[Prospective evaluation of intrasphincteric injections of autologous muscular cells in patients with stress urinary incontinence following radical prostatectomy]. / Évaluation prospective du traitement de l'incontinence urinaire post-prostatectomie par injections intrasphinctériennes de cellules musculaires autologues.

PURPOSE: Cell therapy for urinary incontinence management has been experienced in animals with encouraging results, but studies in human beings are lacking. Our primary objective was to assess the safety of intrasphincteric injections of autologous muscular cells in patients with postprostatectomy incontinence (PPI). Secondary objectives focused on complications efficacy. METHODS: We conducted an open, prospective study in a single center on 12 patients presenting PPI. Patients underwent intrasphincteric injections of autologous muscular cells isolated from a biopsy of deltoid muscle. The primary endpoint was the Q(max) variation at the three month visit in order to assess potential bladder outlet obstruction. Secondary endpoints assessed side effects and efficacy parameters based on symptoms, quality of life score, voiding diary, pad-test, and urethral pressure profile at one, two, three, six and 12 months after injection. RESULTS: No immediate complication occurred and no significant variation was noted on Q(max). The only side effects possibly product-related were three cases of urinary tract infection treated by antibiotics. An acceptable safety and tolerability of the procedure whatever the injected dose of muscular cells was demonstrated. Results on efficacy after one year were heterogeneous, with 4/12 patients describing reduced urine leakage episodes, 1/12 patient presenting increased maximal closure pressure, and 8/12 patients showing improvement on pad-test. CONCLUSIONS: Cell therapy consisting of intrasphincteric injections of autologous muscular cells in patients with PPI was a feasible and safe procedure. The results point out that some subjects may positively respond to this procedure, but clinical efficacy remains to be confirmed.

[Erectile dysfunction and cavernosal endothelial cells]. / Dysfonction érectile et cellules endothéliales caverneuses.

The physiopathology of erectile dysfunction (ED) is multifactorial. The recent discovery of the precise role of cavernosal endothelium in the functional regulation of the smooth muscle cells allowed to understand the physiological bases of erection. The purpose of this article is to make a synthesis of the current knowledge on the endothelial function and to allow a better understanding of the pathological responsible mechanisms of ED. Endothelium provides cavernosal smooth muscle cells relaxation by two main pathways: the NO/cGMP pathway induced by production of neural nitric oxide (NO) in cavernosal nerve terminals, and the AC/cAMP pathway which by-passes the NO route by using other mediators. This action allows the initiation and maintenance of erection. Risk factor-associated cavernosal endothelial alterations (diabetes mellitus, hypertension, hypercholesterolemia) are mostly induced by unifying mechanisms, including oxidative stress and accumulation of reactive oxygen species, alteration of NO production, or decrease of VEGF expression. The same cellular mechanisms can also be observed during aging. To a comprehensive appraisal of physiological bases of viable endothelium in erectile function, it is crucial to understand its biological activities. The hemodynamic evaluation of endothelial function and the current therapeutic implications will be later approached.

[Effect of wound infiltration of ropivacaine in postoperative pain after extraperitoneal laparoscopic radical prostatectomy]. / Effet de l'infiltration pariétale d'anesthésique local (ropivacaïne) sur la douleur postoperatoire après prostatectomie radicale laparoscopique sous-péritonéale.

PURPOSE: Evaluation of the efficiency of wound infiltration of ropivacaine in postoperative pain after extraperitoneal laparoscopic radical prostatectomy. MATERIAL AND METHODS: Prospective single institution study included 130 patients treated by extraperitoneal laparoscopic radical prostatectomy from January to March 2007. One hundred and two patients were included and randomised in two groups according to the year of birth (pair or impair). Only patients from the first group (year pair) had wound infiltration at the end of the procedure. The second group (year impair) was the control group. An analogic visual scale (EVA) permitted evaluation of pain at 30 minutes, 1, 6 and 12 hours after the procedure. Use of analgesics after procedure were noted for each patient. RESULTS: In the first group, the median of EVA was 1.44, 1.34, 1.72 and 1.51 respectively at 30 minutes, 1, 6 and 12 hours. In the second group, the median of EVA was 1.28, 1.36, 1.46 and 1.44. We found no statistically significant difference for pain and use of analgesic between the two groups (p=0.71, 0.96, 0.47 and 0.86 respectively at 30 minutes, 1, 6 and 12 hours). CONCLUSION: Ropivacaine in wound infiltration did not decrease significantly the postoperative pain and must not be used systematically.

