[Radical prostatectomy: open or "minimally invasive"? Our experience with open surgery and related comments]. / Prostatectomie radicale: voie ouverte ou "mini-invasive"? Expérience en chirurgie ouverte et point de vue.

Radical prostatectomy remains the gold standard for treatment of localised prostate cancer. Standardisation of the open retro-pubic anatomic prostatectomy by P Walsh allows skilled but not expert surgeons to achieve a high standard of performance. Learning curve is short with this technic, with minor morbidity. Rates of incontinence are low and impotency is now rather uncommon in the younger patient while oncological control is optimal for histologicaly organ confined cancer. "Mini invasive technics", laparoscopy and robot-assisted laparoscopy, have a longer learning curve, including a higher rate of complications that are unusual with open surgery. Operating time remains longer, costs are superior to the open technic and oncological control is not yet clearly validated while rates of classical late complications are not lower. Consequently, most urologist still prefer the open approach

Renal transplantation in the elderly: a long-term, single-centre experience.

BACKGROUND: End-stage renal failure increases with advancing age and renal transplantation should be considered in end-stage renal failure patients older than 60 years. However, there is a paucity of data on long-term patient and graft survival in this population. METHODS: From October 1983 to March 1999, 310 renal transplantations were performed at Geneva University Hospital in 283 patients, of which 49 were done in 48 patients older than 60 years (mean age 65.6+/-4.1 years). The following data were analysed at 1, 5, and 10 years, and compared between the patients >60 years and <60 years old: actuarial patient and graft survival, serum creatinine, causes of graft loss, and patient death. RESULTS: Patient survival at 10 years was 81% for patients <60 years and 44% for patients >60 years. Graft survival at 10 years was 59% for patients <60 years and 32% for patients >60 years. Graft survival at 10 years censored for death with functioning graft was 65% for patients <60 years and 81% for patients >60 years. Main causes of mortality in the older patients were related to cardiovascular events (47%), neoplasia (41%), and sepsis (18%). Overall, recipient and donor age were not predictive factors for graft survival, as shown by multiple logistic regression. CONCLUSIONS: Renal transplantation should be considered in patients older than 60 years, since graft survival is excellent in this population. Although these patients have a shorter life expectancy, they benefit from renal transplantation similarly to younger kidney transplant recipients.

Cyclosporine toxicity in renal transplant recipients detected by nailfold capillaroscopy with Na-fluorescein.

BACKGROUND: Cyclosporine represented a major advance in the medical management of patients with organ transplantation, but its use is limited by the frequent occurrence of hypertension and renal toxicity diagnosed by invasive renal biopsy. Renal histology shows a specific arteriolopathy. It was hypothesized that cyclosporine may also induce subclinical microvascular changes in the skin that might be detected noninvasively by a combination of dynamic capillaroscopy [capillary blood cell velocity (CBV)] with and without intravenous Na-fluorescein (NaF) injection and laser Doppler fluxmetry (LDF). METHODS: The nailfold skin microcirculation was evaluated in 112 consecutive renal transplant recipients (54 +/- 11 years old; 70 males and 42 females) receiving cyclosporine. The investigation was made the same day as a routine renal biopsy performed in all patients more than two years after transplantation. Renal biopsies were blindly classified as positive (N = 33) when significant specific signs of cyclosporine toxicity were clearly observed (AH2-AH3) and were otherwise negative (AH0-AH1, N = 79) according to the Banff classification. RESULTS: Time to fluorescence peak after NaF injection (tpNaF) was significantly longer in patients with positive biopsies than in patients with negative biopsies (13.9 +/- 8.1 vs. 17.5 +/- 9.4 sec, P = 0.009). All patients but three with negative biopsies (93%) had a tpNaF less than 10 seconds (sensitivity 91%, negative predictive value 93%). On the other hand, CBV, LDF, plasma levels of cyclosporine, and endothelin were similar in the two groups. CONCLUSION: Nailfold fluorescence capillaroscopy is an accurate and simple mean to rule out cyclosporine toxicity in renal transplant recipients. A normal test could avoid invasive renal biopsy in about 40% of the patients. Renal biopsy would, however, still be indicated when the test is abnormal.

Optimization of the kinetics of cooling of kidneys: a pig model.

