Adverse events associated with currently used medical treatments for cystinuria and treatment goals: results from a series of 442 patients in France.

OBJECTIVE: To evaluate medical treatments, in terms of adverse events (AEs) and therapeutic goals, in a large series of patients with cystinuria. PATIENTS AND METHODS: Data from 442 patients with cystinuria were recorded retrospectively. Crystalluria was studied in 89 patients. A mixed-effects logistic regression model was used to estimate how urine pH, specific gravity and cysteine-binding thiols (CBT) correlate with risk of cystine crystalluria. RESULTS: Alkalizing agents and CBT agents were given to 88.8% (n = 381) and 55.3% (n = 238) of patients, respectively. Gastrointestinal AEs were reported in 12.3%, 10.4% and 2.6% of patients treated with potassium bicarbonate, potassium citrate and sodium bicarbonate, respectively (P = 0.008). The percentages of patients who experienced at least one AE with tiopronin (24.6%) and with D-penicillamine (29.5%) were similar (P = 0.45). Increasing urine pH and decreasing urine specific gravity significantly reduced the risk of cystine crystalluria, whereas D-penicillamine and tiopronin treatments did not reduce this risk (odds ratio [OR] 1 for pH ≤6.5; OR 0.52 [95% confidence interval {95% CI} 0.28-0.95] for 7.0 8.0, P <0.001). CONCLUSION: Adverse events were frequent with D-penicillamine and tiopronin. Alkaline hyperdiuresis was well tolerated and reduced cystine crystalluria. Urine specific gravity ≤1.005 and urine pH >7.5, while warning about calcium-phosphate crystallization, should be the goals of medical therapy.

CKD and Its Risk Factors among Patients with Cystinuria.

BACKGROUND AND OBJECTIVES: Cystinuria is an autosomal recessive disorder affecting renal cystine reabsorption; it causes 1% and 8% of stones in adults and children, respectively. This study aimed to determine epidemiologic and clinical characteristics as well as comorbidities among cystinuric patients, focusing on CKD and high BP. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This retrospective study was conducted in France, and involved 47 adult and pediatric nephrology and urology centers from April 2010 to January 2012. Data were collected from 442 cystinuric patients. RESULTS: Median age at onset of symptoms was 16.7 (minimum to maximum, 0.3-72.1) years and median diagnosis delay was 1.3 (0-45.7) years. Urinary alkalinization and cystine-binding thiol were prescribed for 88.8% and 52.2% of patients, respectively, and 81.8% had at least one urological procedure. Five patients (1.1%, n=4 men) had to be treated by dialysis at a median age of 35.0 years (11.8-70.7). Among the 314 patients aged ≥16 years, using the last available plasma creatinine, 22.5% had an eGFR≥90 ml/min per 1.73 m(2) (calculated by the Modification of Diet in Renal Disease equation), whereas 50.6%, 15.6%, 7.6%, 2.9%, and 0.6% had an eGFR of 60-89, 45-59, 30-44, 15-29, and <15, respectively. Among these 314 patients, 28.6% had high BP. In multivariate analysis, CKD was associated with age (odds ratio, 1.05 [95% confidence interval, 1.03 to 1.07]; P<0.001), hypertension (3.30 [1.54 to 7.10]; P=0.002), and severe damage of renal parenchyma defined as a past history of partial or total nephrectomy, a solitary congenital kidney, or at least one kidney with a size <10 cm in patients aged ≥16 years (4.39 [2.00 to 9.62]; P<0.001), whereas hypertension was associated with age (1.06 [1.04 to 1.08]; P<0.001), male sex (2.3 [1.3 to 4.1]; P=0.003), and an eGFR<60 ml/min per 1.73 m(2) (2.7 [1.5 to 5.1]; P=0.001). CONCLUSIONS: CKD and high BP occur frequently in patients with cystinuria and should be routinely screened.

Biological significance of perineural invasion (PNI) in prostate cancer.

