Effects of nasal calcitonin on bone mineral density following parathyroidectomy in patients with primary hyperparathyroidism.

AIM: To investigate whether nasal salmon calcitonin (CT; 200 U/day) given in addition to calcium helps to restore the bone mass after parathyroidectomy (PTX) in patients with primary hyperparathyroidism (PHPT). METHODS: Twenty patients with PHPT were enrolled after successful PTX and received 1 g calcium per os daily for 1 year. They were randomly assigned either to nasal CT (CT group) or to no treatment. The bone mass was measured using dual-energy X-ray absorptiometry at multiple sites. RESULTS: Eight patients in each group completed the study. After 12 months, the bone mass increased significantly at whole-body level and at lumbar spine in both groups, increased at hip and epiphyses of tibia or radius in the CT group only, and did not change at diaphyses of tibia and radius in either group. CONCLUSIONS: Bone mass increases after PTX for PHPT in patients receiving oral calcium. CT may help to restore the bone mass at sites of the appendicular skeleton, where trabecular bone predominates.

Ileal orthotopic bladder substitutes. What we have learned from 12 years' experience with 200 patients.

The perfect bladder substitute has not been devised yet. The ileal orthotopic bladder substitute, however, provides adequate capacity, convenient voiding patterns, optimal continence rate, preservation of renal function, acid-base balance, and calcium metabolism. The authors describe important surgical details based on experience with more than 200 patients. To achieve a good functional result, patient selection, postoperative voiding reeducation, and meticulous follow-up are important.

[Ureterosigmoidostomy in adults: long term results]. / Urétérosigmoïdostomie chez l'adulte: résultats à long terme.

In 65 patients (pts) (130 renal units) with invasive bladder cancer treated at our institution from 1971 to 1992, ureterosigmoidostomy was performed. Early complications (< 3 month) occurred in 25 patients: 9 pts had a pyelonephritis, 3 pts underwent surgery for revision of the ureteral anastomosis because of leakage and 3 had abdominal wall revisions. 4 pts had a severe hyperchloremic metabolic acidosis, 2 pts had respiratory problems. Late complications observed were: 12 pts with pyelonephritis, 4 pts with ureteral stenosis and 9 pts with hyperchloremic metabolic acidosis. 5 patients were incontinent and 3 pts had a anastomotic colon cancer after 10, 12 and 17 years respectively. In 26/65 (40%) of patients with survival over 5 years continence and quality of life were evaluated by means of a questionnaire. 23/26 pts (88%) were continent during daytime and complete continence during the night was reported by 14/26 pts (54%). Quality of life was assessed in a global manner (family and social life, sexuality, comfort, travel and sport) and was rated as satisfactory in 24/26 pts (92%). 2 pts were unsatisfied due to diarrhea. In conclusion, good long-term functional results can be obtained with ureterosigmoidostomy with a careful follow-up. Our long-term results may serve as a basis for comparison with other more recently developed continent urinary diversions such as low pressure systems.

Summary of 10 years' experience with an ileal low-pressure bladder substitute combined with an afferent tubular isoperistaltic segment.

We report on 10 years of experience with an ileal low-pressure bladder substitute combined with an afferent tubular segment following cystectomy in 100 consecutive men. The median follow-up period was 30 months (range 3-108 months), with a 2.5-year minimum in survivors. A total of 42 patients died, 33 of these dying of bladder cancer. The early complication rate was 11%, including 2 deaths due to postoperative sepsis. In all, 14 patients required reoperation for late complications. The reservoir's median functional capacity increased to 500 ml at 12 months and was paralleled by improving continence: 92% by day (after 1 year) and 80% by night (after 2 years). Four ureteric strictures occurred. No coordinated, isolated pressure rise developed in the reservoir during voiding, which was accomplished by pelvic floor relaxation with abdominal straining, if necessary. Raised intraabdominal pressure acted equally on the reservoir and ureters, preventing reflux during voiding. This technique is straightforward, allows radical cancer surgery, and protects the upper tract. The favorable functional results are comparable with those achieved by similar techniques, but meticulous follow-up is essential.

