[Prognostic value of erythrocyte polyamines levels in renal cell carcinoma. Prospective study in 418 cases]. / Valeur pronostique des polyamines érythrocytaires dans le cancer du rein. Etude chez 418 patients.

OBJECTIVES: Polyamines: Spermine (Spm) and Spermidine (Spmd), are essential for cell proliferation and differentiation. A measurement of erythocytes polyamines (EPA) was developed in our institution. Our objective was to evaluate this marker as a new prognostic factor in renal cell carcinoma. PATIENTS AND METHODS: A blood sample was prospectively taken before surgery, among 418 patients who had an enlarged nephrectomy (n=318) or a partial nephrectomy (n=100) to quantify EPA rates by using the HPLC technique. The qualitative and quantitative variables have been compared using chi(2) and Student statistical analyses. The survivals have been normalized by the Kaplan Meier and Cox methods. RESULTS: The average age of our population was 64 years (21-88). The average decline was 41 months (1-214). The median size of tumors was 6.5cm (1-24). The median rate of Spm and Spmd were respectively 4.7 (1-83) and 9 (2-86)nmol/8.10(9) erythrocytes. Spm and Spmd were linked to the T stage (p=0.001), and the ECOG (p=0.001 and 0,008). Spm was not linked at N and M stages but at the Fuhrman grade (p=0.001). Spmd was linked to the N, M stages (p=0.04). With univariate analysis, the tumor diameter, the TNM stage, the Fuhrman grade as well as Spm and Spmd (p<0.0001) were predictors of specific survival. With multivariate analysis, some prognostic factors remained independent: the TNM stage, the ECOG and Spmd, a continuous variable (p=0.0001), pushing the rank of Fuhrman out of the model. When Spm and Spmd were dichotomized in quantitative variables, they were both independent factors. CONCLUSION: The EPA is a new prognostic tool, before surgery, which will be tested for its integration into prognostic normograms.

Absence of VHL gene alteration and high VEGF expression are associated with tumour aggressiveness and poor survival of renal-cell carcinoma.

BACKGROUND: The von Hippel-Lindau gene (VHL) alteration, a common event in sporadic clear-cell renal-cell carcinoma (CCRCC), leads to highly vascularised tumours. Vascular endothelial growth factor (VEGF) is the major factor involved in angiogenesis, but the prognostic significance of both VHL inactivation and VEGF expression remain controversial. The aims of this study were to analyse the relationship between VHL genetic and epigenetic alterations, VHL expression and VEGF tumour or plasma expression, and to analyse their respective prognostic value in patients with CCRCC. METHODS: A total of 102 patients with CCRCC were prospectively analysed. Alterations in VHL were determined by sequencing, Multiplex Ligation-dependent Probe Amplification (MLPA) and methylation-specific MLPA. Expression of pVHL and VEGF was determined by immunohistochemistry. Plasma VEGF was measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: VHL mutation, deletion and promoter methylation were identified in 70, 76 and 14 cases, respectively. Overall, at least one VHL-gene alteration occurred in 91 cases (89.2%). Both VEGF tumour and plasma expression appeared to be decreased in case of VHL alteration. Median progression-free survival and CCRCC-specific survival were significantly reduced in patients with wild-type VHL or altered VHL and high VEGF expression, which, therefore, represent two markers of tumour aggressiveness in CCRCC. CONCLUSION: Stratifying CCRCCs according to VHL and VEGF status may help tailor therapeutic strategy.

The postoperative bacteriuria score: a new way to predict nosocomial infection after prostate surgery.

