[Contribution of the preoperative urodynamic findings in the determination of risks factors of urinary incontinence after radical retropubic prostatectomy]. / Apport de l'exploration urodynamique préopératoire dans la détermination des facteurs de risques de l'incontinence post-prostatectomie radicale totale.

UNLABELLED: The aim of the study was to determine whether preoperative urodynamic evaluation helps the physiotherapist to adapt preoperative management of patients undergoing radical retropubic prostatectomy (RP) by identifying a group at risk of incontinence. MATERIAL AND METHODS: We compared the preoperative urodynamic evaluation of 229 men scheduled for RP with their continence status, evaluated by standardized pad-test and questionnaire, at 6 weeks and 4 months postoperatively. RESULTS: The primary urinary incontinence risk has been obtained for five patient's categories, namely normal, bladder instability, bladder outlet obstruction, hypocontractility, and mixed results. None of the patients diagnosed with detrusor instability and bladder outlet obstruction was continent at six weeks from surgery. At four months, although it improves, the continence status remains significantly poorer than observed in all other groups. CONCLUSION: Preoperative urodynamic evaluation of patients scheduled for RP allows identifying patients with a high risk of postoperative urinary incontinence.

Transitional cell carcinoma involving the prostate: a clinicopathological retrospective study of 76 cases.

PURPOSE: We reviewed the degree to which extension from transitional cell carcinoma into the prostate affects survival. We also compared whether prostatic stromal invasion occurring via direct extension through the bladder wall differs from stromal invasion arising intraurethrally. MATERIALS AND METHODS: A total of 76 men who underwent radical cystectomy for transitional cell carcinoma also had prostate involvement. Patients were separated into group 1-18 with primary bladder tumor extending transmurally through the bladder wall to invade the prostate and group 2-58 with prostate involvement arising from within the prostatic urethra. In the latter group the degree of prostate invasion was classified as urethral mucosal involvement, ductal/acinar involvement and stromal invasion. RESULTS: The 5-year overall survival and recurrence-free rate were 22% and 28% in group 1 versus 43% and 45% in group 2, respectively. In group 2 survival rates were similar in those with prostatic urethral and ductal tumors (without stromal invasion). Five-year overall survival rates without and with stromal invasion were 49% and 25%, respectively (p = 0.024). Prostate involvement decreased survival, which varied according to primary bladder stages (Pis, P1, P2a/b and P3a/b, p = 0.004) or superficial (Pis, Pa and P1) and muscle invasive (P2a/b and P3/b, p = 0.045), disease in 2 groups. Those with positive lymph nodes experienced poorer outcomes in each group. The 5-year overall survival rate in the 19 men with positive lymph nodes was 13% and it was 44% with negative lymph nodes (p = 0.034). The major prognostic factors were age, degree of prostate invasion and lymph node involvement. CONCLUSIONS: The invasion pathways of prostate invasion in patients with transitional cell bladder carcinoma have a statistically significant prognostic role in survival. Transitional cell carcinoma of the bladder extending into the prostate through the bladder wall and bladder carcinoma that did not directly infiltrate the prostate through the bladder wall are 2 distinct clinicopathological entities that should not be included in the same staging grade.

Does site-specific labelling and individual processing of sextant biopsies improve the accuracy of prostate biopsy in predicting pathological stage in patients with T1c prostate cancer?

OBJECTIVE: To evaluate whether individual labelling and processing of the sextant of origin improves the accuracy of prostate biopsy in predicting the final pathological stage after radical prostatectomy in patients with T1c prostate cancer. PATIENTS AND METHODS: The charts of 386 patients treated for prostate cancer by radical prostatectomy between January 1996 and June 1999 were reviewed. In all, 124 patients fulfilled the following inclusion criteria: no abnormality on digital rectal examination (DRE) or transrectal ultrasonography, a prostate specific antigen (PSA) level before biopsy of < or = 20 ng/mL, and prostate cancer diagnosed after one set of random sextant biopsies, with the cores being submitted in six separate containers individually labelled for the sextant of origin. RESULTS: Within this series of patients with a low tumour burden, the preoperative PSA, biopsy Gleason score and unilateral vs bilateral involvement were not significant predictors of disease extension. The percentage of positive cores and the number and topography of positive sextants were both statistically significant predictors of organ-confined disease. Although these two variables appeared to be statistically equivalent on a first analysis in the overall series, a subgroup of patients was identified who benefited from the complete topographical information, i.e. those 52 (42%) patients with a Gleason score of < 7, 25-75% positive biopsies and < or =3 positive sextants. CONCLUSION: These results support the individual labelling of biopsy cores in selected patients with a normal DRE and a moderately elevated PSA, as it helps to better predict the final pathological stage. This substantial benefit outweighs the additional effort by the pathologist.

The role of endourology in ureteropelvic junction obstruction.

