[Local recurrence after radical prostatectomy for prostatic cancer]. / Les récidives locales après prostatectomie radicale pour cancer de la prostate.

The local recurrence rate after radical prostatectomy for prostate cancer has varied across studies but seems sufficiently high (20 to 40%) to warrant a reappraisal of the oncological usefulness of this procedure performed in isolation using current techniques. Local recurrence can be either biological or clinical. In biological recurrences, the only abnormality is recurrent PSA elevation. It has been suggested that this event, even in the absence of ultrasound changes or histological documentation, should lead to additional therapy, usually in the form of local radiation therapy, and that the efficacy criterion for this treatment should be a fall in PSA to undetectable levels. However, differences in the "ultrasensitive" assays used to detect PSA pose a serious obstacle to comparisons of published studies. Furthermore, in most publications, the pathological stage is more severe than the clinical stage, and this clinical underestimation of disease severity complicates the evaluation of recurrence rates. In clinical recurrences, rectal digital examination or endorectal ultrasonography show abnormalities and, more importantly, examination of a biopsy specimen establishes that these abnormalities are due to malignant disease. Symptoms may or may not be present. Many authors, particularly in Europe, feel that only clinical recurrences warrant additional treatment, usually in the form of radiation therapy. However, as a preliminary, all available imaging techniques should be used to confirm that the absence of metastases. A valuable tool in this situation is the study of PSA kinetics (elevation rate or postoperative doubling time). If the recurrence seems local, radiation therapy alone is the best initial option, since concomitant hormone therapy leads to a decrease in PSA levels even in the presence of metastatic disease, thus depriving the patient and physician of a valuable therapeutic test. Success rates after radiation therapy for recurrences have varied widely across studies. Some authors consider that this treatment approach is ineffective or provides only transient benefits. Follow-ups were often short, particularly given the considerable variability of the natural history of prostate cancer. The enthusiasm initially generated by radical prostatectomy should be tempered, at least regarding the possibility of a complete cure.

[Rectal injuries in radical prostatectomies for cancer. Survey of the ANFUC (Association National de Formation Urologique Continue) 1994]. / Les plaies du rectum dans les prostatectomies radicales (PR) pour cancer. Enquête de l'ANFUC 1994.

This survey was conducted by 28 urologists members of the ANFUC who reported rectal wounds observed during radical prostatectomy procedures performed for cancer. There were 1,816 procedures reported, 1,785 suprapubic prostatectomies and 28 perineal operations. Kraske access was used in 3 cases. There were 33 wounds to the rectum reported by 17 operators including 31 in suprapubic prostatectomies (1.7% of the operations) and 2 after transperineal operations (7.14%). Preoperative radiotherapy was never used and mechanical preparation was performed in most of the cases with rectal complications (27/33). The wound was sutured in all cases and a colonic derivation was required in 4. Retrospectively this procedure was judged unnecessary in 2 or 3 cases. The post-operative period was uneventful in all cases and the derivations were closed 2 or 3 months later. The conclusions drawn from this survey were the following: the rate of rectal complications in radical prostatectomy is higher in the perineal route. When no preoperative radiotherapy has been performed, simple suture of the rectal wound is sufficient and colonic derivation is not always necessary. It does not appear necessary to interpose an epiploic flap in such cases which would have the disadvantage of requiring opening the peritoneal cavity. These considerations are only applicable to the nonirradiated rectum. Preoperative radiotherapy would undoubtedly have a major effect, but we have had no experience in this series.

[Intestinal perforations in percutaneous surgery of the kidney]. / Les perforations digestives dans la chirurgie percutanée du rein.

Using 9 personal surveys and 11 cases found in the literature, the authors analyse the etiologies of this iatrogenic accident, the often secondary modalities of the diagnosis and the benign nature of the fistula which usually heals spontaneously.

[Vesico-intestinal fistulas]. / Fistules vésico-entérales.

The authors report the various locations (ileal, appendicular, colic, rectal and through Meckel diverticulum) of the fistulas between the bladder and the digestive tract and specify the mainly inflammatory etiologies and specifically those due to the Crohn disease or those caused by tumors aggravated by irradiation and repeated surgery.

[Prostatic or urethral rectal fistulas]. / Fistules prostato-ou uréthro-rectales.

Reporting 7 new observations of prostatic or urethro-rectal fistulas, the authors insist on their etiological modalities specially of traumatical, inflammatory, post-irradiation, cancerous and congenital origin. The diagnosis methods and surgical techniques are also mentioned.

[Intestinal urinary fistulas of renal and pelvis origin]. / Fistules entéro-urinaires d'origine rénale et pyélique.

As the authors point out the uncommon occurrence of these fistulas between the calicopyelic cavities with the colon, the duodenum and still more unusually with the stomach and the jejunum, they report the etiological and clinical features found in the published cases. Usually the only solution is a nephrectomy.

[Total prostatectomy for cancer. Mortality and morbidity. Apropos of 1288 operations. The ANFUC survey]. / La prostatectomie totale pour cancer. Mortalité et morbidité. A propos de 1288 interventions. Enquête de l'ANFUC.