Experience in 100 patients with an ileal low pressure bladder substitute combined with an afferent tubular isoperistaltic segment.

Between April 1985 and April 1993, 100 consecutive men underwent lower urinary tract reconstruction after cystectomy. An ileal low pressure reservoir using the Goodwin cup-patch principle was combined with an afferent ileal tubular segment. The early complication rate was 11%, including 2 postoperative deaths due to septicemia. After a median followup of 27 months (range 3 to 96) 14 patients required surgery for late complications (intestinal obstruction, urethral stricture or tumor recurrence, hernia or ureteral stenosis). A total of 32 patients died of metastatic bladder cancer and 7 died of other causes. The functional capacity of the bladder substitute was increased to the desired 450 to 500 ml. after 3 to 12 months, which was paralleled by improving urinary continence. After 1 year 92% of the patients were continent by day and after 2 years 80% were continent at night. Upper tract surveillance with excretory urography, renal ultrasound and serum creatinine estimation has shown 4 left ureteral strictures but not significant upper tract deterioration or ureteral recurrence. Significant reflux was not observed during video urodynamics unless the reservoir was overfilled. During voiding, by outlet relaxation and straining if necessary, the intra-abdominal pressure increase with straining acted equally on the reservoir and ureters. Therefore, unlike voiding with a normal bladder, no isolated intravesical pressure increase occurred and, thus, there was no reflux from the reservoir. The combination of an ileal low pressure reservoir with an afferent isoperistaltic ileal segment and an open end-to-side ureteroileal anastomosis allows for radical cancer surgery with resection of the ureters where they cross the iliac vessels and minimizes the risk of ureteral stenosis. The unidirectional peristalsis of the ureters and the afferent tubular ileal segment seem to protect the upper urinary tract sufficiently. The surgical technique is straightforward and allows for later conversion to an ileal conduit if necessary. The functional results of the bladder substitute are comparable to other similar reservoir techniques, provided that the patients are carefully selected, well rehabilitated and meticulously followed.

Analysis of early failures after intravesical instillation therapy with bacille Calmette-Guérin for carcinoma in situ of the bladder.

OBJECTIVE: To analyse the clinical and therapeutic consequences of early treatment failure after bacille Calmette-Guérin (BCG) instillation therapy for carcinoma in situ of the bladder. PATIENTS AND METHODS: A total of 115 patients with carcinoma in situ (Tis) of the bladder were treated by intravesical instillation of living BCG vaccine (Immun BCG Pasteur F). Twenty five patients had primary Tis and 90 had secondary Tis with synchronous or prior superficial papillary tumours. All papillary tumours were resected before instillation of BCG. All patients completed one series of 6 weekly instillations of 120 mg BCG. RESULTS: Twenty-two of 25 patients (88%) with primary Tis responded completely, with negative cytology and cystoscopy findings within a median follow-up period of 44 months. Three of the 25 (12%) had cytological evidence of disease within 9 months of therapy and were considered to be early treatment failures. One patient had muscle-invasive bladder cancer, one had Tis and invasive cancer of the prostatic urethra, and the last, in whom a second BCG course also failed, had Tis of both ureters. Seventy of 90 patients (78%) with secondary Tis had a complete response after treatment with BCG, with repeated negative cytology and cystoscopy examinations within a median follow-up time of 40 months. Twenty of the 90 (22%) with secondary Tis had positive cytology within 9 months after BCG therapy and were considered early treatment failures. Five of these 20 had a cystectomy, three for persistent Tis of the bladder and two for a solid urothelial carcinoma of the prostate. The remaining 15 early failures received a second course of BCG. Four of these 15 patients responded and the remaining 11 failed the second course. The 11 failures included two patients with multifocal T1 G3 bladder cancers. four with invasive bladder cancer, two with solid urothelial carcinomas of the prostatic urethra, and three with Tis of the upper urinary tract. CONCLUSIONS: According to these data, early treatment failure after 6 weekly instillations of 120 mg Immun BCG Pasteur F is an alarming signal which requires immediate re-assessment of the patient to exclude a muscle-invasive bladder cancer or an extravesical carcinoma in situ, either in the upper urinary tract or in the prostatic urethra.