Endopyelotomy has benefited from abundant confirmatory investigations, and significant progress in different technical modalities has occurred. Retrograde techniques, including the Acucise (Applied Medical, Laguna Hills, CA) cutting balloon and the ureteroscopic Holmium laser incision, are becoming preferred approaches while the other modalities retain their specific indications. Long-term results and potential complications have been carefully studied and reported. Better identification of risk factors has prompted precise preoperative investigations and allowed for careful patient selection, leading to improved results. These results approach those of open pyeloplasty, but with minimal morbidity.

Immediate vs. delayed androgen deprivation for prostate cancer.

Androgen ablation has been the standard treatment of symptomatic patients with metastatic prostate cancer for more than 50 years. Within the last 15 years, the introduction of prostate-specific antigen (PSA) has induced a stage migration toward less extensive disease and a dramatic decrease in the proportion of men presenting with N+/M+ disease. Historical studies, conducted during the pre-PSA era, are therefore of limited interest in counseling modern patients. The routine use of radical therapies such as radical prostatectomy and radiotherapy has considerably expanded the problem of timing of endocrine treatment in range and complexity. Advanced disease is now diagnosed in patients with limited involvement of extraprostatic sites and even in patients presenting an isolated elevation of PSA after radical treatment. In the absence of clear guidelines, data from past literature and ongoing modern studies were compiled in the present review in an attempt to generate practical considerations.

Intermittent endocrine treatment.

Intermittent endocrine treatment or cyclic therapy of prostate cancer aims at prolonging survival by delaying progression to androgen independence and at improving quality of life by avoiding the side effects of continuous androgen ablation. In this paper we first review the available experimental data suggesting the clinical application of this therapeutic strategy and interpret them with caution. We then examine the published reports of phase II clinical studies showing the feasibility of this approach. Intermittent endocrine treatment is capable of inducing multiple apoptotic regressions; improvement in the sense of well-being and quality of life - including sexual function - is regularly reported. A period of 6-9 months on therapy is usually recommended; the mean off-therapy interval approaches 50% of the duration of the treatment cycle. The mean time to disease progression was 32 months. The definitive answer to the important question of prolonged survival awaits the completion of ongoing randomized studies.

Assessing the risk of unsuspected prostate cancer in patients with benign prostatic hypertrophy: a 13-year retrospective study of the incidence and natural history of T1a-T1b prostate cancers.

OBJECTIVE: To determine the incidence and natural history of stage T1a-T1b prostate cancer in patients undergoing surgery for benign prostatic hypertrophy (BPH), and thus evaluate the effect that recent medical and 'minimally invasive' treatments (which provide no prostate sample for pathological examination) might have on the percentage of patients with unsuspected prostate cancer. PATIENTS AND METHODS: A series of 1648 patients undergoing surgery for BPH over a 13-year period were reviewed retrospectively; the period overlapped the introduction of serum prostate specific antigen (PSA) as a detection method. RESULTS: Stage T1 prostate cancer was found in 182 patients (11%), comprising 126 (11%) of 1199 transurethral resections and 56 (12%) of 449 open enucleations. The introduction of systematic PSA assays gradually reduced the mean incidence of T1 cancer from 23% to 7%, with a greater effect on T1b (from 15% to 2%), while the incidence of T1a remained nearly constant (+/-5%). The pathological features of surgical specimens from 43 radical prostatectomies undertaken for T1 tumours were reviewed. Locally advanced disease (stage >/=pT3) was apparent in 13% of T1a and 28% of T1b tumours. Amongst the patients electing for surveillance, only 8% of those with T1a progressed within 30-97 months of follow-up (mean progression time 73 months), whereas 29% of those with stage T1b progressed within 36 months of follow-up (mean progression time 17 months). CONCLUSION: These results show that the use of the PSA assay has decreased but not suppressed the incidence of pT1 prostate cancer, with a greater effect on those tumours at higher risk of progression (T1b). This suggests that the detection of prostate cancer based on PSA and transrectal ultrasonography is appropriate for screening patients and is sufficiently accurate that treatments for BPH that provide no pathological materials can be applied safely.

The role of antibiotics in the treatment of chronic prostatitis: a consensus statement.

Practical guidelines for the diagnosis and treatment of chronic prostatitis are presented. Chronic prostatitis is classified as chronic bacterial prostatitis (culture-positive) and chronic inflammatory prostatitis (culture-negative). If chronic bacterial prostatitis is suspected, based on relevant symptoms or recurrent UTIs, underlying urological conditions should be excluded by the following tests: rectal examination, midstream urine culture and residual urine. The diagnosis should be confirmed by the Meares and Stamey technique. Antibiotic therapy is recommended for acute exacerbations of chronic prostatitis, chronic bacterial prostatitis and chronic inflammatory prostatitis, if there is clinical, bacteriological or supporting immunological evidence of prostate infection. Unless a patient presents with fever, antibiotic treatment should not be initiated immediately except in cases of acute prostatitis or acute episodes in a patient with chronic bacterial prostatitis. The work-up, with the appropriate investigations should be done first, within a reasonable time period which, preferably, should not be longer than 1 week. During this period, nonspecific treatment, such as appropriate analgesia to relieve symptoms, should be given. The minimum duration of antibiotic treatment should be 2-4 weeks. If there is no improvement in symptoms, treatment should be stopped and reconsidered. However, if there is improvement, it should be continued for at least a further 2-4 weeks to achieve clinical cure and, hopefully, eradication of the causative pathogen. Antibiotic treatment should not be given for 6-8 weeks without an appraisal of its effectiveness. Currently used antibiotics are reviewed. Of these, the fluoroquinolones ofloxacin and ciprofloxacin are recommended because of their favourable antibacterial spectrum and pharmacokinetic profile. A number of clinical trials are recommended and a standard study design is proposed to help resolve some outstanding issues.

