[Pigtail suture stent: decisive progress towards double-pigtail stent tolerance and unexpected properties of the suture in the ureter]. / Sondes JFil et MiniJFil: progrès décisifs dans la tolérance des sondes urétérales et propriétés inattendues du fil urétéral.

OBJECTIVE: Double-pigtail stent intolerance reduces the quality of life of patients. By decreasing the amount of material within the bladder, it should be possible to attenuate the symptoms linked to the stent. We evaluated the tolerance of a new stent with a dedicated questionnaire. PATIENTS ET METHODS: The major innovation of the pigtail suture stent (PSS and MiniPSS) was in the replacement of the lower part of the double-pigtail stent with a 0.3 F suture. One hundred and eight patients agreed to be fitted with a PSS. The double-pigtail stents of 24 patients complaining strongly of symptoms were replaced with PSS (group 1) and sixty-eight other patients were fitted directly with the PSS after an endoscopic intervention on the ureter (groups 2 and 3). Sixteen patients with non-obstructive kidney stone received MiniPSS (group 4). RESULTS: Completed questionnaires were obtained from 94 patients. In group 1, the replacement of the double-pigtail stent with a PSS significantly decreased urinary symptom scores (34.4±9.0 vs 20.3±7.4, P<0.0000007), and pain scores (10.1±5.1 vs 4.8±3.2, P=0.0001). The scores of the two first groups fitted with a PSS were similar. Following PSS or MiniPSS implantation, a clear dilation of the ureteral meatus was probably induced by the sutures, facilitating the introduction of an ureteroscope or a flexible ureteroscope sheath (12 F). Following extracorporeal shockwave lithotripsy, the stone fragments gradually slid down the PSS sutures, without renal colic. CONCLUSION: The PSS seems to improve the tolerance of ureteral stent. Unexpectedly, following PSS implantation, we observe a clear dilation of the ureter. We believe that use of a double-pigtail stent should no longer be considered the only way to drain the ureter. Instead, the form of the stent should depend on the patient's disease. LEVEL OF EVIDENCE: 5.

Urinary continence following radical prostatectomy assessed by a self-administered questionnaire.

OBJECTIVES: A total aim of this study was to assess the incidence of urinary incontinence in patients following radical prostatectomy and determine the factors that may influence this incidence. METHODS: A total of 135 men underwent radical retropubic prostatectomy at our center between 1987 and 1997. 120 patients were sent a questionnaire regarding preoperative and postoperative voiding habits. Data collected included preoperative and postoperative continence status, interval to postoperative continence status, associated urinary symptoms, willingness to undergo radical prostatectomy again if need be and additional postoperative procedures. Patient age, date of surgery, number of neurovascular bundles resected at prostatectomy and duration of follow-up were also noted. RESULTS: Of the 120 patients, 116 (96.7%), a mean of 65.2 (range 48-76) years old, responded to the questionnaire. Mean follow-up was 4.3 years (range 1-10.8). Continence was defined as no regular use of pads. Our overall urinary incontinence rate was 14.4%. Of the respondents, 88. 8% (103/116) had achieved final continence status by 6 months postoperatively, and 95% (110/116) would undergo surgery again if need be. Of the patients considered incontinent postoperatively, 66. 6% had associated urgency. Age, year of surgery, number of neurovascular bundles resected at prostatectomy, preoperative urinary leakage of postvoiding dribbling, postoperative pelvic floor exercises, and anastomotic stricture had no significant impact on postoperative continence status. CONCLUSIONS: Using an anonymous self-administered questionnaire, we found a 14.4% incontinence rate after radical prostatectomy. These results allow patients to have realistic expectations when counseled prior to this operation.

Diagnosis and prediction of recurrence and progression in superficial bladder cancers with DNA image cytometry and urinary cytology.

