[Study of the efficacy and medium-term complications of 41 sacral nerve neurostimulators (Interstim, Medtronic, U.S.A.) in refractory urinary disorders]. / Etude sur l'efficacité et les complications à moyen terme de 41 implantations de neuromodulateur des racines sacrées (Interstim, Medtronic, U..S.A.) dans les troubles urinaires réfractaires.

OBJECTIVE: Single-centre retrospective follow-up study (short-term and medium-term efficacy, complications, revisions) of patients treated for refractory urinary disorders by sacral nerve neurostimulation (Interstim, Medtronic, U.S.A.). MATERIAL AND METHOD: A sacral nerve neurostimulation screening test was performed in 79 patients with refractory urinary disorders between 1999 and 2005 and a neurostimulator was implanted in 41 of these patients. Patients were evaluated by bladder diary, MHU urinary disability score, and urodynamic assessment. RESULTS: The mean follow-up was 20.5 months. A significant improvement of bladder diary parameters and MHU urinary disability score was observed at 6, 12, and 24 months of follow-up. At 20.5 months, 22 (54%) patients were considered to be failures and 3 were explanted. Five patients were considered to be a success, and 14 were improved, i.e. 19 (46%) success/improvement at 20.5 months of follow-up. The only predictive factor of success was a history of symptoms lasting less than 5 years before neurostimulator implantation. A complication was observed in 70% of patients. More than one half of patients reported pain at some time during follow-up. Four infections were observed, one of which required explantation. Ten technical problems due to accidental deactivation or interference with a magnetic field were observed. Seven patients (17%) required revision: repositioning of the leads due to inefficacy in 3 cases, and change of position of the device in 4 cases. CONCLUSION: Sacral nerve neurostimulation is an effective treatment in refractory urinary disorders in more than 45% of implanted patients, although this effect tends to wane over time. Our results are less favourable than those described in the literature, but were based on stricter endpoints. A high complication rate, mainly pain, was observed, but most required only symptomatic management. This technique nevertheless remains a good alternative to invasive surgical management of functional disorders.

[Complications of Bricker ileal conduit urinary diversion: analysis of a series of 246 patients]. / Complications des urétérostomies cutanées trans-iléales selon Bricker. Analyse d'une série de 246 patients.

OBJECTIVE: The objective of this retrospective study was to evaluate the mortality and early and late morbidities of Bricker ileal conduit urinary diversion. PATIENTS AND METHODS: Between January 1990 and December 2002, 246 Bricker ileal conduit urinary diversion was performed in our centre in 164 males (67%) and 82 females (33%) with a mean age of 64 years (range: 9 to 90 years). Bricker diversion was performed in 73.6% of cases for underlying tumour (prostate, bladder, cervical, colon cancer), and in 26.4% of cases for benign disease (neurogenic bladder radiation bladder bladder exstrophy, incrusting cystitis). Cystectomy was associated with Bricker diversion in 62.2% of cases. The mean follow-up was 24 months (range: 1 to 151 months). The following parameters were studied: mortality and early and late medical or surgical, urological and gastrointestinal complications. RESULTS: The postoperative mortality was 6.9% (17 deaths, 16 in patients in whom Bricker diversion was performed for cancer). The early morbidity was marked by gastrointestinal complications (ileus, fistula, evisceration) in 46 cases (1.7%), 25 of which required re-operation. A medical complication was observed in 41 patients (16.7% of the series), responsible for 60% of the postoperative mortality (10 of the 17 deaths). A urinary fistula was observed in 7 patients (2.8%). The late morbidity consisted of parietal complications (incisional hernia, peristomal hernia, stricture of the stoma) in 18.3% of cases. Urological complications consisted of acute pyelonephritis (11%), ureteroileal stricture (4.9%) and urinary stones (4.9%). CONCLUSION: Bricker ileal conduit urinary diversion is associated with considerable mortality, especially in cancer patients. Early complications are essentially gastrointestinal, while late complications tend to be parietal or urological.

