 3 cases and lymphoma in one case. The operative mortality was 3% and postoperative morbidity was 8%. The surgical procedure consisted of performing a neo-bladder with ileocaecal segment. The technique of ureterocaecal implantation changed during the study period. On a functional point of view, 28 ureterocaecal stenosis were reported (15%). It were rare (2.4%) with the last ureterocaecal anastomosis technique. The diurnal continence rate was 100%. The nocturnal continence rate was only 25%. On uroflowmetric point of view, the detubularization permitted to obtain low pressure bladders with 15% rate of atonic bladder. Transverse taeniamyotomy of the caecum permitted to increase the uroflowmetric performance of the bladder without atonic risk. The 5 and 10 year overall actuarial survival rate were respectively 5% and 30%. Tumoral stage was a significant prognostic factor. An adjuvant chemotherapy was performed in 28 patients. The 5 year actuarial survival rate of the patients with a chemotherapy was 82% versus 28% for the patients without chemotherapy (p < 0.01). Caecocystoplasty after radical cystectomy was a reliable technique in our experience.

[Stage M1b prostatic adenocarcinoma: prognostic factors, value of bone scintigraphy]. / Adénocarcinome prostatique de stade M1b: facteurs de pronostic, intérêt de la scintigraphie osseuse.

Based on a retrospective study of 52 patients with prostatic adenocarcinoma and bone metastases (stage M1b), the authors analysed the following prognostic factors at the time of diagnosis: age, general status, bone pain, haemoglobin, local tumour volume, ureteric repercussions, pre and post-treatment PAP and PSA levels, Gleason score, and metastatic spread on bone scan. This study demonstrated two predominant prognostic factors for the appearance of early or late therapeutic escape: tumour differentiation established by the Gleason score (P = 0.003), stage of the disease, i.e. local tumour volume (p = 0.001) and bone mass invaded on bone scan (p = 0.0002). The other prognostic factors can be deduced from these two parameters. Qualitative analysis of the initial bone scan allowed patients with peripheral bone metastases to be distinguished from those with exclusively axial involvement. The two-year survival was 50% in patients with peripheral metastases versus 93% in patients without peripheral metastases (p < 0.05). Although bone metastasis constitutes a decisive prognostic factor, the detection of peripheral bone metastases appears to be a factor of poor prognosis.

[Value of radiologic examinations in the diagnosis and staging of upper urinary tract tumors]. / Valeur des examens radiologiques dans le diagnostic et la stadification des tumeurs de la voie excrétric urinaire supérieure.

From 1980 to 1991, 109 patients were treated for a tumour of the upper urinary tract. All patients were examined by intravenous urography (IVU) which had a sensitivity of 61%. The combination of IVU + RUP established the diagnosis in 72% of cases. Renal ultrasonography and abdominal computed tomography (CT) were performed in 41 and 67 cases, respectively. The sensitivity of ultrasonography was 40% and that of CT was 72%. CT was more sensitive for tumours of the renal pelvis (78%) than for ureteric tumours (53%) (p < 0.02) and when the tumour diameter exceeded 2 cm (70% vs 45%: p < 0.01). The sensitivity of CT for lymph node extension was 47% with an accuracy of 88%. Preoperative CT staging was compared to pathological staging: CT staging had an accuracy of 56%; in 31% of cases, CT underestimated the parietal extension of the tumour. The sensitivity of CT to assess invasion of the renal parenchyma and of the perirenal fat was 52% and 74%, respectively (p < 0.01). Morphological examinations are able to diagnose a tumour of the upper urinary tract in 3 out of 4 cases. Correct preoperative staging can only be achieved on one half of cases, which constitutes a drawback to the development of conservative treatment techniques.

[Tumors of the superior urinary tract and associated bladder tumors: clinical and etiological aspects]. / Tumeurs de la voie excrétrice urinaire supérieure et tumeurs de vessie associées: aspects cliniques et étiologiques.

In a series of 107 patients treated over an 11-year period for upper urinary tract tumours (UTT), 30 had a synchronous or metachronous associated bladder tumour. The bladder tumour preceded the UTT in 10.3% of cases, the bladder tumour was synchronous in 6.5% of cases and the bladder tumour occurred after the UTT in 15% of cases, the incidence of UTT after cystectomy over this 11-year period was 3.3%. The median time to recurrence of the UTT after bladder tumour was 17 months. The median time to recurrence of the bladder tumour after the UTT was 12 months. The risk of bladder recurrence after treatment of the upper tract tumour was studied in relation to site, type of treatment, multifocal nature, stage and grade of the UTT and the presence of a previous or synchronous associated bladder tumour. None of these parameters constituted a predictive factor of bladder recurrence after treatment of an upper tract tumour. Comparison of survival between the UTT + bladder tumour group and the UTT alone group did not reveal any significant difference (p = 0.10). The theory of cellular implantation facilitated by vesicorenal reflux and the multifocal theory are complementary explanations of the multifocal and recurrent nature of urothelial tumours.