[Permanent implant prostate cancer brachytherapy]. / La curiethérapie du cancer prostatique par implants permanents.

With an experience of more than 20 years for the pionneers (and more than 10 years in France), permanent implant brachytherapy using Iodin 125 seeds is now recognized as a valuable alternative therapy for localized low-risk prostate cancer patients. An extension of the indications of exclusive brachytherapy towards selected patients in the intermediate-risk group is presently under study. Moreover, for patients in the high-risk group, brachytherapy, as an addition to external radiotherapy, could represent one of the best way to escalate the dose for some patients. Various permanent implant brachytherapy techniques have been proposed; preplanning or real-time techniques, loose seeds or stranded seeds, manual or automatic injection of the seeds. The main point here is the ability to perfectly master the procedure and to comply with the dosimetric constraints which have been recently redefined by the Groupe européen de curiethérapie--European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) group. Mid- and long-term results which are now available in the literature indicate relapse-free survival of about 90% at 5-10 years, the best results being obtained with satisfactory dosimetric data. Some comparative data have shown that the incontinence and impotence rates after brachytherapy seemed to be significantly inferior to what is currently observed after surgery. However, a risk of about 3-5% of urinary retention is usually reported after brachytherapy, as well as an irritative urinary syndrome which may be significant and last several months. In spite of those drawbacks, with excellent long-term results and low rates of incontinence and impotence, brachytherapy can be expected to be proposed to an increasing number of patients in France in the next future.

[Genetic determinants of anatomical variants of the prostate]. / Facteurs génétiques déterminant les variations anatomiques de la prostate.

INTRODUCTION: The determinants of macroscopic and microscopic anatomical variants of the prostate during ageing are poorly defined. The authors evaluated the correlation between specific gene polymorphisms involved in androgen and oestrogen synthesis and gross (prostatic weight) and microscopic anatomy (stroma/epithelium ratio) of the prostate during ageing. METHODS: The prostatic weight and stromal surface area of an autopsy series of 85 men over the age of 50 were measured, then compared as a function of gene polymorphisms involved in androgen or oestrogen regulation. The following polymorphisms were studied: number of CAG repeats of the androgen receptor (AR), number of TA repeats and the V89L variant of the 5-alpha-reductase gene (SRD5A2) for androgens, and the A1A2 variant of 17-alpha-hydroxylase (CYP17) and number of TTTA repeats of the aromatase (CYP19) for oestrogens. RESULTS: No correlation was observed between the number of TA repeats of the SRD5A2 gene or TTTA repeats of the CYP19 gene and anatomical parameters of the prostate. A statistically significant positive correlation was observed between age and prostate weight (r=0.21, p=0.05) and a statistically significant negative correlation was observed between prostate weight and number of CAG repeats (r=-0.32, p=0.003). The group with less than 20 CAG repeats was associated with a higher prostate weight than the other group. The stromal surface area was greater in the [20-23] CAG repeat group (p=0.02), and in the A2A2 group of CYP17 (p=0.016) than in the other groups. CONCLUSION: A small number of CAG repeats is associated with a higher prostate weight. The mean number of CAG repeats of the androgen receptor and the A2A2 variant of the CYP17 gene are associated with a larger stromal surface area.

[Renal angiomyolipoma complicated by extension to the renal vein and inferior vena cava]. / Angiomyolipome rénal compliqué d'une extension à la veine rénale et à la veine cave inférieure.

Renal angiomyolipomas are renal hamartomas. They are usually found incidentally, presenting as well-defined echogenic masses on sonography and fat containing tumors on CT and MRI. We report a case of angiomyolipoma with sonographic and CT evidence of extension to the renal vein and inferior vena cava.

[Vesico-urethral anastomosis during total laparoscopic prostatectomy]. / Anastomose urétrovésicale lors de la prostatectomie radicale laparoscopique.