BACKGROUND: In order to better understand the biological significance of perineural invasion (PNI) in prostate cancer, we aimed to analyze in situ the expression of molecules involved in tumor growth or nerve trophicity. METHODS: Tissues from 66 radical prostatectomies performed for prostate cancer (40 with PNI and 26 without PNI) were selected and included in a tissue microarray (TMA): PNI areas (when available), cancer far from nerves, and nerves far from cancer. The expression of the following molecules was analyzed using immunohistochemistry on TMA slides: macrophage migration inhibitory factor (MIF) and its receptor CD74, EGF receptor (EGFR), heregulin (HRG) and its receptor ErbB3, and the proliferation marker Ki67. RESULTS: Cancer cells in the PNI areas showed increased proliferation, EGFR and CD74 expression, when compared to cells far from nerves (P = 0.009, 0.0005, and 0.02, respectively). Moreover, cell proliferation and CD74 staining were increased in cancers with PNI features compared to cancers without PNI (P = 0.001), even when adjusting for Gleason score, tumor size, and pathological stage. CONCLUSIONS: These results suggest that cancer cells in the PNI areas could acquired a growth advantage that could be triggered by the growth factor receptors EGFR and CD74.

Tamsulosin hydrochloride vs placebo for management of distal ureteral stones: a multicentric, randomized, double-blind trial.

BACKGROUND: α-Blockers induce selective relaxation of ureteral smooth muscle with subsequent inhibition of ureteral spasms and dilatation of the ureteral lumen. The aim of the study was to evaluate the efficacy and safety of the α-blocker tamsulosin hydrochloride in patients with ureteral colic owing to a distal ureteral stone. METHODS: This was a multicenter, placebo-controlled, randomized, double-blind study. Patients with emergency admission for ureteral colic with a 2- to 7-mm-diameter radio-opaque distal ureteral stone were included in the study. They received tamsulosin (0.4 mg/d) or matching placebo until stone expulsion or day 42, whichever came first. The main end point was time to stone expulsion between inclusion and day 42. Sequential statistical analysis was performed using the triangular test. RESULTS: A total of 129 patients with acute renal colic were recruited from emergency wards between February 1, 2002, and December 8, 2006, in 6 French hospitals. Of these 129 randomized patients (placebo, 63; tamsulosin, 66), 7 were excluded from analyses: 5 for major deviations from inclusion criteria, 1 for stone expulsion before the first treatment administration, and 1 for consent withdrawal. At inclusion, mean (SD) stone diameters were 3.2 (1.2) and 2.9 (1.0) mm in the placebo and tamsulosin groups, respectively (P = .23). Expulsion delay distributions during 42 days did not show any difference (P = .30). The numbers of patients who spontaneously expelled their stone within 42 days were 43 of 61 (70.5%) and 47 of 61 (77.0%) in the placebo and tamsulosin groups, respectively (P = .41). Corresponding delays were 10.1 (10.0) and 9.6 (9.8) days (P = .82). Other secondary end points and tolerance were not different between groups. CONCLUSION: Although well tolerated, a daily administration of 0.4 mg of tamsulosin did not accelerate the expulsion of distal ureteral stones in patients with ureteral colic. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00151567.

Expression of estrogen related proteins in hormone refractory prostate cancer: association with tumor progression.

PURPOSE: Despite increasing evidence that estrogen signaling has a key role in prostate cancer development and progression, few studies have focused on the estrogen pathway in the transition from hormone sensitive to hormone refractory tumors. We investigated the expression of proteins related to androgen and estrogen metabolism in paired prostate cancer samples collected before androgen deprivation therapy and after hormonal relapse. MATERIALS AND METHODS: The study included 55 patients treated for prostate cancer only with androgen deprivation therapy and in whom tissue was available before treatment induction and after recurrence. Immunohistochemistry was performed using tissue microarray with antibodies directed against androgen receptor, phosphorylated androgen receptor, estrogen receptor α, estrogen receptor ß, 5α-reductase 1 and 2, aromatase, BCAR1 and the proliferation marker Ki67. RESULTS: Compared to hormone sensitive samples, tissues collected after hormonal relapse were characterized by increased expression of Ki67, androgen receptor, phosphorylated androgen receptor (p <0.001) and BCAR (p = 0.03), and by lower staining for 5α-reductase 2 (p = 0.002), estrogen receptor ß (p = 0.016) and aromatase (p <0.001). Shorter time to hormonal relapse was associated with high expression of aromatase and BCAR1 on diagnostic biopsy, together with low staining for estrogen receptor α in stromal cells. Overall survival was significantly shorter when tissues collected after relapse showed a high proliferation index and low estrogen receptor α expression. CONCLUSIONS: Results revealed dysregulation of proteins involved in androgen pathways, and in estrogen synthesis and signaling during the development of hormone refractory prostate cancer.