[Treatment of benign prostatic hyperplasia (BPH) by transurethral needle ablation (TUNA) and 36-month follow-up of the retreatment rate]. / Traitement de l'hyperplasie bénigne de prostate (HBP) par thermocoagulation au moyen d'aiguilles par voie trans-urétrale (TUNA) et suivi a 36 mois du taux de retraitement.

OBJECTIVE: Benign prostatic hyperplasia (BPH) is a disease affecting about 25% of men over the age of 40. One half of these men report symptoms that interfere with their daily activities. MATERIAL AND METHODS: In this multicentre study, 102 patients with BPH were treated by transurethral needle ablation (TUNA). The efficacy of treatment was evaluated for 12 months after the operation by means of Madsen and IPSS (International Prostate Symptom Score) scores. The course of uroflowmetry and quality of life (International Score) and sexual function were also assessed for one year. The safety of treatment was evaluated according to the type and frequency of complications. The results show an immediate and significant improvement of symptoms (p < 0.0001 for Madsen and IPSS scores and maximum flow rate between M0 and M12) demonstrating the efficacy of the TUNA system. A very positive impact of TUNA was demonstrated on quality of life. No negative impact was reported on sexual function and the operation had very few repercussions with a low adverse event rate. The retreatment rate (surgical and/or drug) was evaluated 36 months after the operation by means of an optional follow-up questionnaire subsequently completed by the investigators. RESULTS: After 3 years, based on the 80 questionnaires returned, 43 patients (53.8%) were stable and did not need any other medical or surgical treatment for BPH. Thirty-seven (37) patients (46.3%) required retreatment: 21 were treated with drugs (26%), 17 were treated surgically (21.25%) including 1 patient who was also retreated with drugs. This study demonstrates the significant and lasting improvement of BPH symptoms by TUNA, which constitutes an alternative attractive to surgery in young patients and/or patients worried about their sexuality.

[Renal hydatid cyst: preoperative diagnosis and therapeutic implications]. / Kyste hydatique du rein: diagnostic de présomption et implications thérapeutiques.

Renal hydatid disease is a rare condition in temperate climates, but must be diagnosed. The authors describe the systematic radiological and serological assessment for a renal cystic mass establishing a preoperative diagnosis. On the basis of this preoperative diagnosis, essential precautions can be taken to avoid the specific complications of this disease and a nephron-sparing procedure can be performed.

Management of artificial urinary sphincter dysfunction.

OBJECTIVE: The long-term outcome of artificial urinary sphincter (AUS) is unpredictable because of, among others, the risk of breakdown of one of its components. Our objective was to define a strategy for an accurate diagnosis and an appropriate management of these problems. PATIENTS AND METHODS: From 1985 to 2000, 298 AUS (AMS 800) have been implanted in 288 patients aged 53 +/- 21 years (8 to 87 years). There were 130 women with urinary stress incontinence, 84 with neurological disorders, 76 following prostatic surgery and 8 for other reasons. Diagnosis was often done following the recurrence of urinary incontinence. The pump was systematically checked and all patients underwent radiographic and urodynamic studies. We have systematically looked for the defective component in order to avoid replacing the entire sphincter. RESULTS: Fifty-five patients (19%) have been re-operated on after a median follow-up of 23 months (11 days-10 years): Thirty-two only once, 20 twice and 3 patients 4 times. There were 55 depressurizations, 18 device dysfunctions without depressurization and 11 removals of the sphincter. Among the 55 depressurizations, 30 were related to a perforation of one component, 24 to a functional but insufficient sphincter and 1 to tubing disconnection. In forty cases, only one component of the AUS was replaced while 2 components were replaced in 10 cases, the entire AUS in 4 cases and no component in one case. CONCLUSION: The longer the follow-up the greater is the probability of a dysfunction. We systematically continue to look for the defective component and just to replace it instead of the entire sphincter.

