[Endoscopic extraperitoneal colposuspension]. / Colposuspension par voie endoscopique extra-péritonéale.

The authors point out the advantages and the inconveniences of the different surgical procedures (conventional surgery, transperitoneal celioscopy and extraperitoneal endoscopy) performed in order to treat urinary stress incontinence. An original extraperitoneal endoscopic procedure, using a non resorbable mesh (polypropylene), is proposed. The technique is based on the principle of the open approach described by Burch. The short branches of an Y shaped mesh are sutured at the antero-lateral walls of the vagina. The basis of the Y is pulled out of the extraperitoneal space by using a grasper introduced through a short incision of the skin and the subcutaneous tissues, and perforating the aponeurosis of the rectus muscle. This technique provides the surgeon with an effective and strong tension on the mesh under endoscopic view control. The basis of the mesh is then fixed at the insertion of the rectus muscle on the pubic bone.

Transurethral hyperthermia for benign prostatic hyperplasia patients with retention.

From 1989 to 1990, 32 poor surgical risk patients with urinary retention were treated with transurethral microwave hyperthermia at the department of urology, University of Leuven in Belgium. Mean patient age was 73 years (range 58 to 90 years) and mean duration of retention was 4 weeks (range 3 to 12 weeks). Followup ranged from 13 to 82 weeks, with a mean of 31 weeks. Bilobar or trilobar hyperplasia was diagnosed in 25 patients (78%), while 7 (22%) had median lobe or median bar hypertrophy. The mean prostatic volume was 52 cc (range 25 to 150 cc). Transurethral microwave hyperthermia was given with a helical antenna at 915 MHz. once or twice per week. The mean number of transurethral microwave hyperthermia sessions was 8.9 (range 5 to 10). Each session consisted of a 60-minute treatment at a mean maximum temperature of 45.4C (range 43.7 to 47.2C), average temperature 43.9C (range 42.7 to 45.5C) and minimum temperature 42.0C (range 40.2 to 43.0C). The temperature was continuously monitored, including thermal mapping in all patients. Of the 25 patients who presented with bilobar or trilobar hyperplasia 18 (72%) were catheter-free for the duration of followup. Of the 7 median lobe or median bar patients 1 (14%) showed sufficient improvement to warrant catheter removal. This patient, however, had recurrent retention 4 months after transurethral microwave hyperthermia. In patients with bilobar and trilobar hyperplasia a strong correlation was observed among maximum temperature (p = 0.0006), average temperature (p = 0.0033) and treatment response. As expected, no such correlation existed between minimum temperature and response to treatment (p = 0.56). Our study has again demonstrated therapeutic activity in patients with benign prostatic hyperplasia treated with transurethral microwave hyperthermia. A new finding was a strong correlation between temperature and response.

Endovaginal sonography: new diagnostic approach for urethral diverticula.

Too often a urethral diverticulum is a long-standing and unrecognized problem. Suprapubic sonography has been proposed for assessment of this pathological condition. We report on endovaginal sonography as a new improved imaging modality for the diagnosis of urethral diverticula. In positive cases additional morphological information can be obtained from positive pressure urethrography or from diverticulography via fine needle puncture under digital guidance or under sonographic control. Direct puncture of the lesion allows the injection of contrast material to facilitate the diverticulectomy.

A mysterious cyst on the corpora in a patient with ulcerative colitis.

A case of a man with a cystic tumor destroying the corpus cavernosum at the penile basis is described. A surgical excision was performed. The real nature and the origin of the cyst is not elucidated.

Ectopic colonic epithelium of the bladder complicated by development of an adenocarcinoma.

A case of a female patient with an adenocarcinoma of the bladder emerging from ectopic colonic epithelium is reported. Although urothelial metaplasia in itself is not a premalignant lesion, patients with metaplasia of the bladder epithelium should be followed up very strictly since malignant degeneration has been proved to occur.

Is there a place for conservative surgery in the treatment of renal carcinoma?