Percentage of positive biopsy cores at the onset of hormone therapy for prostate cancer: prognostic significance.

INTRODUCTION: The percentage of positive prostate biopsy cores (%PBC) has been shown to be a prognostic factor in localized prostate cancer. We hypothesized that it would predict time to hormonal independence and survival in prostate cancer patients treated with androgen deprivation therapy (ADT). PATIENTS AND METHODS: We used clinical data from 403 men treated with ADT between 1980 and 1999 and focused on a subgroup of 220 patients treated with GnRH analogue. %PBC was defined as the number of positive biopsy cores multiplied by 100 and divided by the total number of biopsy cores. RESULTS: Median %PBC was 83.3% (16.7-100%). Mean follow-up was 57.4 months. Survival at 5 years in men with 83.3% PBC or less was 62.3, 89.1 and 82.6% for recurrence-free, specific and overall survival, respectively, significantly better than that of men with a %PBC of more than 83.3% (32.2, 74.7 and 67.7%, respectively; p < 0.004). Among the factors available in the pretreatment setting, namely age, clinical stage, PSA, Gleason score, bone scan and %PBC, the latter was independently associated with survival in multivariate analysis. CONCLUSIONS: %PBC may improve the ability to predict time to hormonal resistance and survival in patients treated with ADT for prostate cancer. This finding warrants further investigation.

One preoperative dose randomized against 3-day antibiotic prophylaxis for transrectal ultrasonography-guided prostate biopsy.

OBJECTIVE: To compare the incidence of infective events between a single dose and 3-day antibiotic prophylaxis for transrectal ultrasonography (TRUS)-guided prostate biopsy. PATIENTS AND METHODS: Patients were randomized to receive either one preoperative dose consisting of two ciprofloxacin 500 mg tablets 2 h before prostate biopsy, or 3 days of ciprofloxacin treatment. They had a clinical examination at study inclusion, the day of the biopsy and 3 weeks later. The day after the procedure all patients were contacted by telephone to inquire about any significant event. Biological testing and urine cultures were conducted 5 days before and then 5 and 15 days after the biopsy; a self-administered symptom questionnaire was completed by the patient 5 days before and then at 5 and 15 days. RESULTS: The study group included 288 men, of whom 139 were randomized to the single-dose arm and 149 to the 3-day arm. Six patients in each group had an asymptomatic bacteriuria with no leukocyturia. One patient in each group had documented prostatitis, with Escherichia coli identified on urine culture. The strain identified in the patient from the 3-day group was resistant to ciprofloxacin. There was no difference between groups in symptoms at 5 and 21 days after biopsy. CONCLUSIONS: Current TRUS-guided prostate biopsy techniques lead to very few clinical infectious complications when accompanied by antibiotic prophylaxis. We found no argument to advocate the use of more than one dose of antibiotic prophylaxis.

Continuous versus six months a year maximal androgen blockade in the management of prostate cancer: a randomised study.

OBJECTIVE: To evaluate systematically interrupted androgen suppression (SIAS) 6 mo a year compared with continuous androgen suppression (CAS) in prostate cancer treatment. PATIENTS AND METHODS: All patients underwent maximal androgen blockade for 6 mo. Then, depending on the randomisation arm, they continued (CAS) or stopped their treatment for 6 mo before they resumed it a year later and so on (SIAS). Primary end points were patient's health-related quality of life (HQOL) and time to progression. Secondary end points were cancer-specific and overall survival. Progression was defined by a clinical event or PSA value exceeding double the value obtained at the end of the first 6 mo of therapy. RESULTS: Sixty-two patients were randomised to CAS and 67 to SIAS. There were no significant differences between groups at baseline. Androgen suppression was associated with HQOL deterioration except for an improvement in urinary symptoms. The 6-mo off-therapy period was not long enough to regain normal testosterone values. There was no difference in HQOL scores between CAS and SIAS except that men in the latter group reported a greater need for painkillers but a better ability to have an erection. Progression occurred in 62 patients (48.1%) with no significant difference between CAS and SIAS with a mean follow-up of 44.8 mo. Death occurred in 41 patients and specific death in 19 patients (10% and 19% of the CAS and SIAS groups, respectively). CONCLUSIONS: Although patients in the SIAS group were maintained off-therapy 50% of the time, insufficient testosterone recovery in this group likely explains why differences between the two groups were moderate or absent with regards to HQOL and survival, respectively.