[Mixed epithelial and stromal tumour of the kidney]. / Tumeur mixte epithéliale et stromale du rein.

The authors report the case of a patient with mixed epithelial and stromal tumour, a rare, recently described entity, as only 40 cases have been reported, mixed epithelial and stromal tumours are essentially observed in women during the perimenopausal period with a history of treatment with oestrogen-progestogens or gynaecological surgery. No clinical or radiological arguments can differentiate these tumours from other renal tumours. Histological examination reveals a tumour with an epithelial component and a stromal component presenting the characteristics of ovarian stroma and expressing oestrogen and progesterone receptors. The prognosis of these tumours is usually very favourable, although caution is advised in view of the limited number of published cases and a recent report of a malignant case.

Prognostic value of bone scan in patients with metastatic prostate cancer treated initially with androgen deprivation therapy.

PURPOSE: We analyzed whether classifying bone prostate cancer metastases correlates with survival in patients treated primarily with androgen deprivation. MATERIALS AND METHODS: We identified 86 patients with bone metastases who were followed between September 1988 and September 1999. Only those treated initially with androgen deprivation as monotherapy were included in this study. Clinical, pathological and radiological information were obtained by patient chart review. The 86 patients were divided into 2 groups according to metastasis grade on bone scan at diagnosis. Group 1 included patients with metastases on the axial skeleton and group 2 included those with bone metastases on the appendicular skeleton. In addition to our classification, we stratified patients according to the Soloway and Crawford et al classifications, and analyzed survival. RESULTS: There were no statistical differences in the groups with axial versus appendicular metastases in terms of patient age, biopsy Gleason score, serum prostate specific antigen or clinical stage. Median survival was 53 and 29 months in patients with axial and appendicular bone metastases, respectively. Those with axial disease had better survival than those with appendicular bone metastases (p = 0.048). No statistical difference was observed when grading bone scan according to the Soloway and Crawford et al classifications. CONCLUSIONS: Classifying bone scans according to the site of metastases (axial versus appendicular) had many advantages. It is easy to understand and helps urologist better predict the patient prognosis. Axial metastases carries a better prognosis than appendicular metastasis.

[Prognostic factors of prostate cancer treated with first-line hormone therapy]. / Facteurs pronostiques du cancer de la prostate traité par hormonothérapie de première intention.

OBJECTIVE: Endocrine therapy of prostate cancer is designed to eliminate the action of androgens to prevent the growth of hormone-sensitive cancer cells. The duration and quality of the response to this treatment vary from one patient to another. The objective of this study was to evaluate the prognostic factors of patients treated by first-line endocrine therapy for prostate cancer. MATERIAL AND METHODS: From September 1988 to September 1999, 170 patients receiving first-line endocrine therapy for prostate cancer were included. Endocrine therapy consisted of LHRH analogues alone in 59.4% of cases, complete androgen suppression in 21.2% of cases, antiandrogens alone in 17.6% of cases and oestrogens in 1.8% of cases. Clinical, laboratory, scintigraphic and histological data were collected. The overall survival was studied by univariate analysis as a function of pretreatment criteria using Kaplan-Meier survival curves. RESULTS: The mean survival of the population was 33 +/- 26 months (range: 2-126 months). The following parameters were associated with a significant reduction of overall survival: age greater than 70 years, high ECOG score, mode of presentation of the cancer by alteration of general state, presence of bone pain, presence of bone metastases particularly in the appendicular skeleton, dilatation of renal cavities, Gleason score > 5, PSA level > 100 ng/ml, haemoglobin < 13.5 g/dl, serum creatinine > 105 mumol/l, low plasma testosterone, high alkaline phosphatase, poor response to treatment assessed by PSA greater than 4 ng/ml at 3, 6 and 12 months. CONCLUSION: Determination of these prognostic factors can be used to predict the patient's response to endocrine therapy and survival. These factors can also be used to stratify patients in comparable groups for clinical trials.

[T1 bladder tumors: value of a second endoscopic resection]. / Tumeurs de vessie T1: intérêt d'une deuxième résection endoscopique.