Testicular torsion after previous orchidopexy for undescended testis.

We report one case of acute testicular torsion following orchidopexy for an undescended testis. A review of the literature reveals only ten similar cases. History of a previous testicular surgery should not preclude the possibility of a torsion in that testicle. We conclude that at orchidopexy for an undescended testis, eversion of the tunica vaginalis is an essential step to avoid any future torsion.

[Correction of severe median hypospadias. Review of 77 cases treated by the onlay island flap technic]. / Correction des hypospades de gravité moyenne. Revue de 77 cas traités par la technique du "onlay island flap".

Seventy-seven hypospadias, selected from a series of 504 treated in our institution, were operated using the pediculated transverse "onlay" preputial graft. We try to demonstrate that this technique produces excellent functional and cosmetic results. Chordee can be corrected using extensive dissection of the urethral plate with association, if necessary, of a Nesbit type of dorsal plication. Complications rate, in our hands, is lower in comparison to the technique described by John Duckett, where the urethral plate is divided and a complete urethral tube is performed. We report 4 fistulas, one distal end breakdown of the repair and one postoperative hematoma that had to be revised. Because of this low complication rate, in many cases, the "onlay" pediculated graft replaces advantageously the Duckett type of repair.

Urodynamic and electrophysiological testing in pediatric neurourology.

In our institution, children with voiding disorders are submitted to a detailed evaluation comprising a careful clinical examination, laboratory tests, imaging (kidney ultrasonography and voiding cystourethrography) and urodynamic tests. Depending on the etiology of voiding dysfunction, children are subjected to a non invasive or an invasive urodynamic evaluation. Non invasive urodynamic testing comprises a free urinary flowmetry associated or not with an EMG recording of the pelvic floor. Invasive urodynamic testing consists of a pressure-flow study or a video-XR-urodynamic test. In rare instances, genitourinary electrophysiological investigations will be performed. Herein we describe these different urodynamic and electrophysiologic tests.

Is adrenalectomy part of radical nephrectomy?

Standard radical nephrectomy entails en bloc removal of the kidney together with Gerota's fascia and the ipsilateral adrenal. Thanks to the refinement of imaging techniques (ultrasound, CT and MRI), smaller tumors are being diagnosed. In addition, direct extension to the adrenal gland or adrenal metastasis can be detected in most cases. This is why several authors reserve adrenalectomy for large and/or upper pole tumors or abnormal appearing glands on preoperative CT-scan. However, preoperative diagnosis is not always accurate. Furthermore, micrometastatic adrenal invasion at the time of nephrectomy and late recurrences in the persistent adrenal have been documented, so that partisans of adrenalectomy only spare the adrenal in exceptional cases. The authors have reviewed several series in the litterature as well as there own, and conclude that ipsilateral adrenalectomy can be omitted for small middle- or lower pole tumors when the adrenal appears normal on CT and during the surgical intervention.

Endopyelotomy. Prognostic factors and patient selection.

Although clearly a valid alternative to dismembered pyeloplasty for ureteropelvic junction obstruction in adults, endo(uretero)pyelotomy has not been universally accepted in the general urologic community because of the 10% to 30% inferior success rate and the concern regarding hemorrhagic complications. Identification of prognostic factors for success and complications are therefore of primary importance. The length of stricture, the grade of hydronephrosis, and the level of renal function are well recognized prognostic factors. Crossing vessels also play a role, and in association with the grade of hydronephrosis, they seem to be a major prognosticator of outcome. With attention to such prognostic factors, and appropriate patient selection, results can now approach the gold standard of dismembered pyeloplasty.

An antigen recognized by autologous CTLs on a human bladder carcinoma.

By stimulating blood lymphocytes with autologous bladder carcinoma cells that had been transfected with B7-1, we obtained a panel of CTL clones which lyse specifically the bladder tumor cells in an MHC class I-restricted fashion. Based on inhibition with anti-HLA Abs and the recognition of allogeneic tumor cells, we could distribute our clones in three groups that recognized three distinct Ags. We characterized one of these Ags by screening a cDNA library prepared with the RNA from this bladder tumor line. This new tumor Ag is a peptide presented by HLA-B4403 molecules. It is produced by a point mutation in a gene that is recorded in databases under the name KIAA0205, is ubiquitously expressed, and whose function is unknown. We also found this mutation in the tumor sample that was originally resected from this patient, but the mutation was not found in the 100 or more independent tumors of various histologic types that were tested. This report is the first to describe the isolation of CTL clones directed against human bladder cancer and the molecular characterization of a bladder tumor Ag.