[Prognostic significance of "sawtooth" PSA and "stepwise" PSA]. / PSA "en dents de scie" et PSA "en escalier": quelles implications pronostiques?

OBJECTIVE: To evaluate the risk of diagnosing prostate cancer on repeated biopsies in patients with fluctuating PSA values compared to patients with stable or regularly increasing PSA values. MATERIAL: Retrospective study conducted on the 2000-2003 databases of 2 French teaching hospitals. Selected patients had a first negative prostatic biopsy, then at least one other series of prostatic biopsies. "Sawtooth" PSA was defined by a PSA value less than that of the previous assay. Other cases were described as "stepwise" PSA. RESULTS: 191 patients were included: 79 in the "sawtooth" group and 112 in the "stepwise" group. Prostate cancer was diagnosed in 53 patients (27.7%), on the second prostatic biopsy 39 cases. Prostate cancer was detected in 17 (21.5%) of the 79 patients of the "sawtooth" group. This proportion was not significantly different (p = 0.14) from that observed in patients of the "stepwise" group: 36/112 (32.1%). No significant difference in terms of age, stage, Gleason score and initial PSA was observed between patients with a diagnosis of prostate cancer in the "sawtooth" and "stepwise" groups. CONCLUSION: In our study, the risk of diagnosing prostate cancer on repeated prostatic biopsies was not greater in patients with "stepwise" PSA compared to patients with "sawtooth" PSA.

[Biomedical research legislation applicable since 28 August 2006]. / Dispositions réglementaires de la recherche biomédicale applicables depuis le 28 août 2006.

The new legislation concerning biomedical research entered into force on 28 August 2006. This legislation, which goes further than the recommendations of European Directive 2001/20/EC, introduces several modifications reinforcing the role of the Comité de Protection des Personnes (Ethics Committee) and the various administrations. The protection of subjects is reinforced by increased control of participants and investigators. Publication of lists of authorized research is designed to strengthen European research. The authors propose a summary of the new legislation to facilitate preparation of protocols.

[National prospective survey on the surgical quality of renal transplants in France. Study conducted by the Association Française d'Urologie Transplantation Committee]. / Enquête nationale prospective sur la qualité chirurgicale des greffons rénaux en France. Etude du Comité de Transplantation de l'Association française d'Urologie.

STUDY OBJECTIVE: The objective of this prospective study was to describe the nature of the lesions observed during brain-dead cadavre donor kidney harvesting in France and to identify the risk factors for these lesions. MATERIAL AND METHODS: A questionnaire elaborated by the AFU Transplantation Committee concerning the quality of kidneys harvested from cadavre donors was sent to all centres performing renal transplantation in France in 2000. This prospective study was conducted over a period of 1 year and concerned the overall multi-organ harvesting procedure based on all data concerning the renal parenchyma, arteriovenous and ureteric characteristics, and the outcome of the transplants. RESULTS: Twelve centres completed the survey, allowing analysis of the data of 201 donor kidneys. 91% of harvesting surgeons were urologists. Various incidents were reported during 11% of harvesting procedures, but 1/3 of the abnormalities were not recorded by the harvesting surgeon. Isolated kidney harvesting was found to be a risk factor (20% vs 8.6%). The rate of parenchymal abnormalities was 50%, 2/3 of which were related to inadequate removal of perirenal fat. Atheroma was a risk factor for arterial lesions during harvesting (21% vs 6.50). Venous abnormalities were detected in 9% of cases: 89% of them were due to the harvesting procedure and 59% of them were not identified by the harvesting surgeon. The fact of not being a transplant surgeon was a risk factor for venous lesions (21.9% vs 6.5%). 4% of ureteric lesions were observed with no consequence on graft outcome. CONCLUSION: Adequate removal of perirenal fat before conditioning is not acquired. Isolated kidney harvesting and atheroma were risk factors for parenchymal and arterial lesions, respectively. Venous harvesting anomalies were more frequent among non-transplant surgeons.