OBJECTIVE: Urinary tract infections are the leading nosocomial urologic infections and may be a cause of added morbidity and costs, and sometimes sepsis. The aim of this study was to design a predictive score for these complications after prostate surgery. DESIGN: Multicenter prospective survey. SETTING: Eleven French urology centers. PATIENTS: All patients undergoing transurethral resection of prostate (TURP) during a 3-month period. RESULTS: The overall incidence of postoperative bacteriuria was 25.0% (95% confidence interval, 17.7%-29.5%). Almost all patients (95.7%) received antibiotic prophylaxis. A predictive postoperative bacteriuria score (POBS), with a 6-point scale of 0 to 5, was constructed on the basis of independent risk factors identified in multivariate analysis of a test sample of patients (n=135) and tested in a validation sample (n=73). Significantly more infections occurred in patients with a POBS of 2 or higher (87 [8%] vs 48 [50%]; P<.0001). With the test sample, this yielded a sensitivity of 77%, a specificity of 77%, a positive predictive value of 50%, a negative predictive value of 92%, and a global accuracy of 77%. CONCLUSIONS: POBS could be used to distinguish patients at risk of developing infection after TURP. This information might be useful for implementing selective prevention measures or for adjustment for differences in nosocomial infection rates when comparing data between urology centers.

[Acute and chronic prostatitis, how will we manage it ten years from now?]. / La prostatite aiguë et chronique, quette prise en charge? Perspectives pour tes dix prochaines années.

Pelvic pain syndrom arises in an increasing number of men during their life. The present classification of prostatitis in four categories facilitates a comprehensive review of its diagnosis and treatment. The development of techniques related to molecular biology will favour a deeper knowledge in the future.

[Treatment of heterotopic ossification by extracorporeal shock wave: 26 patients]. / Traitement des paraostéoarthropathies par ondes de choc. Etude sur 26 patients.

OBJECTIVES: To evaluate the effects of extracorporeal shockwave therapy (ESWT) on heterotopic ossification leading to functional limitations in the short and medium term. METHODS: Twenty-six patients with heterotopic ossification received sessions of ESTW (4000 shocks, 3/s), with an energy ranging from 0.54 to 1.06 mJ/mm2, once a week for 4 consecutive weeks. Intermediary assessments performed 1 month after the last session related to pain (on a visual analog scale [VAS]), range of motion, functional independence (FIM), walking distance (whenever possible), radiology, and blood calcium and alkaline phosphatase levels. Eighteen patients with total hip arthroplasty (THA) were followed up by quiz, at 11 months, on average. RESULTS: Heterotopic ossification was neurogenic in 5 patients and nonneurogenic in 21. The length of evolution of ossification was 32+/-21 months. The measurements showing significant improvement in the short term were pain, with a mean decrease of 4.32 to 1.14 on a VAS; joint flexion, with an mean increase of 8.18+/-11.9 degrees; and walking distance, with a mean increase from 1126 to 2776 m. The treatment was tolerated for the most part. THA cases showed a decline in factors initially shown to be improved. However, the long-term results were superior to clinical status before treatment. CONCLUSION: ESWT might be an interesting treatment for heterotopic ossification and can be a complement to usual medical treatment, physiotherapy, and before surgery.

Clinical significance of cell proliferation, microvessel density, and CD44 adhesion molecule expression in renal cell carcinoma.

Renal cell carcinoma (RCC) is known to have a wide variation in clinical outcome despite the use of conventional prognostic factors, such as staging or grading. A better knowledge of the biologic aggressiveness of RCC could facilitate the selection of patients at high risk of tumor progression. The aim of this study was to determine if use of measurements of vascular density, cell proliferation, and cell adhesion could better predict the biologic behavior of RCC. We immunohistochemically analyzed CD34, Ki-67, and CD44H expression on formalin-fixed, paraffin-embedded tissues from 73 RCCs for quantifying microvessel density (MVD), Ki-67 labeling index (LI), and CD44H LI, respectively. Univariate cancer-specific survival analysis showed that tumor stage (P < .01), tumor size (P < .001), nuclear grade (P < .01), metastasis (P < .001), MVD (P < .03), Ki-67 LI (P < .001), and CD44H LI (P < .0001) were predictors of tumor-related death. There was a statistical correlation between CD44H LI and both Ki-67 LI (r' = .3) and MVD (r' = -44). Ki-67 LI (P < .04) and CD44H LI (P < .02), as well as metastasis (P < .008), emerged as independent predictors of cancer-specific survival in multivariate analysis in patients with metastases (P < .04 and P < .02, respectively) and in patients without metastases (P < .006 and P < .00001, respectively). Our study suggests that vascular density, cell proliferation, and cell adhesion represent a complex tumor-host interaction that may favor progression of RCC. Cell proliferation and CD44H expression appear to be powerful markers to identify patients with an adverse prognosis.