OBJECTIVE: To investigate the roles of urinary cytology and image cytometric analysis of nuclear DNA ploidy pattern in the diagnosis and prediction of recurrence and/or progression of superficial bladder cancers. PATIENTS AND METHODS: Aliquots of catheterized urine from 92 patients with primary (23) or previous (69) superficial bladder cancers were assessed using urine cytology and image-analysis cytometry independently. RESULTS: Of the 23 primary superficial transitional cell carcinomas (TCCs), 11 (48%) were detected by urinary cytology while 12 (52%) were detected by image-analysis cytometry (P>0.05) and 13 (57%) were revealed by combined cytology and cytometry. Of 42 recurrent superficial TCCs, 29 (69%) were detected by urinary cytology, whilst 19 (45%) were diagnosed by cytometry (P<0.05) and 29 (69%) by combined cytology and cytometry. The degree of ploidy in relation to pathological stage and/or grade showed an increasing frequency of aneuploid pattern in more invasive and undifferentiated tumours, but with no statistical significance (P>0.05). The positivity of DNA image cytometry had no significant association (P>0.05) with tumour recurrence and/or progression. CONCLUSIONS: DNA image cytometry can provide a limited but not significant advantage over urinary cytology in the detection of primary superficial TCCs, but it does not seem to be indicated for the prediction of tumour recurrence and/or progression.

Diagnosis and prediction of recurrence and progression in superficial bladder cancers with DNA image cytometry and urinary cytology

OBJECTIVE: To investigate the roles of urinary cytology and image cytometric analysis of nuclear DNA ploidy pattern in the diagnosis and prediction of recurrence and/or progression of superficial bladder cancers. PATIENTS AND METHODS: Aliquots of catheterized urine from 92 patients with primary (23) or previous (69) superficial bladder cancers were assessed using urine cytology and image-analysis cytometry independently. RESULTS: Of the 23 primary superficial transitional cell carcinomas (TCCs), 11 (48%) were detected by urinary cytology while 12 (52%) were detected by image-analysis cytometry (P > 0.05) and 13 (57%) were revealed by combined cytology and cytometry. Of 42 recurrent superficial TCCs, 29 (69%) were detected by urinary cytology, whilst 19 (45%) were diagnosed by cytometry (P < 0.05) and 29 (69%) by combined cytology and cytometry. The degree of ploidy in relation to pathological stage and/or grade showed an increasing frequency of aneuploid pattern in more invasive and undifferentiated tumours, but with no statistical significance (P > 0.05). The positivity of DNA image cytometry had no significant association (P > 0.05) with tumour recurrence and/or progression. CONCLUSIONS: DNA image cytometry can provide a limited but not significant advantage over urinary cytology in the detection of primary superficial TCCs, but it does not seem to be indicated for the prediction of tumour recurrence and/or progression.

Heterogeneity of DNA distribution in diploid cells: a new predictive discriminant factor for solid tumour behaviour.

Spatial nuclear DNA heterogeneity distribution of Feulgen-stained DNA diploid cells was studied by image cytometry in voided urine of 119 patients without bladder tumour (n = 20) and with initial (n = 23) or previous (n = 76) diagnosed bladder tumour. For each patient, repetitive DNA measurements were performed during 1-4 years of follow up. Only cells of diploid DNA histograms and diploid subpopulations of aneuploid DNA histograms were used for analysis. DNA heterogeneity distribution of these diploid cells was quantified by statistical parameters of each nuclear optical density distribution. Discriminant analysis was performed on three groups of DNA histograms. Group A (n = 44): aneuploid DNA histograms of patients with bladder tumour. Group D (n = 55): 38 diploid DNA histograms of the 20 patients without bladder tumour (subgroup D1) and 17 diploid DNA histograms of patients with a non-recurrent bladder tumour (subgroup D2). Group R (n = 27): diploid DNA histograms of patients with bladder tumour recurrence. No statistically significant discriminant function was found to separate D1 and D2. However, the first canonical discriminant function C1 differentiated diploid cells of diploid DNA histograms (group D and group R) from diploid cell subpopulations of aneuploid DNA histograms (group A). Mean C1 values were 1.06, 0.84 and -1.45 for groups R, D and A, respectively. The second canonical discriminant function C2 differentiated diploid DNA histograms of patients with bladder tumour recurrence (group R) from diploid DNA histograms of patients without bladder tumour or without bladder tumour recurrence (group D). Mean C2 values were 1.78 and -0.76 for groups R and D, respectively. In 95% confidence limit, the rate of rediscrimination using the two first canonical discriminant functions C1 and C2 were 86.4, 74.5 and 74.1% for groups A, D and R, respectively. Percent of "grouped" cases correctly classified was 78.6%. Thus spatial DNA heterogeneity distribution of diploid cells seems to quantitate probable genetic instability as a function of clinical evolution such as tumour recurrence, and suggests the possible presence of aneuploid stemlines in a heterogeneous tumour, even if a diploid DNA histogram is observed in a single sample. From standardized C1 and C2 canonical discriminant function coefficients, a DNA heterogeneity index (2c-HI) is proposed to characterize diploid cells providing a descriptive and predictive discriminant factor for solid tumour behaviour.

