[Imaging and hepatic injuries. Development of a therapeutic strategy and role of non-surgical treatment. 33 cases]. / Imagerie et traumatismes hépatiques. Evolution de la stratégie thérapeutique et place de l'abstention chirurgicale. 33 observations.

Among 67 blunt hepatic traumas treated during a 4 years period, 34 required an emergency surgery for reasons of severe bleeding, with 16 deaths of which 11 were directly due to the liver injury. 33 patients, whose hemodynamic stability contrasted with major hepatic lesions (5 deep fractures, 28 central hematomas combined with 5 subcapsular hematomas and 3 multiple parenchymatous fractures), were subjected to nonoperative management. One patient died from sudden hemorrhage and a second one underwent further drainage for a residual pelvic abscess. In the 32 alive patients, a close watch over with ultrasound and CT scan gave prominence to a complete disappearance of the lesions within 4 to 24 weeks. The nonoperative management of such hepatic injuries may be a safe and reasonable alternative to a high risk surgery, as far as the hemodynamic condition or associated visceral lesions do not require an emergency surgery.

[Percutaneous placement of ureteral prostheses. 150 cases]. / Mise en place percutanée de prothèses urétérales. 150 observations.

Percutaneous placement of ureteral stents was attempted on 150 occasions with an 85 p. 100 success rate. Whether released or not, this type of prosthesis ensures that the urine is drained internally from kidney to bladder. Stenting is effective as palliative treatment of malignant stenosis or curative treatment of benign stenosis, as it maintains the ureteral lumen diameter after balloon catheter dilatation. It also dries up post-operative urinary fistulae and it controls and promotes their healing. Because of the satisfactory results obtained, the percutaneous technique is increasingly preferred to surgery performed under difficult conditions.

The prognosis of renal vein thrombosis: a re-evaluation of 27 cases.

Twenty-seven patients with renal vein thrombosis were retrospectively studied to evaluate their long-term prognosis and relevant prognostic factors. Twenty-four patients presented with a nephrotic syndrome, and 15 had renal impairment (8 acute; 7 moderate). Ten patients had a previous history of proteinuria, and 14 of nephrotic syndrome. Renal biopsy performed in 20 patients, of whom 19 were nephrotic, showed membranous glomerulonephritis in 14, focal segmental glomerulosclerosis in three, minimal change glomerulonephritis in two, and periarteritis nodosa in one. Renal vein thrombosis was angiographically proven in all patients and was bilateral in 18, localised to the left renal vein in seven, and to the right in two. Thrombosis of the inferior vena cava was associated in seven patients. Ten patients were treated by anticoagulants alone, nine by surgical thrombectomy, seven by thrombolysis, and two did not receive any specific treatment. One patient underwent successively thrombectomy and then thrombolysis. Eleven patients died within the first 6 months, mainly from haemorrhagic complications (n = 5) or severe sepsis (n = 2). Survivors were followed up from 6 months to 19 years. Nephrotic syndrome improved or even disappeared in 12 patients, and renal function did not worsen throughout the follow-up in any patients. The main prognostic factors were initial renal function and type of nephropathy: patients with membranous glomerulonephritis had a significantly better renal function and a lower mortality rate than patients with other nephropathies. Initial renal insufficiency was significantly associated with a poor prognosis. There was no advantage, in terms of survival, kidney function and nephrotic syndrome, of either thrombectomy or thrombolysis over anticoagulants alone, despite two complete venous recanalisations after thrombolysis. Accordingly, patients with renal vein thrombosis from membranous glomerulonephritis should be treated by anticoagulants alone, since the long-term prognosis of this disease seems unaffected by intercurrent renal vein thrombosis. With respects to the risk-to-benefit ratio, thrombectomy should be avoided and thrombolysis considered only in patients with initial acute renal failure from acute renal vein thrombosis.

Fistulas of the upper urinary tract: percutaneous management.

We treated 40 patients with urinary fistulas by interventional radiology. The antegrade percutaneous route, catheterization of the ureter and bypassing of the fistula enabled ureteral stenting in 36 patients (90 per cent). Criteria for successful treatment were healing of the fistula, normal renal function (evaluated by excretory urography and radionuclide studies) and absence of secondary stenosis at 6 months. Of the patients 28 (70 per cent) were treated successfully. The number of nephrectomies after failure of percutaneous techniques (5 of 40, or 12.5 per cent) seems lower than in the case of surgery. The results were excellent for fistulas occurring after endourology (all 9 successful) or after ureterointestinal anastomoses (7 of 8). On the other hand, the results appear disappointing in patients with fistulas in transplanted kidneys (3 of 4 failures).