Fluctuating prostate-specific antigen levels in patients with initial negative biopsy: should we be reassured?

OBJECTIVE: To evaluate whether the risk of having a positive repeat prostate biopsy is lower in patients with fluctuating prostate-specific antigen (PSA) levels than in patients with a steady or steadily increasing PSA level. PATIENTS AND METHODS: Files were extracted from the 2000-2003 databases of two teaching hospitals; 191 patients who had a first negative biopsy followed by one or more sets of biopsies and at least two PSA measurements were included. A 'fluctuating PSA level' in a patient was defined as a PSA series including at least one PSA value lower than the one immediately preceding it. RESULTS: The median PSA level at the first biopsy was 7 ng/mL, while that for the second, third and fourth biopsies were 8.0, 8.0 and 8.7 ng/mL, respectively. The median time between the first and second, and the second and third PSA tests was 290 and 317 days, respectively. Prostate cancer was eventually detected in 53 men (27.7%) in whom 39 it was at the first repeat biopsy. Among the 79 patients with a fluctuating PSA level, 17 (22%) had prostate cancer, vs 36 (32%) among the 112 with a 'steady' PSA level; the difference was not significant (P=0.14). When considering the 53 patients diagnosed with prostate cancer, the 17 with a fluctuating PSA level and the 36 others had no significant difference in age, T stage, first PSA level and Gleason score. CONCLUSION: In the present study, by contrast with the common and unfounded view, the risk of having a positive repeat prostate biopsy was no lower in men with a fluctuating PSA level than in those with a steady or steadily increasing PSA level. The practical and economical implications warrant further studies to confirm these findings.

[Macroscopic haematuria after transurethral resection of the prostate]. / "Chute d'escarre" après résection endoscopique de la prostate.

UNLABELLED: Although macroscopic haematuria during the month following transurethral resection of the prostate, due to sloughing of necrotic tissue, is a phenomenon well known to urologists since introduction of endoscopic resection, its pathophysiological and epidemiological characteristics are poorly defined. The objective of this retrospective study was to define the incidence of serious macroscopic haematuria after transurethral resection of the prostate (TURP) and to identify the risk factors for macroscopic haematuria. PATIENTS AND METHODS: The hospital database was used to identify patients treated by TURP between 1997 and 2004 and rehospitalized during the 31 days following the procedure. Files of patients presenting with haematuria and bladder clots were selected and analysed. RESULTS: Ten of a series of 624 patients undergoing TURP were hospitalised for bladder clots and their case files were analysed: median age: 72 years, median duration of TURP: 45 min and median weight of resection: 12 g. The operators' experience and the duration of post-TURP catheterization were not informative. In 2 cases, prostate cancer was diagnosed after analysis of resection chips. Two patients were treated by anticoagulants. Patients were essentially rehospitalized during the 2nd week (median: 11th day). A bladder catheter for was inserted for lavage in each case. No patient required reoperation or removal of clots under general anaesthesia. Two patients were transfused. CONCLUSION: We did not identify any risk factor for sloughing leading to macroscopic haematuria during the month following TURP. Macroscopic haematuria justifying rehospitalization is a rare event. However, in view of this low incidence, optimal analysis could only be performed in the context of a national prospective register.

[Does the initial or secondary status of T1G3 bladder tumours have a prognostic impact?]. / Le statut initial ou secondaire des tumeurs de vessie T1G3 a-t-il un impact pronostique?