The conservative management of corynebacterium group D2 encrusted pyelitis.

OBJECTIVE: To evaluate the conservative management of encrusted pyelitis (EP), an infectious disease caused by urea-splitting micro-organisms (Corynebacterium group D2 being the most common), and characterized by stone encrustation of the collecting system. PATIENTS AND METHODS: Four patients (aged 17-62 years) with EP caused by Corynebacterium group D2 were treated conservatively with intravenous vancomycin and percutaneous acidification of the renal collecting system. Percutaneous nephrostomy tubes were placed to allow irrigation with Thomas' acid solution, the outflow being ensured by ureteric catheters. Patients were monitored and the results of and tolerance to treatment evaluated clinically, by biological assays, and by imaging techniques (ultrasonography, computed tomography and pyelography). RESULTS: No kidneys were lost and in all patients with initial renal failure, creatinine levels recovered to previous values. The adverse effects were moderate, consisting of flank pain or discomfort, and low-grade fever. Three patients developed asymptomatic fungal urinary tract infections requiring antifungal agents. The encrustations were treated effectively and almost disappeared in two patients, while the other two had no residual calcification. One transplanted-kidney recipient developed a ureteric stricture requiring surgical repair. Within a mean follow-up of 16 months, there was no recurrence of EP and the residual encrustation remained small. CONCLUSION: The conservative treatment of EP can avoid surgery in many cases, although there are some adverse effects of irrigation. The long-term follow-up and prevention of recurrent EP are nevertheless required.

Outcome of posterior urethral valves: to what extent is it improved by prenatal diagnosis?

PURPOSE: To assess the impact of prenatal diagnosis and evaluation on the outcome of posterior urethral valves we studied all cases of valves detected prenatally, including cases of pregnancy termination due to posterior urethral valves. MATERIALS AND METHODS: Between 1989 and 1996, 30 neonates with prenatally detected posterior urethral valves were treated at our hospital. The prenatal parameters analyzed were age of gestation at diagnosis, ultrasonographic appearance of renal parenchyma and amniotic fluid volume. Fetal urine was analyzed in 9 cases. We reviewed the outcome of 10 neonates treated for posterior urethral valves which were not diagnosed prenatally during the same period. RESULTS: Of the 30 neonatal survivors 6 (20%) had renal failure, including end stage renal disease in 2, after a mean followup of 4 years. Renal failure developed in 2 of 5 cases detected before 24 weeks of gestation, in 1 of 6 with oligohydramnios and in 2 of 5 with abnormal parenchymal renal ultrasound. Normal parenchymal ultrasound and amniotic volume could not predict for good outcome. Renal failure developed in 2 of 7 cases predicted by fetal urinalysis as good prognosis and in 1 of 2 cases predicted as poor prognosis. Pregnancy was terminated for posterior urethral valves in 5 cases based on prenatal criteria of severe renal impairment. Considering these cases as poor outcome, the rate of poor prognosis increased from 20 to 31%. Among the 10 neonates without a prenatal diagnosis of posterior urethral valves renal failure developed in 2 (20%), including end stage renal disease in 1. CONCLUSIONS: When negative parameters were absent and/or fetal urine predicted good outcome there were no cases of end stage renal disease in early infancy, which was a significant help in parent counseling. The predictive value of the currently available prenatal parameters needs to be updated with larger series specifically dealing with posterior urethral valves. According to the current data, the outcome of posterior urethral valves is not yet significantly improved by prenatal diagnosis.

The rectal administration of lidocaine gel and tolerance of transrectal ultrasonography-guided biopsy of the prostate: a prospective randomized placebo-controlled study.