We determined the kinetics of cooling in multiple organ procurement for the kidney in a pig model. A biometric analysis by regression enables us to define the factors which influence the rate of temperature decrease: weight of the donor, average rate of perfusion and difference of temperature between the rectal temperature and the temperature of the perfusion solution at initiation of cooling. The description of the temperature as a function of time follows an exponential model of the type T(t) = T0. e(dt) where d is the rate of decrease. The rate of decrease varies according to the above factors. The cellular viability ratio (CVR), was correlated to the rate of cooling. The mean CVR was 91% (SD 4.95) when the rate of cooling was more than 1 degrees C/min. This was compared to 75% (SD 11.17) when the rate was less than 1 degrees C/min (p = 0.023). Our experience leads us to believe that the average cooling rate is frequently too low (<1 degrees C/min). This model can be used to predict and control the kinetics of cooling and may help to define the best way of cooling for future xenotransplantation.

Kinetics of cellular viability in warm versus cold ischemia conditions of kidney preservation. A biometric study.

We have determined the kinetics of the cellular viability ratio (CVR), defined as the number of living cells over the total cell count, in pig kidneys using propidium iodide and fluorescein diacetate staining, as a function of time and preservation conditions. The kidneys were preserved in warm or cold ischemia in order to mimic the conditions of transplantation from non-heart-beating donors or multiple removal with optimal preservation of the graft, respectively. To determine the CVR, the cells were obtained by a fine-needle aspiration biopsy, which minimizes the damage to the graft. A biometric analysis by regression enabled the determination of the time dependence for warm ischemia (CVR(t) = 80.0 x e(-0.733-t)(+2.7/-0.36)) and for cold ischemia (CVR(t) = 80.0 x e(-0.022-t)(+1.57/-0.64)) with a confidence interval of 95%. These master curves allow us to predict, under the described conditions, the CVR after a given ischemia time. The half-life of the cells can be deduced from the time-dependent CVR(t), and is 0.64 hr (38 min) for warm ischemia and 21.4 hr for cold ischemia. Further, the CVR for a given kidney can be used to assess its condition at removal: if the CVR is below 48% at 2 hr after removal, one can conclude that the organ has suffered a period of warm ischemia.

[Lymphocele after kidney transplantation: drainage by laparoscopy]. / Lymphocèle après greffe rénale: drainage par laparoscopie.

Our video shows the laparoscopic drainage of a big lymphocele responsible of kidney graft obstructive failure. Apart from the laparoscopic access, the technique is similar to open surgery. An ellipsoid peritoneal window (approximately 6 x 3 cm) is created with scissors and electrocautery. The lymphocele is entered and completely drained. A few adhesions are divided. To keep the window open, we secured its anterior margin with clips. Postoperative period was uneventful, with immediate improvement of the kidney graft function. After 4 months, there was no lymphocele seen on computerized tomography.

High incidence of ectopic nucleolar organizer regions in human testicular tumors.

Eight primary testicular germ cell tumors, one teratocarcinoma cell line, and one Leydig cell tumor were studied to determine the importance of modifications of the nucleolar organizer regions (NORs) in human testicular tumors. Cytogenetic analysis after silver staining showed active ectopic NORs in two primary embryonal carcinomas (EC) in the cell line and in single cells of each of two seminomas (S). In one EC, an ectopic NOR was localized to chromosomal region 1q4; the others were on unidentified rearranged chromosomes. All tumors in which ectopic NORs were observed were hyperdiploid and possessed marker chromosomes typical of human germ cell tumors. Quantitative DNA analysis was performed on three tumors: a teratocarcinoma (TC) and the Leydig cell tumor, which had provided no analyzable mitoses, and a seminoma which was cytogenetically diploid. In all three cases, the major populations were hyperdiploid. The results, in combination with those of an earlier study, provide evidence that active ectopic NORs are common in human testicular tumors.

Traumatic rupture of the urinary tract in a patient presenting nephrogenic diabetes insipidus associated with hydronephrosis and chronic renal failure: case report and review of the literature.

We report the case of a 34-year-old Japanese man suffering from a nephrogenic diabetes insipidus (NDI) associated with bilateral hydronephrosis, hydroureters and enlarged trabeculated bladder without obstruction. He also presented with chronic renal failure which has rarely occurred in similar cases. The patient was admitted after a traumatic rupture of the left urinary tract which had never been described until now in NDI. He was treated successfully by transient peritoneal and vesical drainages. This paper focuses on the very rare complication of chronic renal failure secondary to hydronephrosis in cases of NDI. The literature of this association is reviewed.

[Urologic complications of kidney transplants. Geneva cases, 1981-1990--observations on 200 transplantations]. / Complications urologiques des greffes rénales. Casuistique genevoise, 1981-1990--à propos de 200 transplantations.