Value of nocturnal penile tumescence and rigidity (NPTR) recording in impotent patients with multiple sclerosis.

The etiology of impotence in patients with multiple sclerosis (MS) is difficult to assess due to the possibility of normal nocturnal penile tumescence and rigidity (NPTR) recording despite neurologic involvement. Sixteen patients with MS and impotence were studied with Rigiscan, cavernous artery doppler, neurophysiological tests and intracavernous injection of PGE1. When more restrictive criteria of normality than usual are used for Rigiscan (rigidity > or = 80% and/or duration > 30 minutes), an inverse relationship between NPTR recording and sexuality score or PGE1 dose is reported. No significant difference is noted for neurophysiological tests. With such criteria, Rigiscan alone or combined with intracavernous PGE1 is a valuable means to differentiate neurogenic from psychogenic impotence in MS patients. Neurophysiological tests are of limited clinical value.

Short term therapy for uncomplicated urinary tract infection today. Clinical outcome upholds the theories.

The clinical and bacteriological activity of fosfomycin trometamol (FT) has been compared with several other antibiotics in the treatment of uncomplicated urinary tract infections. A single dose of FT had activity comparable with a 5-day course of trimethoprim in a trial where the causative organism and its sensitivity were unknown. In another trial FT showed better long term eradication compared with a 5-day course of cephalexin and other studies suggested a single dose of FT was comparable with a 7-day course of nitrofurantoin or norfloxacin. There were few important side effects with fosfomycin therapy and it was considered a safe and effective first line treatment in uncomplicated urinary tract infection.

Recurrent pyelonephritis without vesicoureteral reflux: is there a role for an antireflux procedure?

PURPOSE: To evaluate the results of an endoscopic antireflux procedure in women with recurrent acute pyelonephritis and no evidence of vesicoureteral reflux (VUR) on voiding cystograms. PATIENTS AND METHODS: From 1989 to 1999, 603 female patients were hospitalized for acute pyelonephritis with unilateral loin pain, chills, fever, and a positive urine culture. Of these patients, 48 (8%) had recurrent episodes of acute pyelonephritis and underwent a thorough diagnostic work-up including intravenous urography or renal CT scan, cystoscopy, and voiding cystourethrography (VCUG). Vesicoureteral reflux was demonstrated in 21 patients, who were then offered an antireflux procedure, either surgical or endoscopic. Another 27 patients had no reflux on VCUG; in 15 cases, the upper urinary tract was normal, and the ureteral orifices did not show any abnormality on cystoscopy. The other 12 patients in this group with a normal VCUG had one or more abnormal findings normally associated with VUR: renal scarring in five and ureteral duplication in two. Golf-hole ureteral orifices were noted in two patients. The intravesical ureter was short (< 5 mm) in five patients. In spite of the normal VCU, we offered these patients endoscopic treatment of VUR by submeatal injection of Teflon or microparticulate silicone (Macroplastic). The median follow-up before treatment was 4 years (range 1-15.3 years); 0.3 episodes of acute pyelonephritis per patient-month of follow-up were noted. The frequence of preoperative and postoperative episodes of acute pyelonephritis was compared with Wilcoxon's paired analysis. The median postoperative follow-up was 3.9 years (range 1.1 months-10.2 years). RESULTS: There were no significant postoperative complications. One patient had two episodes of acute pyelonephritis during pregnancy. On the whole, 11 patients (91%) were free of recurrent pyelonephritis after treatment. Overall, 0.003 episodes of acute pyelonephritis per patient-month of postoperative follow-up were observed. The result was statistically significant (P < 0.01). CONCLUSION: Recurrent acute pyelonephritis is frequently related to VUR. Intermittent reflux can be difficult to demonstrate on voiding conventional or nuclear cystograms but can be suspected in the presence of ureteral duplication, renal scarring, or abnormal ureteral orifices. Adult patients with recurrent episodes of upper urinary tract infection and normal cystograms should be considered for an endoscopic antireflux procedure in the presence of anatomic abnormalities commonly associated with reflux.