Vesico-urethral anastomosis is the last step of radical prostatectomy. Whatever the approach, radical prostatectomy remains a difficult surgical intervention. The dissection steps are similar whatever the selected access, open or laparostopic. Laparoscopic anastomosis requires specific skills that must be adequately mastered by the surgeon before starting any laparoscopic radical prostatectomy program. Pelvi-trainers allow training on the anastomosis technique, with reproducible results. This chapter presents the key points for laparoscopic vesico-urethral anastomosis.

Ablation of superficial bladder tumors with focused extracorporeal pyrotherapy.

OBJECTIVES: We report the first experimental studies of focused extracorporeal pyrotherapy. METHODS: Focused extracorporeal pyrotherapy has been used to treat superficial bladder tumors in a Phase II protocol in 25 patients. In 5 cases, for technical reasons, pyrotherapy was not used. In 20 patients (10 under general anesthesia and 10 under spinal anesthesia), the mean treated volume was 3 cm3 with an average of 300 shots and a mean skin focused length of 90 mm. Treatment time was 44 minutes; hospital stay was 2 days. Postoperatively, two skin burns and one acute retention were observed. RESULTS: Of 20 patients, 15 (75%) had a normal urinary cytology bladder ultrasonography and cystoscopy at 1 month. In 67% of patients with primary tumor, there was no recurrence at 1 year; 33% had recurrent tumors. No infiltrative tumor or metastases have been observed during this follow-up (3 to 21 months). CONCLUSIONS: These encouraging results show that ablation of superficial bladder tumor is feasible. The technique must be improved to allow treatment of larger tumor volume in a shorter time.

Laparoscopic radical prostatectomy: assessment after 240 procedures.

Radical prostatectomy can be successfully performed by transperitoneal laparoscopy by a urologic team experienced in laparoscopy and radical prostatectomy. Operative and postoperative morbidity rates are low. Postoperative pain is minimal, allowing reduction of the length of hospital stay. The oncologic results seem satisfactory based on short-term follow-up. The improvement of the quality of intraoperative vision related to magnification of the image allows a more precise procedure. This subjective improvement of the quality of dissection should reduce the usual functional sequelae of conventional radical prostatectomy, such as incontinence and impotence. This finding needs to be confirmed by a larger series of patients with longer follow-up. Laparoscopic radical prostatectomy is now performed routinely and is proposed as a first-line surgical treatment for localized prostatic cancer at the authors' center.

Identification of alpha 1-adrenoceptor subtypes present in the human prostate.

alpha 1-Adrenoceptors (ARs) play an important role in mediating human prostatic smooth muscle contraction. In the present study cDNA fragments covering different domains of 3 alpha 1-AR subtypes (alpha 1b, alpha 1c and alpha 1d) were generated from human prostate by reverse transcription coupled to the polymerase chain reaction (RT-PCR). The reconstituted partial sequence (349 amino acids) of the human prostatic alpha 1c-AR PCR products showed 94% identity at the amino acid level with that of the corresponding region of the cloned bovine brain alpha 1c-AR. Using human alpha 1-AR subtype selective cDNA probes in Northern blot analysis, the co-expression of mRNA transcripts corresponding to alpha 1b-, alpha 1c- and alpha 1d-AR subtypes was detected in 4 different regions (apex, base, periurethra and lateral lobe) of the human prostate. Competitive inhibition experiments of [3H]-prazosin binding to membrane preparations of human prostate revealed that the non-selective alpha 1-subtype antagonist, alfuzosin, produced a monophasic inhibition curve, whereas oxymetazoline produced a 2-component inhibition curve with pKi values of 8.54 and 5.46. The high-affinity alpha 1-AR component of the oxymetazoline inhibition curve was predominant (57%-66%) and showed an affinity for oxymetazoline comparable to that of the alpha 1c-AR subtype. As such our results illustrate the expression of different alpha 1-AR subtypes in human prostate and importantly that alpha 1c represents the predominant alpha 1-AR subtype present in this tissue.

Feedback from operative performance to improve training program of laparoscopic radical prostatectomy.