Prognosis after extracorporeal shock wave lithotripsy of radiopaque renal calculi: a multivariate analysis.

To obtain a better understanding of the prognostic factors influencing treatment outcome after extracorporeal shock wave lithotripsy (ESWL), a multivariate logistic analysis of the data from 246 patients has been undertaken. All of the patients were treated with the Dornier lithotriptor HM-3 for radiopaque renal calculi. Treatment success was defined as stone-free within 3 months of one ESWL session and without adjuvant measures after ESWL. In a first analysis, 210 patients with solitary and multiple calculi without adjuvant measures before ESWL were studied. Of 210 patients, 141 (67%) were free from stones after 3 months). Significant influences on the success rate were body mass index and stone number. In a second analysis only those 160 patients with solitary calculi were considered. In this group, age, body mass index, stone location, stone burden and serum calcium significantly influenced the prognosis. When patients with adjuvant measures were added to the analysis an increasing prognostic importance of the stone burden was seen. In patients with a small to medium stone burden (< 4.0 cm3), the number of stones seemed to be more important than the stone burden. Patients appear to have the best chance for successful ESWL when their body mass index is between 20 and 28, their age is between 40 and 60 years, their stones are in the renal pelvis and solitary, the stone burden is < 1.0 cm3, and when their serum calcium is normal.

Extracorporeal shock wave lithotripsy in situ or after push-up for upper ureteral calculi: a prospective randomized trial.

A total of 110 patients with upper ureteral calculi was admitted to a prospective trial and randomly allocated to 2 groups: 1 group treated with in situ extracorporeal shock wave lithotripsy (ESWL) and 1 group treated with ureteral manipulation before ESWL. All patients had solitary upper ureteral calculi without urinary infection. The stones had to be smaller than 1 cm. and located more than 2 cm. lateral to the spine. ESWL was performed with the Dornier HM3 lithotriptor. One patient in the in situ ESWL group had to be treated twice because disintegration of the stone was insufficient after the initial treatment session. All other patients underwent only 1 treatment session. Because 16 patients were lost to followup, 94 were evaluable for the analysis of immediate and long-term results. For disintegration of the stones in situ ESWL needed significantly more shock waves (1,844 +/- 639 versus 1,297 +/- 473, p < 0.001) and a higher voltage (19.5 +/- 1.4 versus 18.7 +/- 0.9 kv., p < 0.001). There were no severe complications in either treatment group. At 3 months 44 of 46 patients (96%) after in situ ESWL and 45 of 48 (94%) after ureteral manipulation before ESWL were free of stones. In view of these results it is suggested that uncomplicated upper ureteral calculi (as defined previously) should be treated first with in situ ESWL, thus, avoiding an invasive procedure.

[Partial kidney resection in renal cell carcinoma]. / Die Nierenteilresektion beim Nierenzellkarzinom.

In 18 patients with renal cell carcinoma in anatomical or functional single kidneys, with limited renal function or bilateral tumors, partial renal resection was absolutely indicated to preserve renal function. In 17 patients with small peripheral tumors and intact contralateral kidney, partial renal resection was performed electively. One patient of each group died during postoperative care. During follow-up, 4 patients with absolute indication for partial renal resection showed progression of the disease. Three developed distant metastases, and in one patient local relapse with infiltration of the inferior cava vein occurred. These 4 patients had had a bilateral synchronous or asynchronous stage pT2 or pT3 renal cell carcinoma and died from the neoplasm within 10-36 months postoperatively. 13 of 18 patients with absolute indication remained tumorfree during a median follow-up period of 57 months. Partial renal resection saved 15 of these 17 patients from dialysis. Sixteen of 17 patients in whom partial renal resection was performed electively remained tumorfree during a median follow-up period of 28 months. The results suggest that, given an absolute indication to prevent dialysis, partial renal resection should be performed whenever technically possible. In patients with small peripherally located tumors and intact contralateral kidney, partial renal resection as an elective procedure must be considered a genuine alternative to radical nephrectomy.