OBJECTIVE: This retrospective study evaluated the prognostic value of the initial or secondary status of pT1G3 bladder tumours. MATERIALS AND METHODS: Between 1990 and 2000, 93 patients presented with T1G3 bladder tumour. Seventy-five patients, 54 with initial T1G3 and 21 with secondary T1G3, with no history of invasive bladder tumour, were included in the study. Seventy-two per cent were treated by intravesical BCG. No patient received maintenance therapy. The median follow-up was 53 months (range: 2 to 285 months). RESULTS: On univariate analysis, a significant difference of overall survival was observed in favour of secondary T1G3 tumours compared to initial T1G3 tumours (p < 0.003), while no difference was observed for recurrence, progression and specific survival. This difference was no longer significant on multivariate analysis, but BCG therapy and smoking were significantly correlated with overall and specific mortality. BCG was also correlated with risk of progression. CONCLUSION: Patients with a secondary T1G3 tumour had a better overall survival. This difference was no longer significant when other prognostic factors were taken into account.

Urinary/serum prostate-specific antigen ratio: comparison with free/total serum prostate-specific antigen ratio in improving prostate cancer detection.

OBJECTIVES: To test the previously reported hypothesis, that the urinary/total serum (U/S) prostate-specific antigen (PSA) ratio improves the detection of prostate cancer, by evaluating the clinical usefulness of the U/S PSA ratio and comparing it with the free/total (F/T) serum PSA ratio. METHODS: A total of 165 patients undergoing transrectal ultrasound-guided prostate biopsy were prospectively included in this multicenter study. In all patients, PSA was measured from preoperative serum and 12-hour urine specimens in a centralized laboratory. RESULTS: Prostate cancer was identified in 83 of 165 patients. The differences between patients with and without prostate cancer were statistically significant (P <0.001) when considering the total PSA value (median, 10.2 ng/mL and 6.6 ng/mL respectively), F/T serum PSA ratio (0.11 and 0.18), and U/S PSA ratio (1.2 and 4.2). In the group of 79 patients with a PSA level between 4 and 10 ng/mL, receiver operating characteristic curves showed that the U/S PSA ratio was associated with a larger area under the curve (0.63; 95% confidence interval, 0.51 to 0.73) than the total PSA value (0.55; 95% confidence interval, 0.43 to 0.66) or F/T serum PSA ratio (0.60; 95% confidence interval, 0.49 to 0.71). The U/S PSA ratio did not correlate with patient age or prostate volume. CONCLUSIONS: Our results confirmed that the U/S PSA ratio may be a useful test in prostate cancer detection when the total serum PSA level is between 4 and 10 ng/mL. The F/T serum PSA ratio and U/S PSA ratio did not correlate. This suggests that these two tests could complement each other.

Encrusted cystitis and pyelitis in children: an unusual condition with potentially severe consequences.

OBJECTIVES: To report our experience with the management of encrusted cystitis and pyelitis (EC and EP) in the pediatric population. EC and EP are well-known entities in adults but are rarely identified in children. They consist of mucosal encrustations and are due to specific microorganisms. METHODS: Between 1996 and 2001, 4 children with a mean age of 9 years (range 4 to 13) were treated for EC (n = 2), EP (n = 1), and EC and EP (n = 1). The latter was a kidney transplant recipient. We retrospectively evaluated the clinical characteristics of the patients and the results of conservative management. RESULTS: The delay between the beginning of the symptoms and the diagnosis was longer than 1 month in all cases. The diagnosis of EC was not evoked and was made during cystoscopy in all cases. EP was diagnosed during pyelotomy in 1 patient because it was evoked and confirmed by computed tomography scan in the kidney transplant recipient. Corynebacterium urealyticum was identified in the urine of all patients. EC was treated by antibiotics and endoscopic debulking, and EP was treated by antibiotics and local acidification. The duration of antibiotic therapy was between 1 and 6 months. The tolerance to local acidification of the kidneys was poor. Cure was achieved in 3 cases, but the treatment of EP failed in the kidney transplant recipient and graft removal was decided after 6 months of failed management because intractable febrile urinary tract infections became life threatening for the patient. CONCLUSIONS: EC and EP are uncommon in children; however, these diseases must be considered. They must be diagnosed rapidly and require, if possible, conservative management. Nevertheless, kidney loss can occur in transplant recipients with EP.

[Long-term follow-up of 88 patients operated for primary vesicorenal reflux in childhood]. / Suivi a long-terme de 88 patients opérés dans l'enfance d'un reflux vésico-rénal primitif.