OBJECTIVE: To quantify the percentage of residual tumour following systematic second endoscopic resection of pT1 bladder tumours before starting treatment with intravesical instillations and to definitively exclude muscle invasion. MATERIAL AND METHODS: From January 1995 to December 1999, 52 patients with a first diagnosis of pT1 bladder tumour underwent a second endoscopic resection 3 to 5 weeks later. Nine surgeons, 5 seniors and 4 juniors, managed these patients and the initial resection was considered to be complete in every case. The second resection consisted of resection of the initial tumour bed and distant biopsies either directed to zones of suspicious CIS zones or quadrant biopsies in the case of optically healthy mucosa. RESULTS: Of the 52 included patients, 19 (36.5%) had residual disease on the second endoscopic resection. Pathological staging was: pT0 = 63.5% (33 patients), pTa = 11.5% (6 patients), pTis = 3.85% (2 patients), pT1 = 17.3% (9 patients), > or = pT2 = 3.85% (2 patients). Residual tumour tissue was revealed at the resection site in 84.2% of cases and in another site in 15.8% of cases. Residual tumour was significantly more frequent in the case of multifocal tumour than in the case of solitary tumour (57.9% vs 24.23%), and when managed by a junior surgeon compared to a senior surgeon (53.8% vs 30.8%). CONCLUSION: This second endoscopic procedure appears to be essential to ensure the absence of residual tumour before starting conservative treatment for pT1 bladder tumours.

Prolonged hydrodistention of the bladder for symptomatic treatment of interstitial cystitis: efficacy at 6 months and 1 year.

OBJECTIVE: To determine the efficacy of hydrodistention of the bladder for symptomatic treatment of interstitial cystitis after 6 months and 1 year of follow-up and to identify a predictive factor. METHODS: The study included 65 consecutive patients (a first retrospective series of 33 and a second prospective series of 32) treated by hydrodistention of the bladder for urinary symptoms attributed to interstitial cystitis. All experienced pain on bladder filling, which was relieved by micturition or bladder voiding, and had more than two nocturias. Glomerulations were detected at short hydrodistention during cystoscopy. No patients were subject to NIH exclusion criteria. Hydrodistention was performed continuously for 3 h without rest intervals under epidural anesthesia using a balloon with a pressure equal to the patient's mean arterial pressure. Efficacy was defined as the disappearance of pain on bladder filling or the persistence of moderate, non-disabling pain for which the patient did not request treatment, and a low frequency of nocturia (zero to two times). The efficacy period was estimated according to Kaplan-Meier methods for survival curves. The second series was used to verify the analytic results of the first series. RESULTS: Treatment efficacy was 12/32 (37.7% CI: 20.7-54.3) at 6 months and 7/32 (21.9% CI: 7.6-36.2) at 1 year for the first series, and 18/30 (60.0% CI: 45.0-75.0) at 6 months and 13/30 (43.3% CI: 25.6-61.1) at 1 year for the second series. In both series, results were better for the subgroup of patients with a bladder capacity > or = 150 ml during cystometry before distention. CONCLUSIONS: This study showed good but transient efficacy in the least developed or least severe forms of the disease.

[Functional anatomy and semiology of the bladder]. / Anatomie fonctionnelle et sémiologie de la vessie.

Continence and micturition result from an inversely related evolution of urethra and bladder pressures. On filling, the bladder pressure remains low and the urethral pressure is high: filling bladder pressure mainly depends on its visco-elastic properties while urethral pressure is actively kept high by the tonic activity of smooth and striated urethral sphincters. It is the other, way round when the bladder empties: bladder pressure rises and urethral pressure lower, because the parasympathetic impulses; in the adult, the reflex loop passes through the pontine center. The volitional control of this micturitional reflex implies an ability to recognize a specific feeling: the desire to urinate. Physical examination and investigations enables to assess bladder and sphincter function, through a rich semiology.