[An uncommon tumor of the urinary bladder: the small cell carcinoma]. / Une tumeur vésicale rare: le carcinome à petites cellules.

Primary small cell carcinoma of the urinary bladder is an uncommon tumor, compared to the frequency of urothelial tumors. Fifty percent of cases are combined with a non endocrine carcinomatous component. We report six new cases of this tumor, three of pure, and three associated with an urothelial carcinoma. Diagnosis is easy established by the immunohistochemical study which show the neuro-endocrine differentiation of these aggressive tumors. Pathologist needs to look for a neuro-endocrine part in all bladder cancer, as its presence modify the treatment. Chemotherapy is used in these cancers, due to their high metastatic power. Places of radical surgery and radiotherapy need to be specified.

Factors influencing adrenal metastasis in renal cell carcinoma.

OBJECTIVES: We determine the incidence and characteristics of adrenal involvement in localized and advanced renal cell carcinoma, and evaluate the role of adrenalectomy as part of radical nephrectomy. MATERIAL AND METHODS: From 1993 to 1999, 210 patients with renal cell carcinoma (RCC), (139 men and 71 women, mean age 60.8 years, range 12-96) underwent radical nephrectomy with associated adrenalectomy. Patients were divided into two subgroups of 106 with localized (stage T1-2 tumor, groupl) and 104 with advanced (stage T3-4N01M01, group2) renal cell carcinoma. A retrospective review of preoperative computerized tomography (CT) of the abdomen was performed. Radiographic findings were subsequently compared to postoperative histopathological results to assess the predictive value of tumor characteristics and imaging in determining adrenal metastasis. RESULTS: Of the 210 patients, 15 (7.1%) had adrenal involvement. Tumor stage correlated with probability of adrenal spread, with T3-4 and T1-2 accounting for 13.4% and 0.9% of cases, respectively (p < 0.001). Upper pole intrarenal RCC most likely to spread was local extension to the adrenal gland, representing 53.3% of adrenal involvement. In contrast, multifocal, lower pole and mid region RCC tumors metastasized hematogenously, representing 21.4%, 7%, and 14% of adrenal metastasis, respectively. The relationship between intrarenal tumor size (mean 7.8 cm, range 4 to 21) and adrenal involvement was not statistically significant. Preoperative CT demonstrated 97.7% specificity, 98.4% negative predictive value, 87% sensitivity and 80% positive value for adrenal involvement by RCC. CONCLUSIONS: Ipsilateral adrenalectomy should only be performed if a lesion is seen preoperatively on CT scan or if gross disease is seen at the time of nephrectomy. The prognosis is poor for RCC with ipsilateral involvement even with complete removal. Because of this poor prognosis we believe that adrenal involvement should constitute a separate stage category.

[Intraluminal renal metastasis from a rectal adenocarcinoma: an unusual site]. / Métastase pyélocalicielle d'un adénocarcinome d'origine rectale: une localisation inhabituelle.

Primary adenocarcinoma of the urinary tract are uncommon. But secondary involvement of pyelocalyceal system by metastasis of colorectal origin is rare. We report a case of late rectal metastasis with renal pelvis growth presenting as a pyonephrosis. This study emphasizes the relevance of cytokeratin 7 and 20 immunostaining in such differential diagnosis.

[Treatment of cystitis in women]. / Traitement de la cystite chez la femme.