Radical prostatectomy or wait-and-watch?

With intensified screening and the use of new diagnostic tools for prostate cancer (prostate-specific antigen, rectal ultrasound, magnetic resonance imaging with rectal coils, etc), the number of newly diagnosed cases of prostate cancer is rising rapidly, whereas the frequency of death due to prostate cancer remains almost stable. It must therefore be assumed that the number of patients in whom a diagnosed prostate cancer will not be fatal is also increasing. Consequently, not every prostatic carcinoma requires radical treatment when diagnosed. Also, it must be concluded that not every man who is a long-term survivor after radical prostatectomy owes his survival to the treatment. Long-term survivorship may reflect the relatively benign biological potential of this disease in an individual patient. Therefore, there is an inherent risk of overtreating patients and this must be weighed against the costs, the postoperative morbidity and the, albeit low, mortality of a radical prostatectomy. Nevertheless, as long as we do not have diagnostic tools which, at an early stage of prostate cancer, enable us to determine whether a carcinoma will ultimately have a fatal outcome, we are obliged to offer radical prostatectomy to younger patients (who have a life expectancy of more than 10 years) as long as they have organ-confined disease.

ESWL treatment with ventral shock-wave application: therapy of iliac and distal ureteral calculi.

Because of the interposition of bony structures, extracorporeal shock-wave lithotripsy (ESWL) of middle or iliac ureteral calculi is not feasible in the conventional supine position. By a slight modification of the patient's couch allowing the prone positioning of the patient, 22 patients with calculi covered by bony structures were thus treated. The success rate of 95 percent without complications is promising and renders ESWL therapy as an alternative to ureteroscopic extraction of mid and iliac ureteral calculi.

[Bladder substitution using the double-folded ileum technic (Goodwin's cup-patch technic)]. / Vessie de substitution faite au moyen de l'iléon replié (Goodwin's cup-patch technique).

An internal urinary diversion after radical cystoprostatectomy has been performed in 70 male patients. The bladder substitute was made from an ileal segment, opened along its antimesenteric border and folded twice, according to Goodwin's "cup-patch technique". After an observation time of 6 months to 6 years, the results are in general good: The initial capacity of the pouch made from only 40 cm of ileum (in order to avoid metabolic disturbances) increases to a functional capacity of 500 ml within the first postoperative weeks. The increase of the bladder substitute's capacity is parallel to the improvement of urinary continence. In general, the latter is achieved after 1-3 months during the day, and after 3-6 months during the night. However, loss of a few drops of urine may occur, reason why half of our patients wear a safety pad later than 6 months after surgery, at least during the night. There was no significant difference between those patients with an antireflux nipple and those patients having an ileal tubular afferent segment.

Inferior vena caval tumor extension in renal cell carcinoma.

Tumor extension into the inferior vena cava occurs in 4-10% of renal cell carcinomas. The presence of such inferior vena caval involvement by tumor may be considered the only extrarenal manifestation of renal cell carcinoma which does not significantly affect prognosis which is determined by lymphatic and blood-spread distant metastasis. The indication for operation should therefore not be restricted by the presence of tumor in the inferior vena cava, but the operative approach is influenced by the extent of the tumor thrombus. For this reason, precise preoperative diagnosis is crucial.

Ileal bladder substitute: antireflux nipple or afferent tubular segment?