PURPOSE: We report our preliminary experience identifying factors that contribute to differences in operative performance in laparoscopic radical prostatectomy (LRP) between trainees and experienced laparoscopic urologists based on objective and subjective feedback. MATERIALS AND METHODS: Between December 2001 and May 2002, six trainees at the Institut Montsouris and Ecole Européenne de Chirurgie, Paris, were evaluated to identify the factors contributing to differences in operative performance in LRP between them and experienced laparoscopic urologists, both objectively and subjectively. Objective evaluation was done by an independent observer who was well versed in laparoscopic surgery, while all the trainees evaluated themselves subjectively. All the trainees had in vitro, in vivo, and didactic training sessions during the evaluation period. RESULTS: The following deficiencies were noted objectively in the trainees compared with experienced laparoscopic urologists: (1) lack of perfect knowledge of each step, (2) lack of synchronized movements of the nondominant hand; and (3) easy physical fatigue. The trainees took a long time to dissect the vas deferens, seminal vesicles, and bladder neck because they did not have perfect knowledge of each step. It was difficult for them to pass the needle for ligation of dorsal venous complex because they tried to hold the needle far away from the needle tip at the wrong angle, and the direction of movement was not correct. For the urethrovesical anastomosis, they struggled to find the right angle to pass the needle on the urethral side. CONCLUSION: Lack of synchronized movement of the nondominant hand, easy physical fatigue, and lack of perfect knowledge of operative steps are crucial limitations for live operative performance of trainees in LRP. Incorporation of intensive well-planned in vitro training into the curriculum to correct these deficiencies and feedback from the operative performance can make a significant contribute to shortening the learning curve.

Laparoscopic partial nephrectomy in the pig: comparison of three hemostasis techniques.

BACKGROUND AND PURPOSE: Control of intraoperative bleeding is the main technical difficulty encountered during laparoscopic partial nephrectomy. The objective of this study was to compare the efficacy and morbidity of three renal parenchymal hemostasis techniques: high-frequency bipolar electrical current, high-frequency unipolar spray electrical current, and ultrasound during laparoscopic partial nephrectomy performed in pigs without vascular control. MATERIALS AND METHODS: A standardized laparoscopic transperitoneal right lower-pole partial nephrectomy was performed in 27 pigs with a mean weight of 65 +/- 5 kg. The pigs were divided into three groups according to the technology used: Group 1 = bipolar electrical current, Group 2 = unipolar spray electrical current, and Group 3 = ultrasound. Intravenous urography was performed on the 28th day. The kidneys were then removed for histologic examination, and the pigs were sacrificed. The criteria evaluated were intraoperative and postoperative complications, blood loss, renal function, and thickness of the parenchymal lesions induced. The Kruskal-Wallis nonparametric test for comparison of medians was used for statistical analysis of the data (P < 0.05). Data from pigs that died before the end of the study were excluded from the analysis. RESULTS: All partial nephrectomies were performed laparoscopically, and all pigs were alive at the end of the operation. The postoperative complication rate was 11% (N = 3): two pigs died before the end of the study, one from hemorrhage on Day 6 (Group 2), and the other from prolonged reflex ileus with sacrifice of the pig on Day 7 (Group 3). One pig developed an asymptomatic urinoma (Group 2). Blood loss was significantly lower when ultrasound was used (P = 0.026). Global renal function was not significantly altered in the various groups. The median thickness of tissue necrosis and fibrosis detected in the scar zone was 6 mm (range 4-10 mm) and was similar in the three groups. CONCLUSION: Partial nephrectomy can be performed by laparoscopy without vascular control in the pig. Coagulation by ultrasound appears to present an advantage in terms of limitation of blood loss compared with coagulation by bipolar or unipolar spray electrical currents without presenting any benefit in terms of preservation of the renal parenchyma.

Laparoscopic radical prostatectomy: the lessons learned.