[Ultrasonographic study of adrenal gland tumors (report of 5 cases)]. / Etude échographique des tumeurs de la surrénale (à propos de 5 cas).

The authors study the ultrasound signs of the adrenal gland based on 5 different types of operated adrenal tumours (a lipoma, an adrenal cortical adenoma, a cyst, a corticoadrenaloma, an adrenal metastasis from a renal cell carcinoma). The ultrasonographic morphological criteria of the normal adrenal gland and each type of tumour are recalled and are illustrated by clinical cases. The value of ultrasonography in the investigation of this organ was evaluated in comparison with other imaging techniques. It constitutes a good first-line diagnostic guiding examination, but needs to be completed by other investigations (computed tomography, magnetic resonance imaging, etc.). Ultrasonography can also reveal asymptomatic adrenal tumours ("adrenal incidentalomas") in which the therapeutic decision (surveillance or surgery) must be based on criteria of size and appearance after a complete laboratory and morphological assessment.

[Transverse transcolonic cutaneous ureterostomy after pelvic irradiation]. / Urétérostomie cutanée transcolique transverse après irradiation pelvienne.

The late urological sequelae of pelvic radiotherapy for cancer sometimes require cutaneous urinary diversion. The local conditions often exclude the use of direct or transileal ureterostomy. Three cases of cutaneous ureterostomy using the transverse colon are presented. There was no operative mortality. A single ureterocolonic stenosis was observed at 12 months and was treated endoscopically. The choice of the transverse colon was based on its position away from the field of irradiation and, consequently, teh absence of radiation lesions, its blood supply which can be used to form pedicles and the possibility of resecting irradiated ureteric segments allowing anastomoses with the proximal ureters. The results reported in the literature show an operative mortality of 0 to 4% and a low morbidity. This technique can be considered to be a technique of choice for cutaneous urinary diversions in urological complications of pelvic radiotherapy.

[New uretero-cystoneostomy in cystocecoplasties. Technique and results]. / Nouvelle urétéro-cystonéostomie dans les cystocaecoplasties. Technique et résultats.

Ureteric reimplantations into an intestinal segment are frequently followed by early, secondary or late stenoses. In UCN, it is essential to perform atraumatic ureteric dissection followed by reimplantation of a short ureter well vascularized by a single superior pedicle, i.e. the simplest UCN, putting the least strain on the ureter both during creation of the diversion and during subsequent healing. The ileal segment of an ileocaecocystoplasty must extend above the right iliac vessels. It is open on the antimesenteric border and its distal border is stripped of a 3 mm band of mucosa. To reach its homologue, the left ureter passes underneath the common root of the sigmoid mesocolon. Each optimally shortened ureter is placed in and fixed to the start and the end of a longitudinal mucosal tunnel, about 3 cm long. The ileum is sutured as a cuff around the orifice of each ureter. A ureteric stent is left in place for a fortnight. The ileum is sutured to the right laterocaval retroperitoneal tissue. This UCN is simple and rapid to perform.

[Flow cytometry in bladder lavage fluid for the diagnosis and surveillance of bladder tumors. Preliminary results]. / La cytométrie en flux sur liquide de lavage vésical dans le diagnostic et la surveillance des tumeurs de vessie. Résultats préliminaires.

The authors evaluate the accuracy and practical applications of flow cytometry (FCM) on bladder lavage fluid in the diagnosis and follow-up of bladder tumours. The apparatus used was a Coultronics Epics Profile II cytofluorograph. Two hundred and fifteen samples were obtained with a yield of 86%. The specimens were preserved in ethanol. The staining was performed on whole cells with preservation of the cytoplasm. The analysis of a control group of 45 patients confirmed that the FCM study of ploidy was specific (0.97 for normal bladders and 0.8 for inflammatory lesions). Four aspects were evaluated: Correlation between FCM and the histological type of the tumour: a significant difference was observed between the control group, the invasive tumour group (p < 0.01) and the carcinoma in situ group (< 0.001). A significant difference was observed in the case of high-grade PTA and PT1 tumours. No significant difference was observed between FCM and classical cytodiagnosis when this technique was performed by a trained cytologist. Predictive value of FCM for the recurrence of PTA and PT1 tumours: 40 patients were followed with a mean follow-up of 13 months. The relative risk of recurrence in the case of a tumour with an abnormal FCM was 2 (p < 0.05). FCM and monitoring of conservatively treated tumours: 30 patients with normal endoscopic examination after endoscopic resection of a PTA or PT1 tumour underwent cytometric analysis and cytodiagnosis. In the case of an abnormality on cytometry, randomised bladder biopsies and urography were performed. The positive predictive value for the presence of a lesion not diagnosed by cystoscopy and detected by FCM was 0.38 +/- 0.26. FCM and intravesical chemotherapy: 16 patients with PT1 tumours and abnormal FCM received BCG therapy (11 patients) or mitomycin C instillations (5 patients). A significant difference (p < 0.01) was observed between the 2 treatments in terms of normalisation of cytometry.(ABSTRACT TRUNCATED AT 400 WORDS)

[Ureteral replacement using an ileal graft of reduced diameter. A preliminary report]. / Le remplacement urétéral par un greffon iléal de diamètre réduit. Rapport préliminaire.