[Local treatment of obstructive uric acid calculi]. / Traitement local des calculs obstructifs d'acide urique.

Dissolution of uric acid calculi could be obtained by oral or parenteral urinary alcalinization, but this method cannot apply to the case of obstructive calculi. Nineteen obstructive calculi in 18 patients were treated by in situ alcalinization through a percutaneous nephrostomy catheter (PCN). Eight patients were initially anuric, 7 of whom from an obstructed solitary kidney and 1 from a bilateral obstructive lithiasis. Fifteen calculi were located in the ureter, 3 in the uretero-pelvic junction and 1 in the pelvis. After 48 h of urinary diversion through PCN, an isotonic sodium bicarbonate solution (14 g %) was continuously infused at an average flow rate of 2.8 l/24 h, through either an unique PCN, or a 2 PCN-irrigation circuit in the 7 cases with permanently obstructive calculus. Fifteen calculi (80%) were completely dissolved after 3 to 13 days of alcalinization (average 5.8 days). One large calculus was reduced by 3/4 and further removed by percutaneous lithotripsy. Three patients underwent ureterotomy after 9 to 11 days of uneffective treatment. Local alcalinization is an effective and non invasive treatment for obstructive uric acid calculi, and is logically associated with the necessary urinary diversion.

Nondilated obstructive acute renal failure: diagnostic procedures and therapeutic management.

We examined 80 patients with acute obstructive anuria by ultrasound (US). Four of the 80 patients did not have dilatation of the urinary tract. In all four cases, antegrade pyelography guided by real-time US demonstrated urinary tract obstruction after the four patients had experienced 4, 5, 8, and 34 days of anuria, respectively. Diuresis occurred as a result of percutaneous nephrostomy in all four cases. Three of the patients were successfully treated by percutaneous techniques alone. Our findings demonstrate that even a complete and long-term obstruction of the urinary tract does not necessarily induce dilatation in the upper part of the tract. In such cases, only the direct opacification of the urinary tract can help confirm that the obstruction is present. Even in the absence of dilatation, antegrade pyelography guided by real-time US is a possible diagnostic method and can be the first step in the performance of percutaneous nephrostomy.

[Dissolution of obstructive uric acid calculi by percutaneous nephrostomy and in situ alkalinization]. / Dissolution des calculs uriques obstructifs par néphrostomie percutanée et alcalinisation in situ.

Following the introduction of one or two percutaneous nephrostomy drains, 16 obstructive uric acid calculi were treated by perfusion of excretory cavities with 14% sodium bicarbonate solution. Twelve calculi had dissolved within an average of 5 days, 1 required percutaneous lithotripsy because of incomplete dissolution and 3 were unaltered. Success of this treatment appears to be dependent on the total radiotransparency of calculi, a feature difficult to demonstrate. There were no reports of major complications. The only weakly invasive nature of alkalinization in situ makes it a method of choice to be reserved for obstructive calculi, and a therapeutic strategy is proposed.

[Colonic perforations during interventional urinary radiology]. / Les perforations coliques au cours de la radiologie d'intervention urinaire.

Three patients had colonic perforation as a result of percutaneous nephrostomy and lithotripsy. These patients did not respond to conservative measures and required surgery (colostomy, hemicolectomy, drainage). This report reviews the anatomic and technical aspects of percutaneous access to the kidney. Fluoroscopy and ultrasonography do not allow simple and accurate information of the position of the colon, and CT is the method of choice. Some factors seem of high risk : thin and young patient, female, dilated pelvo-calyceal system, associated colonic obstruction.

[Ultrasonic diagnosis in scrotal pathology. Apropos of 137 tests]. / Apport de l'échographie dans la pathologie des bourses. A propos de 137 examens.