Since 1981, 31 patients have undergone conservative surgery for malignant renal tumours and have been followed up for at least 2 years. The techniques included enucleation or resection (wedge resection or partial nephrectomy). In 10 patients the indications for kidney-sparing surgery were absolute, while in the remainder the conservative surgical approach was a deliberate choice. The tumours varied in diameter from 1.3 to 12 cm and no metastases were detected on pre-operative screening. One patient died post-operatively from myocardial infarction. In the remaining 30 there were no local recurrences. Two patients died from skeletal metastases (1 with bilateral malignancy) and 2 underwent surgery in the post-operative period for haemorrhagic complications. The efficacy of conservative surgery in the local control of renal cancer is an argument in favour of its wider use.

Interstitial temperature measurements during transurethral microwave hyperthermia.

Microwave hyperthermia is presently being investigated as a treatment for alleviating the symptoms of urinary outlet obstruction associated with benign prostatic hyperplasia. Two clinical techniques using intracavitary microwave applicators are being evaluated for safety and efficacy at various institutions. The transrectal technique uses a directional microwave radiator that is inserted into the rectum adjacent to the prostate. The transurethral approach uses a symmetrically radiating applicator located within the prostatic urethra. Transrectal prostatic heating techniques require surface cooling to prevent hazardous temperatures in the intervening rectal mucosa. Since transurethral applicators radiate from within the prostatic urethra, heating is confined to the obstructive tissue immediately surrounding the applicator. Concern has been expressed regarding the possibility of thermal injury to the prostate and adjacent rectum during transurethral hyperthermia treatment. In this report we present interstitial temperature measurements of prostatic and rectal temperatures in 5 patients. Temperature was observed to decrease at a rate of about 6C/cm. outward from the applicator. No clinically significant temperature increase was observed beyond 1 cm, outside the prostatic capsule or in the rectal mucosa.

Transurethral microwave hyperthermia: an alternative treatment for prostadynia?

A total of 15 patients with severe symptoms of prostadynia who were refractory to therapy were treated with transurethral microwave hyperthermia (TUHT) in a phase I trial. All patients had pain as the predominant symptom, 9 (60%) patients gave a history of psychological problems while frequency, urgency, dysuria, nocturia, and impotence were less common symptoms. Treatment consisted of TUHT at 915 MHz given weekly for 5 weeks with a total of 68 treatment sessions and a mean of 4.5 treatments per patient. Each treatment lasted for 60 minutes. The aim was to increase the temperature measured on the urethral surface to greater than or equal to 44 degrees C. T mean for all sessions was 45.5 degrees C. In 91% of treatments, the temperature was greater than or equal to 44 degrees C. Treatment was well tolerated in 87% patients and acute toxicity was mild. Of the 15 patients treated, 2 (13%) did not complete the treatment course due to discomfort during TUHT. Good treatment response, manifested by complete pain relief and a decrease in dysuria, was noted in 7 (47%) patients. A higher (greater than or equal to 46 degrees C) treatment temperature correlated well with good response, P less than .01. Similarly, relief of pain correlated well with the absence of a history of psychological problems, P less than .01. A decrease of obstructive micturition problems was noted in 5 of the 7 patients who had this upon presentation. This study showed evidence of therapeutic activity with the use of TUHT in patients with prostadynia refractory to therapy. The response obtained was limited to less than one-half of the patients. Complete pain relief was obtained in 4 (27%) patients. It is of interest to note that patients who had major benefit did not show evidence of psychological problems and were able to tolerate higher treatment temperatures. The latter could suggest a temperature-related response.

Treatment response with transurethral microwave hyperthermia in different forms of benign prostatic hyperplasia: a preliminary report.

During a 7-month period, 79 patients with benign prostatic hyperplasia (BPH) were treated with 915 MHz transurethral hyperthermia (TUHT). All patients had obstructive and irritative signs and symptoms which warranted surgical treatment considerations. Of the 79 patients treated, 31 had follow-ups of 12 months or longer and seven additional patients experienced treatment failure requiring surgical management. These 38 patients were studied to evaluate the relationship of treatment response to the pretreatment prostatic morphology assessed during cystoscopy. There was a well-balanced distribution of patients regarding the important pretreatment characteristics in different morphological types of prostatic hypertrophy. These important characteristics included: prostate volume, postvoiding residual volume, mean peak flow rate, and mean symptom score on the FDA scale. The study patients were scheduled to receive five 60-min TUHT sessions with temperature controlled on the urethral surface at 45.5 degrees C. The treatment were well tolerated and administered on an outpatient basis without sedation or anesthesia. There was a significant difference in the incidence of major improvement in patients with lateral lobe hyperplasia and those with median lobe enlargement, 73 vs. 30%, P = 0.018. From this study, it appears that BPH patients who are found at cystoscopy to have a predominance of median lobe hypertrophy should, perhaps, be selected for treatment other than TUHT. A Phase I study utilizing a modified transurethral applicator to accommodate the specific problem of patients with median lobe hyperplasia is currently being planned.