Spheroidal bladder substitutes made from double-folded ileal segments, similar to Goodwin's cup-patch technique, are devoid of major coordinated wall contractions. This, together with the reservoir's direct anastomosis to the membranous urethra, prevents major intraluminal pressure peaks and assures a residue-free voiding of sterile urine. In order to determine whether, under these conditions, an afferent tubular isoperistaltic ileal segment of 20-cm length protects the upper urinary tract as efficiently as an antireflux nipple, 60 male patients who were subjected to radical cystectomy were prospectively randomised to groups in which a bladder substitute was formed together with either of these 2 antireflux devices. An analysis of the results obtained in 20 patients from each group who could be followed for more than 1 year (median observation time 30 and 36 months) showed no differences between the groups in metabolic disturbances, kidney size, reservoir capacity, diurnal and nocturnal urinary continence, the incidence of urinary tract infection or episodes of acute pyelonephritis. Later than 1 year postoperatively, intravenous urograms of the renoureteral units of 25% of the patients with antireflux nipples showed persistent but generally slight dilatation of the upper urinary tracts. This observation was significantly more frequent than it was in patients with afferent tubular segments. Urodynamic and radiographic studies showed that the competence of the antireflux nipples was secured by the raised surrounding intravesical pressure. This, however, also resulted in a transient functional obstruction, and a gradual rise of the basal pressure in the upper urinary tracts was recorded. In patients with afferent ileal tubular segments, contrast medium could be forced upwards into the renal pelvis when the bladder substitutes were overfilled. However, despite raised intravesical pressures, peristalsis in the isoperistaltic afferent tubular segment gradually returned contrast medium back to the reservoir. Our results suggest that the combination of an ileal low-pressure reservoir together with an afferent tubular isoperistaltic limb is at least as good as an antireflux nipple valve. Moreover, the use of the afferent ileal limb makes it possible to resect the distal and often diseased ureters together with the paraureteric lymphatics at a safe distance from the bladder tumor. This avoids also distal ischemic ureteric stenosis and makes possible a simple end-to-side ureterointestinal anastomosis with a small complication rate.

[Replacement bladder constructed with the aid of a folded ileum segment]. / Vessie de substitution construite au moyen de l'iléon replie.

An internal urinary diversion after radical cystoprostatectomy has been performed in 70 male patients. The bladder substitute was made from an ileal segment, opened along its antimesenteric border and folded twice, according to Goodwin's "cup-patch technique". After an observation time of 6 months to 6 years, the results are in general good: The initial capacity of the pouch made from only 40 cm of ileum (in order to avoid metabolic disturbances) increases to a functional capacity of 500 ml within the first postoperative weeks. The increase of the bladder substitute's capacity is parallel to the improvement of urinary continence. In general, the latter is achieved after 1-3 months during the day, and after 3-6 months during the night. However, loss of a few drops of urine may occur, reason why half of our patients wear a safety pad later than 6 months after surgery, at least during the night. There was no significant difference between those patients with an antireflux nipple and those patients having an ileal tubular afferent segment.

Enlargement of regional lymph nodes in renal cell carcinoma is often not due to metastases.

Preoperative axial computerized tomography scans in 163 patients with renal cell carcinoma were reviewed to assess the predictive value for the diagnosis of regional lymph node metastases. Computerized tomography was falsely negative in 5 patients: 2 had metastatic lymph nodes in the renal hilus adjacent to the primary tumor measuring 2 and 2.5 cm., and 3 had micrometastases in nodes of less than 1 cm. In 43 patients enlarged lymph nodes with a diameter of 1 to 2.2 cm. (median 1.4 cm.) were diagnosed on the preoperative scan and this was confirmed at nephrectomy and pathologically. In 18 of these 43 patients (42%) histological study showed metastases of the renal cell carcinoma in the enlarged lymph nodes. In the other 25 patients (58%) the enlarged nodes showed only inflammatory changes and/or follicular hyperplasia. This finding was significantly more frequent in patients with tumor involvement of the renal vein and tumor necrosis (p = 0.0044). We conclude that the sensitivity of preoperative computerized tomography is good for the detection of enlarged lymph nodes in patients with renal cell cancer (95%). However, significant lymph node enlargement frequently may be caused by inflammatory changes, especially in the presence of tumor necrosis. This radiological finding should not be misinterpreted as metastatic disease, unless it has been proved cytologically by fine needle aspiration.