Between 1981 and 1990, 200 kidney transplantations were performed at the Cantonal Hospital of Geneva. Overall, 11% of patients developed a urological complication in this series. Of these complications, 40.9% were ureteral stenosis, 22.7% urinary leakages, 13.6% infected vesico-ureteral reflux, 13.6% genitourinary tumors and 9.2% other urological complications. The authors compare their series with the literature.

[First clinical results using a pulsed dye laser Rhodamine 590 lithotripter in treatment of ureteral calculi]. / Premiers résultats cliniques de l'utilisation d'un lithotriteur laser à colorant pulsé Rhodamine 590 dans le traitement des calculs de l'uretère.

A collaborative study about a pulsed dye laser Rhodamin 590 was undergone, 2 years ago, between the laser application center of EPFL and both urological departments of the university of Geneva and the university of Lausanne. First clinical results are presented. Ten patients have been treated for various ureteral stones, mainly calcium oxalate stones. Laser fragmentation was successful in seven cases. No serious complication was noted. Fragmentation efficiency seems better with a 320 microns fiber than with a 200 microns fiber.

[Renal angiomyolipoma: benign tumor?]. / L'angiomyolipome rénal: tumeur bénigne?

Often incidentally discovered, angiomyolipoma (AML) may be revealed by sudden flank pain secondary to perirenal hemorrhage. Tumoral vessels have an increased fragility, leading to potentially major blood loss. Diagnosis is based on the demonstration of a mass which is hyperechogenic by ultrasound and of partially negative density by CT scan. Our cases from 1979 to 1991 are reviewed. Clinical data, investigation and treatment are discussed. Although benign, this tumor may be associated with high morbidity.

[Renal tumors in the elderly patient: therapeutic dilemma]. / Tumeur rénale du patient âgé: dilemme thérapeutique.

We present a retrospective study of 17 elderly patients (older than 75 years) suffering from renal carcinoma, Robson I to III. 12 patients underwent surgical treatment (radical nephrectomy). Peroperative morbidity was low (10%), mean hospitalisation period was 12 days. 60% of patients returned home directly. Mean survival was 5 years. In the 8 patients group with Robson stage I-II, only one death was due to tumor progression. 5 patients underwent a conservative approach (no treatment at all). In this group, two deaths were due to tumor progression. The difference in outcome of these two groups shows a significant advantage for a surgical approach, even in the elderly.

[Endoscopic sphincterotomy in paraplegic patients: retrospective cases in Geneva]. / Sphinctérotomie endoscopique chez les paraplégiques: rétrospective des cas genevois.

We present a review of 59 spinal cord injury patients with spastic sphincter, treated by external sphincterotomy. Bladder voiding is substantially improved with either twelve o'clock or lateral sphincterotomy. Immediate complications are infrequent. 19% of patients need a second intervention. 78% of patients obtain satisfactory long-term results. Conversely, 12% of patients fail to respond and need an indwelling bladder catheter. Those failures are most likely to be found in patients presenting an impaired detrusor function (40%). 72% of patients have erections before treatment. Among them, 10% report erection loss after sphincterotomy. Fibrosis is present in 71% of sphincter resection piece histologies and appears early in the evolution of the affection. This condition is thought to contribute notably to the formation of a fixed sphincteric obstacle.

[Therapy of metastatic prostatic cancer by orchiectomy plus Anandron versus orchiectomy plus placebo. Initial results of a randomized multicenter study]. / Die Therapie des metastasierten Prostatakarzinoms durch Orchiektomie plus Anandron versus Orchiektomie plus Placebo. Erste Ergebnisse einer randomisierten Multizenterstudie.

In the course of a randomized double blind trial conducted by 7 Swiss urological centres, 51 patients with advanced, not pretreated carcinoma of the prostate were included. Following orchiectomy the patients were either administered 300 mg Anandron daily (Roussel RU 23908) or Placebo. Twelve months later the Anandron-group shows a slightly better objective response whereas there is no difference in survival rates. The adverse effects of Anandron-treatment are described.

Ammonium urate urinary stones.

Until the last century, ammonium urate stones were quite common in preindustrial Europe. In contemporary practice these stones are found in developing countries, and are associated with uric acid and ammonium-enriched urine. Such conditions may occur with urealytic infection, resulting in mixed ammonium urate/magnesium ammonium phosphate precipitates and urinary phosphate deficiency of alimentary origin, resulting in precipitates free of magnesium ammonium phosphate, in sterile urine. The latter situation is closely related to a diet poor in phosphate and to a low fluid intake common in endemic lithiasis areas. Ammonium urate and uric acid have different solubility patterns dependent on pH, and consequently treatment will be different in each case.