Transurethral microwave hyperthermia for benign prostatic hyperplasia: preliminary clinical and pathological results.

Transurethral microwave hyperthermia is a new conservative treatment modality for benign prostatic hyperplasia. We treated 15 patients with 915 MHz. microwaves delivered transurethrally by a helical applicator. Of the patients 12 showed substantial objective and subjective improvement of obstructive outflow parameters. Significant improvement in objective study parameters included increased mean flow rate (p less than 0.00021), decreased mean residual volume (p less than 0.00001) and decreased mean prostatic volume (p less than 0.0077). Analysis of patterns of failure showed chronic bladder atony, prostate asymmetry and middle lobe configuration as important factors that could explain the failure of hyperthermia in 3 patients. Toxicity was mild, consisting of bladder spasms, perineal pain, dysuria and hematuria. Hyperthermia-induced pathological changes in prostatic tissues, causing periurethral shrinking and secondary dilatation of the prostatic urethra, are described. The reported clinical results of this phase I study are preliminary due to the short followup. A phase II study to optimize transurethral hyperthermia currently is underway. A phase III study is to be phased in comparing hyperthermia with transurethral resection of the prostate.

Antibiotic cover of transurethral maneuvers with ciprofloxacin and susceptibility behavior of pathogens in patients with neurogenic bladder.

The resistance-inducing capacity of ciprofloxacin is still controversial. In order to assess the changes in susceptibility behavior, ciprofloxacin was given as antibiotic cover for transurethral maneuvers in multiple sclerosis (MS) patients with urinary tract infection prone to recurrence after treatment. The aim was to compare the susceptibility pattern before and after treatment in a double-blind study using two different dose regimens. Sixty-one patients were randomly separated in two groups who received 100 and 500 mg ciprofloxacin orally, twice a day for 4 days. Bacterial cultures were performed before and at the fourth day of treatment as well as at 6 days and 4 weeks after the end of treatment. Altered susceptibility behavior, defined as an elevation of the primary minimum inhibitory concentration by at least two dilution steps, was only found in three causative organisms out of 86, demonstrating the low resistance-inducing capacity of ciprofloxacin. There was no significant dosage-related difference.

Immediate in situ ESWL as monotherapy in acute obstructive urolithiasis: useful or not?

Thirty-two patients with acute obstructive urolithiasis were treated without intervention (stent, nephrostomy tube) within 72 hours after onset of symptoms by extracorporeal shock wave lithotripsy (ESWL). Relief of obstruction, proven sonographically, was obtained within 48 hours in 78.6% of the patients and 90.6% were stone-free 6 weeks after treatment. Best results were obtained for proximal ureteral stones while the influence of stone volume did not appear to be significant. Whereas our stone-free results for treatment of calculi smaller than 5 mm (92.3%) can be criticized because without treatment these stones may pass spontaneously, a high success rate for larger stones (89.4%) was also noted. These results for in situ ESWL compare favorably to those of ESWL with stent bypass and suggest that ESWL monotherapy should be considered as a noninvasive first line therapy when treating acute obstructive urolithiasis.

The operative treatment of tibial shaft fractures: a review of 277 cases.

From 1978 to 1982 two hundred and seventy seven consecutive fractures of the tibial shaft were treated in our centre of traumatic surgery. One hundred and fifty-three were closed fractures and one hundred and twenty-four open. Seven required amputations, eleven patients died to associated lesions. Twenty-one patients did not show up for the follow-up. The remainder two hundred and thirty-eight patients were followed-up for an average time of nineteen months. In the closed fractures the rate of deep infection was 0.74 percent and the rate of non-union was 1.48 percent. In the open fractures the rate of deep infection was 5.7 percent. The end results were good in more than 90 percent of the closed and in more than 80 percent of the open fractures.