A retrospective survey of total prostatectomies performed for cancer was conducted by 30 urologists members of the French Association of Continuing Education (ANFUC). This survey was limited to the operation itself and perioperative complications observed during hospitalization. Urinary sequellae including incontinence and impotency were excluded and reported elsewhere. The follow-up has been considered insufficient to evaluate the effect of total prostatectomy on the cancer. Post-operative mortality was 1%, in agreement with previously reported series. Complications were analyzed in two categories, general and local. General complications were observed in 9.3% of the patients. The most frequent local complications was haemorrhage (14.7%) and lymphocele or lymphatic fistulas (8.5%). There were 28 perforations of the rectum (2.17%) which were treated with simple suture (n = 21) or rectal suture with an upstream stomy (n = 5). Local urinary complications were fistulas of the urethro-bladder anastomosis (n = 25) and narrowing of the anastomosis (n = 5). There were also 4 urethral strictures and 2 complete sections of the urethra which were recognized and repaired immediately. This first analysis of early complications of total prostatectomy shows that this operation involves only acceptable risks in terms of mortality and morbidity. Over the last few years, total prostatectomy has become a routine operation in urology.

[Hypospadias in the adult: report of 15 cases]. / L'hypospadias de l'adulte: à propos de 15 observations.

This paper is based on the analysis of 15 cases of adults between the ages of 17 and 72 years with hypospadias, previously untreated in 2 cases and unsuccessfully treated in the other 13 cases. The author demonstrates the severe sexual, psychological and urinary implications of this malformation when it is not correctly treated during childhood. The difficulties accumulate with age and the problems become more and more difficult to treat, especially as these patients are frequently from poor socioeconomic groups. The conclusion of this study is not original, but once again emphasises the need to correct this malformation as early as possible, at least before puberty and with a minimum of operations (one operation whenever possible).

[Percutaneous nephrolithotomy (PCNL): evaluation of 250 PCNL by the same operator]. / La néphrolithotomie per-cutanée (NLPC): bilan de 250 NLPC par le même opérateur.

The author reports his 8-year experience of PCNL in 250 patients between the ages of 8 and 86 years, including 31 staghorn calculi and 52 ureteric stones treated via a descending approach. The other stones were pelvic or caliceal and 4 occurred in a solitary kidney. The technique used and the complications are described in detail. The most serious complication was infection, which was almost fatal in 1 case. Haemorrhage (7 cases) and intestinal perforation (2 right colonic perforations) never required surgical intervention. There were no deaths or nephrectomies. The results were immediately perfect (stone-free) in 77.6% of cases and in 82.8% of cases after spontaneous elimination of stone debris or repeat PCNL.

[Ischemic testicular necrosis without torsion of the spermatic cord]. / La nécrose testiculaire ischémique sans torsion du cordon spermatique.

Two diagnoses can be contemplated in case of sudden, painful increase in the volume of a testis: torsion of the spermatic cord and acute orchiepididymitis. Two cases observed in young adults show that acute testicular ischemia may occur without any torsion of the cord, probably due to sudden vascular occlusion. However, except in some infrequent vascular diseases, the etiology of such accidents in young adults in good health is still mysterious. The loss of the involved testis is the rule. Possibilities of treatment are limited at present and render the prognosis for the testis very poor.

[Acute and irreversible obstructions due to a known and well tolerated ureteropelvic junction syndrome]. / Les obstructions aiguës irréversibles sur syndrome connu et bien toléré de la jonction pyélo-urétérale.

Hydronephrosis secondary to ureteropelvic junction syndrome (UPJ), especially when it is accompanied by moderate dilatation of the proximal renal cavities tends to be stable with little risk to the kidney. However, there are certain exceptions to this general rule and the situation may very suddenly and almost always unpredictably progress towards complete obstruction of the UPJ with loss of function of the corresponding kidney. From a series of about 400 cases of hydronephrosis, 230 of which were operated, the authors analysed 13 cases of intermittent hydronephrosis, three of which suddenly progressed towards complete, irreversible obstruction of the UPJ. This dramatic outcome is difficult to predict, but it would appear to be wise to operate on cases of intermittent hydronephrosis, even when only moderate, especially when they are symptomatic, i.e. Painful. The authors believe that an episode of renal colic without stones constitutes an absolute indication for surgery.

[Unusual tumors of the testis. Apropos of 22 cases]. / Les tumeurs rares du testicule. A propos de vingt-deux cas.

The authors report their experience of rare non-germ-cell tumours of the testis over a period of 10 years. The criteria of benign disease, justifying testicular preservation in 5 out of 7 cases of epidermoid cysts, are defined. Four cases of Leydig cell tumours, including 3 with gynaecomastia, are described. Three cases of adenomatoid tumours with conservative surgery, 3 lymphomas, 2 mature teratomas and 2 cysts of the rete testis are also reported. The place of ultrasonography is defined and the possibility of conservative surgery is discussed in relation to a review of the recent literature.