PURPOSE: To evaluate the operative, oncologic, and functional results of laparoscopic radical prostatectomy based on an initial series of 350 patients. PATIENTS AND METHODS: Between January 1998 and May 2000, 350 consecutive patients underwent laparoscopic radical prostatectomy according to our technique. The study of operative morbidity was based on all intraoperative and postoperative complications. The oncologic assessment was based on clinical, laboratory, and intraoperative and postoperative pathological data. Postoperative functional results were assessed by the ICS-male self-administered questionnaire. RESULTS: No deaths were observed in this series. Conversion was required in seven cases, exclusively among the first 70 patients. The mean operating time was 217 +/- 59 minutes, including the lymphadenectomy phase that was considered necessary in 21.4% of patients, and 195 +/- 56 minutes for the most recent 200 patients. The mean intraoperative blood loss was 354 +/- 250 mL. The overall transfusion rate was 5.7% and 2.8% in the last 250 patients. Intraoperative complications were reported in 14 patients (4%), and the reoperation rate was 3.7%. The mean postoperative bladder catheterization time was 5.8 +/- 3.3 days, and the catheter could be removed before the 5th day in 41% of patients. The mean hospital stay was 6 +/- 3.9 postoperative days (range 2-33 days). By pathologic stage, the positive surgical margin rate was 3.6% for pT2a specimens (3 patients), 14% for pT2b specimens (29 patients), 33% for pT3a specimens (12 patients), and 43.5% for pT3b specimens (10 patients). In the first 75 patients with pT2N0/Nx negative-margin specimens and a follow-up of >12 months, the PSA concentrations was <0.2 ng/mL in 92% of patients. The continence rate (no protection necessary either during the day or at night) among the first 133 patients was 85.5% and the postoperative erection rate was 59% among 22 selected consecutive patients. CONCLUSIONS: This study confirms the value, in our experience, of the laparoscopic approach to radical prostatectomy, which allows satisfactory cancer control associated with low perioperative morbidity and encouraging functional results in terms both of continence and erectile function.

Retroperitoneal laparoscopic nephrectomy: animal and human anatomic studies.

Retroperitoneal laparoscopic nephrectomy with CO2 insufflation was performed in 11 goats. The hemodynamic and blood gas repercussions of retroperitoneal laparoscopy were compared during the first 30 minutes with those induced by intraperitoneal laparoscopy. With the animal placed in the left lateral supine position, the hemodynamic and blood gas changes were similar with the two techniques and had a similar time course. The technical feasibility of retroperitoneal laparoscopy in animals was confirmed in the fresh human cadaver. The technical feasibility of retroperitoneal laparoscopy and the absence of any particular hemodynamic and blood gas repercussions encourage us to develop this approach for clinical upper urinary tract surgery.

[Renal varices. X-ray computed tomographic diagnosis and treatment by embolization]. / Varices rénales. Diagnostic tomodensitométrique et traitement par embolisation.

Two cases of recurrent macroscopic hematuria in which the diagnosis of left renal vein varices has suggested on CT are described. Bloody efflux was seen from the left ureteric orifice. On CT scans, tubulated contrast-enhanced densities in left perineal fat were seen. Selective renal angiography was normal. Selective left renal phlebography demonstrated intra and perirenal varices. In the two cases, embolization with metallic coli was successfully performed during left renal phlebography, to stop renal varices flux. Diagnostic and therapeutic modalities of renal varices are discussed with predominant place for CT and phlebography.

[What should be done in the presence of isolated microscopic hematuria in man in the work environment?]. / Que faire en présence d'une hématurie microscopique isolée chez l'homme en milieu de travail?

Microscopic haematuria was detected by the strip technique in 3.5% (normal: 1.8%) of 2100 men over 40 years of age, systematically examined at their place of work. Thirty-two agreed to undergo further investigations. Eight (25%) were found to have a urinary tract disease: kidney stones (2), prostatic adenoma (2), vesical diverticulum (1) and, notably, vesical tumour (2). Intravenous urography detected these abnormalities in 75% of the cases but missed the vesical tumours which were detected only at cystoscopy, urine cytology being also negative. The data obtained by cystoscopy were confirmed by vesical echography in 1 case. Thus, we believe that in the presence of even a single episode of microscopic haematuria in a man over 40, an intravenous urography should be performed. If the results are normal, and if the subject is a smoker or presents with an occupational or familial risk of cancer, this examination should be followed by cytology and vesical echography. If both are negative, then cystoscopy is necessary.

[Stauffer's syndrome caused by a benign intracystic renal hematoma]. / Syndrome de Stauffer dû à un hématome intrakystique rénal bénin.

We report a case of Stauffer's syndrome, characterized mainly by cholectasis, that occurred in a patient with benign intracystic renal haematoma and subsided after nephrectomy. Stauffer's syndrome was recognized, in 1961, as a paraneoplastic manifestation, usually associated with hypernephroma. This syndrome has been reported in only 2 cases of benign renal disease, which was a pseudotumoral xanthogranulomatous pyelonephritis.