OBJECTIVE: To determine the long-term outcome of patients operated for primary vesicorenal reflux (VRR) in childhood. MATERIALS AND METHOD: This study concerned 88 patients successfully operated for VRR in childhood before 1986 and who answered a questionnaire in 2001. The medical files were reviewed retrospectively and reflux was re-evaluated according to the latest international classification. RESULTS: The median follow-up was 21.5 years [range: 15-27]. The mean age at the time of diagnosis was 5.5 years. In 92% of cases, reflux presented in the form of acute pyelonephritis (APN). 88.5% of the patients contacted declared that they were in good general health and 15.4% of males and 50.6% of females presented episodes of cystitis. However, only 16% of females and no males reported episodes of APN. The presence of renal lesions did not statistically increase the risk of febrile urinary tract infection. No case of APN occurred during the 37 pregnancies reported. One female patient suffered from renal failure due to an aetiology unrelated to reflux. One female patient with a scarred kidney before the operation presented hypertension. CONCLUSION: This study shows that the outcome of patients operated for primary VRR in childhood is favourable despite the persistence of APN. The increasingly early surgical management of VRR will certainly be optimized by long-term follow-up studies with initial assessment of the lesions based on scintigraphic techniques.

[Urinary stones in subjects over the age of sixty]. / Lithiase urinaire chez le sujet âgé de plus de 60 ans.

OBJECTIVE: Urinary stones, affecting 10% of the French population, is a frequent disease. Data of the literature on this disease in subjects over the age of 60 years reveal age-related changes of risk factors, especially affecting urine composition, but very few data have been reported concerning the clinical characteristics of the disease. Due to the absence of recent data on urinary stones in subjects over the age of 60 in France, we decided to study the epidemiology and urological treatment of urinary stones in the elderly in France. MATERIAL AND METHOD: From November 2001 to August 2002, a survey concerning urinary stones in subjects over the age of 60 was performed by the Association Française d'Urologie Stone Committee among urologist members of the AFU. The parameters studied were epidemiological, clinical, metabolic and therapeutic. The results were analysed on the overall patient population and on the subgroup of patients over the age of 70. RESULTS: The study included 176 patients over the age of 60, 110 of whom were over the age of 70. These patients presented their first episode of urinary stones in 41% of cases. Renal colic was the most frequent presenting symptom. Signs of severity were frequently associated, with urinary tract infection in 24% of cases, associated with sepsis in 49% of cases after the age of 70 years. The incidence of uric acid stones was higher than in the general population. CONCLUSION: Urinary stones can often occur for the first time after the age of 60. This disease appears to be more serious than in the general population due to the high incidence of infectious complications. Uric stones also appear to be more frequent. A multidisciplinary study based on a larger population is necessary to confirm these results.

[Guidelines for the urological management of renal and ureteric stones in adults]. / Prise en charge urologique des calculs rénaux et urétéraux de l'adulte.

Progress in the treatment of urinary stones over the last 20 years requires a clearer definition of the indications for each treatment modality for the urological management of renal and ureteric stones in adults. The Stones Committee of the Association Française d'Urologie reviewed the European and American guidelines, the literature published over the last five years, and the experience of its members to establish a set of practical guidelines for the treatment of urinary stones. The site (kidney or ureter) and size (dimensions) of the stone are the initial descriptive criteria for the choice of treatment. Indications are classified as "standard" for first-line treatments, or "optional" for alternative modalities. The success of treatment is defined by the absence of residual fragments. ESWL is the reference treatment for renal stones less than 20 mm in diameter. PCNL is the most effective treatment for stones larger than 20 mm. Flexible ureteroscopy is still under evaluation. Open surgery and laparoscopy have limited indications in less than 1% of cases. ESWL is the first-line treatment for proximal ureteric stones. ESWL and ureteroscopy are both treatments of choice for stones of the pelvic ureter less than 10 mm in diameter, while ureteroscopy is recommended for stones larger than 10 mm. Stone morphology and composition analysis and an aetiological survey must be performed after surgical treatment and the patient must be given dietary advice to prevent recurrence.