Extensive or even complete loss of the ureter of a functioning kidney makes it impossible to restore the normal continuity of the urinary tract by any available surgical technique. An ileal loop of appropriate length, anastomosed to the bladder with its entire lumen, is the only tissue suitable for replacing this missing ureter; this results in the formation of a megaureter or a vesical diverticulum which, although contractile, presents dimensions and conditions of anastomosis which predispose to the development of vesico-ileal reflux and a risk of torpid infection and dangerous reabsorption of the urine. We consider that it would be useful to use the ileum to create a contractile, reduced calibre tube with properties similar to those of the ureter. This technique, which has rare indications, is feasible as illustrated by the 5 cases reported here, corresponding to 7 uretero-ileoplasties modelled according to this technique. Results were satisfactory with a follow up of 6-24 months.

[Ureter-aorto-iliac prosthesis cross-over and a tumor of the ureter]. / Croisement uretère-prothèse aorto-iliaque et tumeur de l'uretère.

Ureteric stenoses sometimes occur after the insertion of aorto-iliac prostheses. Two cases of neoplastic ureteric stenosis, independent of the ureter-prosthesis crossing are reported, indicating the possibility of such lesions after aorto-iliac prosthetic surgery.

[Quantitative renal DMSA scintigraphy after extracorporeal lithotripsy]. / Scintigraphie rénale quantitative au DMSA après lithotripsie extra-corporelle.

This study reports the results of renal DMSA isotope scan before and after EDAP extracorporeal lithotripsy in 106 patients. An isotope scan was performed before lithotripsy and on the fourth day after lithotripsy and again on the 90th day when alterations were observed on the first post-lithotripsy scan. The assessment of any sequelae was based on the scale of colours of the spectrum, which revealed three types of modifications. The analysis of the results is divided into three periods according to the development in our lithotripsy technique: high firing rates had a success rate of only 40%, with renal scars on isotope scans in 2/3 of cases; low frequency firing rates had a 55% success rate and induced minor changes which were virtually always reversible; in contrast, low frequency firing rates during the 3rd period had a 60% success rate with scars on isotope scans in 1/3 of cases. These isotope scan modifications also depended on the site of the stone. In conclusion, lithotripsy definitely induces renal modifications. The renal parenchyma cannot remain indifferent to lithotripsy beyond a certain threshold. A homogeneous multicentre study with a common protocol is necessary to compare the various lithotriptors and to define cautious and coherent indications for each lithotriptor in the treatment of renal stones.

["Wallstent" endoprosthesis in recurrent urethral stricture in men]. / L'endoprothèse "Wallstent" dans les sténoses récidivantes de l'urètre masculin.

Many patients are condemned to repeated urethral dilatations because of the poor efficacy of treatment for male urethral stricture. The authors have recently used a new urethral prosthesis: a metal-reinforced, meshed tube which opens in the urethra and maintains a it open allowing the urothelium to grow over. The prosthesis therefore becomes incorporated in the wall of the urethra. they have implanted this prosthesis in 21 patients with a mean age of 61 years, essentially in the bulbar urethra, for longstanding strictures measuring 5 to 35 mm and unresponsive to currently available treatments. The endoscopic insertion of the prosthesis is performed after dilatation. The mean follow-up is 9 months. The stricture was correctly treated in all patients (three patients required two sessions). The follow-up of these patients is short and the stability of these favourable results needs to be confirmed by a longer follow-up.

Aortoiliac reconstruction and renal transplantation: staged or simultaneous.

Aortoiliac atherosclerosis can jeopardize the outcome of renal transplantation. During a five-year period, 176 renal transplants were performed. Of these, four patients underwent prior or simultaneous arterial reconstruction. In two, transplantation was successfully performed three and ten months after abdominal aortic aneurysm repair. In the two others with aortoiliac occlusive lesions, simultaneous arterial reconstruction and transplantation were successfully performed. We conclude that the discovery of aortoiliac lesions in a candidate for renal transplantation warrants consideration for staged or simultaneous arterial reconstruction to widen the indications for transplantation in such individuals and provide satisfactory long-term transplant durability.