[Endoscopic treatment of ureterocele. The value of antireflux injection of teflon paste]. / Le traitement endoscopique de l'urétérocèle. Intérêt de l'injection antireflux de pâte de téflon.

On the basis of 5 cases, the author show the possibilities of treating certain ureteroceles via an endoscopic approach only with incision of the ureterocele and elimination of the reflux thus created by an injection of teflon paste under the gaping ureterocele. The best indication for this method is an orthotopic ureterocele affecting a non-double ureter, i.e. the ureterocele usually seen in the adult. Orthotopic ureterocele in the presence of double ureter/kidney also seems suitable for treatment in this way. In contrast, ectopic ureteroceles are probably the least suitable indication.

Endoscopic treatment of ureterocele and antireflux injection with Teflon paste.

By referring to two cases, the author demonstrates the possibility of managing certain ureteroceles exclusively by endoscopic treatment. On one hand, by incising or resecting the ureterocele and, on the other hand, by suppressing the reflux thus created with a Teflon injection under the gaping ureterocele. The best indication for this method is the orthotopic ureterocele on a nondivided ureter, i.e. the ureterocele normally found in adults. It also seems possible to treat the orthotopic ureterocele on a duplex kidney in this way. On the contrary, the worst indications for this method are probably ectopic ureteroceles.

[Importance of unrecognized bladder lesions in the long-term results of antireflux reimplantation in "primary" supposed vesico-ureteral reflux]. / Le poids des lésions vésicales méconnues dans les résultats lointains des réimplantations antireflux pour reflux vésico-urétéral supposé "primitif".

Based on two cases of antireflux uretero-vesical reimplantation for so-called primary reflux and a normal lower urinary tract, the author demonstrates the possible occurrence of major secondary bladder lesions. These lesions seriously compromise the results of reimplantation, sometimes even after an initial success (case 1). The etiology of these bladder lesions remains poorly defined: occult neurological lesions? iatrogenic lesions? Their treatment is difficult and their prognosis is poor.

[Congenital megaureter (MU) in the adult. A series of 55 patients presenting 64 megaureters]. / Le mégauretère (MU) congénital chez l'adulte. Une série de 55 malades représentant 64 mégauretères.

Analysis of series of 64 instances of MU in 55 patients leads the authors to the following conclusions: --MU is fairly rare in adults since it is usually discovered at an earlier age; --adult MU shows little activity, even when it is complicated by lithiasis; --renal involvement frequently bears no strict relationship to the magnitude of the MU and is not always obviously improved by surgery; --surgical treatment of MU (anti-reflux ureterovesical reimplantation, with or without ureteral modelling) gives reliable results (14 successes, 2 failures, and 1 patient lost to follow up), comparable to those obtained in children); --the main operating indications consist of: infection, associated urinary, youth, and the possibility of pregnancy; --the problem of associated lithiasis must be dealt with before or during surgical treatment of MU, never after, because of the risk of postoperative lithic migration. Treatment of associated lithiasis has been appreciably simplified by endoscopic methods, and particularly by extracorporeal litholapaxy.

[Merits of interureteral anastomosis in the treatment of unilateral extensive non-neoplastic lesions of the pelvic ureter in adults]. / Intérêt de l'anastomose inter-urétérale (AIU) dans le traitement des lésions étendues unilatérales non néoplasiques de l'uretère pelvien chez l'adulte.

The authors intend to set out the merits of interureteral anastomosis for unilateral extensive lesions of the pelvic ureter. In order to achieve a good homogeneity on one hand and a greater distance in time (8 and 12 years in two cases) on the other hand, they decided to confine their study to the non-neoplastic lesions of adult patients, which are most often iatrogenic. This brief analysis shows that interureteral anastomosis is simpler than ureteroileoplasty when ureterovesical plasty is impossible (psoic, bladder tubulization). Contrary to a widespread opinion, itl does not seriously jeopardize the receiving, ie. normal, urinary tract. The chances of salvage of the initially threatened upper urinary tract are considerable (at least 75 to 80%). The production of an ureteroureteral reflux is a negligible risk, as is the spread of an infection towards the normal kidney. Of course, these good results can be achieved only with an accurate, minutious procedure, of which the authors describe the essential features. The stability of the results is confirmed by the long period elapsed in some cases.

[Percutaneous placement of a double-J endoprosthesis using a descending approach in malignant pelvic tumor threatening the permeability of the upper urinary tract. Apropos of 10 patients]. / Mise en place d'endo-prothèses double-J par voie percutanée descendante dans les affections malignes pelviennes menaçant la perméabilité des voies urinaires supérieures. A propos de 10 patients.

The percutaneous route should be used for ureteral endoprosthesis placement, whenever ascending retrograde passage is not accessible. The authors review the experience gained from attending 10 patients with advance-stage pelvic malignancies and describe the technique used. Emphasis is placed on care needed when selecting the proper route of entry, as well as on advantages presented by J x 2 large gauge probes developed from new biocompatible polymers. This surgical technique may, some times, ensure comfortable survival in selected, premedicated patients under local anesthesia, in whom it is well-tolerated, and yields low complication rates.