Acute cystitis is a benign curable condition which affects at least one out of every two women at least once in their life. In uncomplicated cases, urinalysis is usually unnecessary as a simple dip stick test is sufficient for diagnosis and prescription of a short antibiotic regimen (a single dose or a 3 day treatment). Complicated acute cystitis requires a more precise diagnosis and justifies urinalysis and imaging. Antibiotics adapted to germ sensitivity is prescribed until bacteriologically sterile urine is obtained (3 to 10 days). Associated malformations of the urinary tract or obstruction must be managed together with careful control of aggravating factors (diabetes) and personal hygiene. Recurrent cystitis, defined as at least 4 episodes, raises a certain number of problems. The casual germ varies, although Escheria coli is found in approximately 70% of the cases. Several factors favour recurrent cystitis including malformations of the urinary tract, lithiasis, bladder reflux, cystocele or modification of the urethral meatus. Other circumstances such as sexual relations, excessive vaginal hygiene, vaginal tampons and clothing habits may play a role. Antibiotics generally solve the problem, but mechanisms which would improve the organism's specific response are currently under study.

[Substitute bladders]. / Les vessies de remplacement.

Following prostato-cystectomy in men or total cystectomy in women the bladder can be replaced by constructing an intestinal pouch to be connected to the urethra. This bladder replacement reservoir should possess the specific qualities of the natural bladder: it should collect and retain the urine at low pressure, protect the upper urinary tract against reflux and distension, control voluntary micturition at a socially acceptable rhythm and avoid the metabolic disorders due to the reabsorption of urine by the intestinal mucosa. Low pressure reservoirs are the ones most commonly used. They are obtained by opening the ileal or ileocaecal graft along its antimesenteric border and rearranging the intestinal tissue to form a pouch connected to the urethra. Detubulated reservoirs have a capacity and a compliance that are close to those of the urinary bladder. Daytime continence is acquired in the immediate postoperative period, and night-time continence is possible in 60 to 70 per cent of the patients. These are the main advantages of bladder replacement by tubular small intestine. The reservoirs thus constructed have few contractions, but they have not yet proved to be capable of full evacuation in the long term. Intermittent bladder catheterization might well be the price to be paid in the future for an immediate improvement in night-time continence.

Variations of intestinal motor activity in bladder replacements and in the intestine.

Urinary reservoirs are made from intestinal segments. The motor activity of the intestinal tract is regulated by hormonal and neurological controls. This study compares the motor activity of intestine in situ with those of a neobladder, following oral intake. The changes in motor activity before and after ingestion of standardized 570 Kcal meal were measured simultaneously in the duodenum and in the neobladder of 4 patients who underwent a Camey tubularized ileocystoplasty. Similar motor movements were produced in the graft and in the duodenum. Modifications due to oral intake were then measured in 14 patients with various types of urinary reservoirs (ilea, ileo-colic or colic; and tubularized or detubularized) by measuring the pressure inside the graft. After oral intake the compliance of the detubularized colic and ileocolic reservoirs was greater than that of ileal reservoirs, even after detubularization, since the motor activity and the basal pressure increased greatly in the tubularized or detubularized ileal bladders and much less in the detubularized colic and ileocolic bladders. It is well known that digestion is maximal in the second half of the night, therefore this link between intestinal and neobladder motor activity might explain one of several mechanisms involved in nocturnal increase in reservoir pressure and urine incontinence.

Does detubularization improve continence in bladder replacement?

Camey in the seventies promoted bladder replacement. In 1987, the French Association of Urology gave us the opportunity to review 729 Tubularized Ileocystoplasty (Camey operation) [1]. The day time continence was excellent or acceptable (mild stress incontinence) on 91% of the patients, the night time continence was excellent (no pads, no leakage) or acceptable (one pad or less than 3 wakes at night) for 44% of the patients (56% had to use a device). Since 1985, the detubularization attempted to improve the continence rate. Today, the review of the literature shows that day time continence has not changed and the night time continence improved less than 20% arising from 44% to 60%. Bladder replacement after prostatocystectomy has been proved to be superior to continent urinary diversion in patients whose urethral and external sphincter can be preserved. Day time continence is excellent in tubularized and detubularized bowel reservoirs. Night time continence, in 30 to 50% of patients, remains an unresolved problem also in detubularized low pressure reservoirs, even if they are of great capacity. The literature is therefore too optimistic when describing night time continence in 85% of the patients. These results are stated in spite of the absence of sensitivity in the neobladder, the loss of reflexic increase in sphincteric activity during bladder filling, and the low sphincteric tonus during sleeping. These optimistic results are due to lack of unanimous criteria for evaluating continence after bladder replacement and not taking into consideration as continence failure the abundant although not frequent nighttime incontinence. In order to improve continence, muscle reeducation and artificial sphincter implantation are the most adequate solutions.(ABSTRACT TRUNCATED AT 250 WORDS)