[Percutaneous ablation of renal calculi]. / Ablation percutanée des calculs rénaux.

Percutaneous removal of renal calculi under nephroscopy was attempted in 34 patients. There were 19 pyelic, 9 caliceal, 3 uretero-pyelic and 3 multifocal calculi. The attempt was successful in 30 cases, the stones being removed by immediate lumbotomy in the 4 cases where it failed; 2 caliceal calculi remaining in situ are being followed up. Complete removal was effected in 19 patients. The smaller calculi were directly removed with special forceps, and the larger ones were either fragmented with a lithotriptor or disintegrated by ultrasounds or intracavitary shock waves. The postoperative period was uneventful. Stay in hospital was reduced to 4 days on average and absence from work, to 8 days. Five patients experienced renal colics due to migration of small fragments. One case of haemorrhage was easily controlled. Percutaneous removal of renal calculi is an elegant, though delicate method which seems to be of interest in persistent or recurrent pyelic or caliceal stones, in small or medium size pyelic stones and in mobile and painful caliceal stones. It undoubtedly has its place in the treatment of renal lithiasis.

[Laparoscopic radical prostatectomy. Preliminary evaluation after 28 interventions]. / Prostatectomie radicale coelioscopique. Première évaluation après 28 interventions.

OBJECTIVE: Evaluate the technical feasibility of laparoscopic radical prostatectomy, its carcinological efficacy and per- and post-operative morbidity. PATIENTS AND METHODS: We performed radical prostatectomy using a new laparoscopic technique in 28 patients between February 1 and August 31, 1998. RESULTS: Radical prostatectomy was achieved totally by a laparoscopic approach in 24 patients (86%). No conversion was required in the last 14 patients. In 9 patients (32%) ilio-obturator node resection was also performed as indicated by preoperative extension work-up. Mean operative time was 270 minutes. The only major complication was one rectal wound (patient n degree 8) which had a benign course after suturing under laparoscopy. The bladder catheter was removed a mean 7.7 days after the procedure. Five patients (18%) required transfusions (mean 2.7 units, range 2-3). Rapid discharge on day 3 was possible due to rapid pain relief postoperatively. Tumor classes were pT2 in 26 patients, NO in 9, NX in 17. The surgical border was doubtful at the apex in one case. The last prostate specific antigen assay was below detectable levels (< 0.1 ng/ml) in 16 patients (89%) among the 18 with levels know prior to the procedure. Continence was assessable in 20 patients after a 1 to 6 month follow-up. Continence was perfect in 18 patients and becoming so in 12. Sexual activity was not assessed in this series due to the short follow-up. CONCLUSION: Radical prostatectomy can be reasonably performed as a routine laparoscopic procedure by a well-trained team. The cancerological results in this series were equivalent to those with conventional retropubic surgery and morbidity was very low. Improved operative vision was considerable, allowing much more precise dissection. The laparoscopic technique appears to be an important improvement for radical prostatectomy and should help improve functional outcome.

[Removal of ureteral calculi by uteroscopy]. / Ablation des calculs urétéraux par urétéroscopie.

Ureteral stones can now be removed endoscopically, using a ureteroscope. This instrument, provided with a direct optic system and an operating tube, is introduced under general anaesthesia after the ureteral opening has been dilated and is pushed up until it reaches the stone which is then removed by means of a basket catheter or a forceps. Voluminous stones can be shattered in situ by ultrasounds or hydroelectric shock waves. Forty-three stones, representing 72% of all attempts, were removed by this method from 30 patients. There were 6 failures due to impassable vesico-ureteral opening, ureteral flexure and wedged in or ascended stone, and 4 complications including 2 cases where the basket catheter went under the mucosa and 1 case each of secondary urinoma and ureteral clotting. There was no perforation nor overt septic complication. Most stones were larger than 10 X 4.5 mm and were located in the pelvic or iliac part of the ureter. Infected stones can be removed endoscopically under antibiotic treatment and provided a draining catheter is left in place. Ureteroscopy notably reduces the need for ureteral lithotomy.