OBJECTIVE: To evaluate the effect of the rectal administration of lidocaine gel on the tolerance of systematic sextant transrectal ultrasonography (TRUS)-guided prostatic biopsies. PATIENTS AND METHODS: From January to September 1997, patients undergoing initial biopsy mapping of the prostate (with six systematic TRUS-guided transrectal biopsies) were randomized using a pre-established randomization list into two groups. In group 1, 15 mL of 2% lidocaine gel (Astra, Södertälje, Sweden) was administered intrarectally 15 min before the biopsies. In group 2 (placebo), 15 mL of trans-sonic hydrophilic gel (Rivadis Laboratory, Thouars, France) was administered transrectally under the same conditions. Patients were randomized and the gel administered by a nurse; neither the patients nor the urologists were aware of which product was administered. At the end of the procedure, patients were asked to score the severity of discomfort of the biopsies, using a self-administered rating scale. RESULTS: In all, 109 patients were included, in either group 1 (56 patients) or group 2 (53 patients). Slight pain or no pain was experienced by the vast majority of patients in both groups. Moderate to severe pain was experienced in 12.5% of patients in group 1 and 11.3% of patients in group 2. There was no difference in patient tolerance between the groups (P=0.39). Only minor complications occurred and complication rates were not significantly different between the groups. CONCLUSION: The rectal administration of lidocaine has no impact on the tolerance to prostatic biopsy.

[Urinary continence after retropubic radical prostatectomy: retrospective study with self-administered questionnaire]. / Continence urinaire après prostatectomie radicale rétro-pubienne: étude rétrospective par autoquestionnaire.

OBJECTIVES: To precisely evaluate the incidence of urinary incontinence after radical prostatectomy and its impact on quality of life. MATERIAL AND METHODS: A self-administered questionnaire was sent to 116 patients operated between 1987 and 1996. Preoperative and postoperative urinary continence, the time until urinary continence was achieved, the presence of urgent micturition, the degree of discomfort caused by urinary incontinence and associated voiding disorders were assessed. RESULTS: The questionnaire response rate was 96.6%. The urinary incontinence rate (continuous use of pads) was 13.4%. No predictive factor for postoperative urinary incontinence was identified. Urge incontinence was present in 31.3% of cases. 85% of patients claimed to be satisfied with the operation and 95.4% declared that they would be willing to undergo radical prostatectomy again. CONCLUSION: The incidence of urinary incontinence after radical prostatectomy is acceptable and the morbidity that it generates is well tolerated and has little impact on quality of life.

[Epidermoid carcinoma of the bladder]. / Carcinome épidermoïde de la vessie.

Squamous carcinoma of the bladder is a rare tumour, little known in Western countries in contrast with the high incidence in the Middle East and East Africa. It has a sex-ratio of 1 and black populations appear to be preferentially affected. Several recent theories of carcinogenesis elucidate the pathophysiology of this tumour. Its risk factors essentially consist of urinary schistosomiasis and mechanical and chemical vesical irritant factors. The diagnosis of this cancer is often delayed, but can be facilitated by strict follow-up of high-risk patients. Prevention appears possible in these patients. Its prognosis, traditionally poor, essentially depends on tumour stage and grade. Treatment is surgical, essentially radical cystectomy, which has a real therapeutic efficacy. The respective roles of chemotherapy and radiotherapy are currently under evaluation.

Encrusted cystitis and pyelitis.

PURPOSE: Encrusted cystitis and pyelitis are chronic inflammations of the bladder and collecting system associated with mucosal encrustations induced by urea splitting bacteria. We review these infectious diseases. MATERIALS AND METHODS: A literature search was performed of the MEDLINE database from 1985 to 1997. Additional articles published before 1985 were also selectively included. RESULTS: Most of the articles were case reports or short series. During the last 10 years increasing numbers of cases have been diagnosed, especially in immunodepressed patients, and particularly in renal transplant recipients. Many bacteria have been demonstrated in this infection but Corynebacterium group D2 is currently the most frequent. The development of encrusted cystitis or pyelitis requires the presence of specific bacteria with an alkaline urine, a preexisting urological procedure and a clinical context predisposing to infection. Clinical diagnosis can be difficult but the presence of alkaline urine containing abundant calcified mucopurulent debris is highly suggestive. Demonstration of the bacteria requires prolonged cultures in enriched media. Treatment is based on adapted antibiotic therapy, acidification of urine and excision of plaques of calcified encrustation. The consequences of treatment failure are serious and can result in graft nephrectomy in kidney transplant recipients. CONCLUSIONS: Early clinical and bacterial diagnosis of encrusted cystitis and pyelitis could improve the prognosis of these infectious diseases.