[Therapeutic strategies in urinary tract infections in women]. / Stratégies thérapeutiques dans l'infection urinaire de la femme.

Simple acute cystitis is cured by single-dose or 3-day treatment. Complicated acute cystitis requires clinical, bacteriological and imaging examinations. Treatment must be continued for 10 days and controlled. Acute pyelonephritis in women requires bacteriology, ultrasonography and plain x-rays and must be rapidly treated by fluoroquinolone or cephalosporin. High-risk acute pyelonephritis justifies admission to hospital, more elaborate examinations and active treatment.

[Current aspects of varicocele. Analysis of cases treated in the Department of Surgery in Brazzaville]. / Aspects actuels du varicocèle. Analyse des cas traités dans un Service de Chirurgie à Brazzaville.

The authors analyze retrospectively the files of patients who have been operated on for varicocele between 5th may 1992 and 5th may (12 months) in Talangaï hospital at Brazzaville. The overall operation rate for that pathology was 1.1%. Prevalence according to age group is as follows: -1 adolescent; -2 young adults; -1 old person. The localization of varicocele was left in all cases. The disease was associated with male infertility in one observation. In all patients, there was a case of primary varicocele. Patients got the surgical cure through the left inguinal route and the post-therapeutic improvement of clinical manifestations was obtained between D30 and D90. The authors make comments on those results and they clarify points on certain current aspects of the disease.

[Vesico-renal reflux in adults. Study of 57 ureters reimplanted by the submucosal advancement method]. / Reflux vésico-rénal de l'adulte. Etude de cinquante-sept uretères réimplantés par avancement sous-muqueux.

Vesicorenal reflux raises specific problems in adults, as regards both the surgical indications and the operative technique. The operative results are discussed in relation to fifty seven ureters reimplanted in thirty six patients, and the indications for surgical management are outlined. Refluxes clinically associated with lumbalgia, fever and pyuria, always require surgery. The most difficult problems arise from "asymptomatic" refluxes revealed by checkups for renal insufficiency, proteinuria or arterial hypertension. In these cases, the characteristics of the ureter (e.g. wide or narrow) and the existence or absence of renal scars must be taken into consideration. Refluxes in narrow ureters should be followed closely, and the advisability of surgery should be carefully weighed in patients with a wide ureter with no visible damage to the parenchyma.

[Piezoelectric extracorporeal lithotripsy. Report of 1-year's experience (350 treatments)]. / La lithotripsie extra-corporelle piézo-électrique. Rapport d'une année d'expérience (360 traitements).

Over the period of one year, 356 extracorporeal lithotripsies were performed in 303 patients with the EDAP piezoelectric lithotripter. The success rate, depending on the frequency (1.2 to 40 Hz) was between 75 and 80%. The treatment was repeated for 13 to 22% of the patients and 15% underwent an auxiliary manoeuvre preoperatively. Morbidity remains low with less than 5% of ureteral obstruction. For simple or small calculi (less than 1 cm), the use of low frequencies (1.2 to 5 Hz) is preferred, making it possible to carry out the treatment without anaesthesia and without hospitalization. For complex or bigger calculi, the use of higher frequencies (10-20 Hz), under neuroleptic analgesia, seems to be more efficient with a shorter time of treatment and a lower complication rate.