Ultrasound imaging of scrotum in 137 patients detected 31 inflammatory lesions of epididymis or testis, 8 tumors, 23 cystic lesions, 21 hydroceles and 19 other affections. Medical or surgical treatment was instituted in 63% of patients, the other 37% failing to attend. Therapy was effective in 90.5% of cases (100% of fluid lesions, 80.6% of inflammatory lesions and 87.5% of tumors). Ultrasound imaging appears to be an excellent complement to clinical examination, when findings are insufficient or when examination is difficult because of severe pain, allowing identification of the fluid or solid nature of a lesion. It is also of specific value for diagnosis of subclinical tumors, surveillance of patients at risk and detailed investigation of inflammatory lesions.

[Obstructive anuria with non-dilated cavities]. / Anuries obstructives à cavités non dilatées.

Four patients with no evidence of acute functional or organic renal failure suddenly developed anuria. Repeated ultrasonographic exploration failed to show any dilatation of the urinary tract. After 4, 5, 7 and 34 days of anuria respectively, an obstacle was detected, located and identified by ultrasonically guided antegrade pyelography, which led to immediate urine derivation by percutaneous nephrostomy. Three of these patients were cured by percutaneous techniques alone. These 4 cases represent a small but not negligible part of a series of 74 patients with obstructive anuria, 70 of whom had dilated renal cavities. They throw doubt not on the reliability of ultrasonography, but on the idea that all obstacles are associated with dilatation upstream. They also confirm that opacification of the urinary tract is the only way of making sure that an obstacle is present. Antegrade pyelography gives excellent contrast images and can be used as first stage of a percutaneous nephrostomy. The other diagnostic methods are fraught with a high proportion of inadequacy or failure.

[Nephrostomy and percutaneous internal bypass. Technic and results. Apropos of 130 cases]. / Néphrostomies et dérivations internes percutanées. Technique et résultats. A propos de 130 cas.

130 percutaneous nephrostomies have been performed on 106 patients, 6 of whom had transplanted kidneys. On 4 of these patients percutaneous drainage of a perinephric abscess was performed at the same time. Over 50% of the patients were in obstructive anuria. No failure was noted in placement of the nephrostomy tubes. Only one major complication occurred, a resolvent septic shock. Minor complications i.e. pelvocalyceal blood clotting, catheter dislodgement, retroperitoneal urine extravasation, are rare. There is no contra-indication to this procedure. 30 indwelling ureteral catheters and 10 double pigtail stent catheters were also inserted by this antegrade technic. The main indications for these procedures are 1) acute or chronic supravesical obstructions, especially infected cases. The therapeutic decision is often difficult in stenosis of neoplastic origin 2) ureteral fistulas which are always dried by a nephrostomy and which can be definitely cured by indwelling catheters, 3) certain types of calculi, which can be either treated by irrigation in situ with stone-dissolving solutions, or removed percutaneously by extraction or ultrasonic lithotripsy.

[Early measurement of portal pressure as a deciding factor in the treatment of ruptured oesophageal varices (author's transl)]. / Mesure précoce de la pression portale pour le traitement des ruptures de varices oesophagiennes.

A retrospective study of 51 patients with ruptured oesophageal varices showed a clear-cut difference in mean portal pressure between those who underwent elective surgery (33.7 cm/H2O) and those who were operated upon while still bleeding after failure of medical treatment (41.3 cm/H2O). It would appear that medical treatment is likely to be unsuccessful in 75% of the cases when portal pressure exceeds 35 cm/H2O. These findings tend to indicate that a rapid therapeutic decision would improve the results of emergency treatment. Early measurement of portal pressure by jugular vein catheterization seems to be essential, but other diagnostic procedures, such as laboratory tests and liver biopsy, are also important. A prospective study of 11 recent cases where these procedures were carried out appears to confirm their value as deciding factors in the treatment of ruptured oesophageal varices.

[Pulmonary xanthogranulomas (author's transl)]. / Xanthogranulomes pulmonaires.

The authors report on six cases of pulmonary xanthogranuloma. They stress the latent character of these dense, round isolated parenchymatous tumors. The tumors have an homogeneous aspect without calcifications and regional adenopathies. The radio-clinical diagnosis is difficult to assess because the para-clinical examinations are regularly negative. The differential diagnosis is made either clinically, especially with hamartochondroma and peripheral cancer, or histologically according to the predominance of various types of cells, especially with a solitary plasmocytoma, a lymphoma or a sclerosant hemangioma. Histology is the only key to diagnosis. For these reasons, the decision for surgical intervention presents a problem as the patients, often young, present no visible signs and the lesions evolve but very slowly.