[Renal cell carcinoma in the department of Hérault: Results over a 30 year period]. / Le cancer du rein dans le département de L'Hérault : résultats de 30 ans d'enregistrement.

OBJECTIVE: The objective of the study was to determine the specificities of renal cell carcinoma (RCC) in the department of Herault using the Herault Tumor Registry over 30 years. METHODS: Data of this study were obtained from the Herault cancer database. We analysed the evolution of RCC from 1987 to 2016, including the incidence, mortality, cancer pathology and staging at the moment of diagnosis. We compared our results with national and international data. RESULTS: We identified 3769 newly diagnosed RCC: 2628 in men (69,7%) and 1141 in women (30,3%). In 2016, RCC was the 8th most frequent cancer, both genders combined, the 7th most frequent cancer in men and the 11th in women. New cases of RCC increased by 4.2 in men and 3.3 in women over the study period. The number of localised forms increased by 9% over 20 years. In 2016, the probability of having a RCC before the age of 75 was of 2.11% for a man and of 0.62% for a woman. CONCLUSION: Over 30 years, the incidence rate of RCC increased in the department of Herault; however, mortality decreased over the same period. This analytical data should be improved by the development of the Registry of Herault Specialised in Onco-Urology (RHESOU). LEVEL OF EVIDENCE: 3.

[RHESOU (Registry in HErault Specialized in Onco-Urology) : the first French Registry specialized in Onco-Urology. One-year experience]. / RHESOU (Registre de l'Hérault spécialisé en onco-urologie) : le premier registre français spécialisé en onco-urologie. Un outil méthodologique de recueil de données en onco-urologie. Bilan de faisabilité sur un an d'expérience.

PURPOSE: In 2016, the Herault tumor registry collected 1961cancers in urology (21.4 % from all Herault cancers this year). RHESOU was created to complete RTH' data with specific parameters in onco-urology. The aim of this study is to describe RHESOU and to give some examples with our first results. MATERIAL AND METHODS: In November 2018, RHESOU (Registry HErault Specialised in Onco-Urology) was founded with the same registry recommendations. It collects specific oncologic parameters and also complete RTH's data. For each urological cancer, a specific survey with different choices was performed to collect a maximum of data which could be present in patients' file. These surveys were used for urological cancers cases that live in Herault in 2017. RESULTS: In 2017, we collected 970 prostate cancers, 581 bladder cancers, 212 kidney cancers, 51 upper excretory tract cancers, 28 testicle cancers and 9 penil cancers. Our urological data collection gives many possibilities to create many requests for detailed analysis in urological cancers. In this article, we reported data from kidney, bladder and prostate cancers. CONCLUSIONS: RHESOU is a new tool opened to the different urologic corporations (urologists, pathologists, oncologists, radiotherapists, radiologists) that permits an overview in urological cancers in Herault. Finally, one important aim is that this tool will be adapted when new treatments or new important parameters appear in the years ahead. LEVEL OF EVIDENCE: 3.

Piezoelectric lithotripsy of ureteral stones: influence of shockwave frequency on sedation and therapeutic efficiency.

OBJECTIVE: The aim of this randomized study was to assess the relation between shockwave frequency, sedation, and efficiency in piezoelectric extracorporeal shockwave lithotripsy (SWL) for ureteral calculi. METHODS: A random sample of 114 patients aged between 15 and 74 (mean 45) years were treated at the shockwave frequencies of 1 (N = 57) or 4 (N = 57) per second using the EDAP LT 02 lithotripter at maximum energy. The stones' largest diameter ranged from 5 to 18 mm (mean 7.6 mm). Lower ureteral stones were treated with the patient in the prone position and upper ureteral stones in supine position. The duration of SWL sessions and stone measurements were statistically similar for patients treated at low and high frequencies. The levels of required sedation (none, intramuscular analgesia, intravenous sedation-analgesia) and stone-free rates after one session were analyzed by Student's t-test or Fisher's exact test. RESULTS: Sedation did not differ statistically with SWL frequency for mid and lower ureteral calculi. However, the use of intravenous sedation-analgesia was less common for patients with upper ureteral stones treated at low rather than high frequency (19% and 100%, respectively; P < 0.0001). The success rate was significantly lower (P = 0.04) for lower ureteral calculi treated at low v high frequency (65 % and 89%, respectively) but was not statistically affected by frequency for upper ureteral stones. CONCLUSION: We recommend high frequency for piezoelectric SWL of lower ureteral calculi, especially for stones with a maximum diameter > or =8 mm. On the other hand, low-frequency SWL appears to be suitable for the treatment of upper ureteral stones.

Study of calcium oxalate crystalluria on renal and vesical urines in stone formers and normal subjects.

OBJECTIVE: The aim of this study is to compare vesical and renal calcium oxalate crystalluria in an attempt to correlate crystal formation with chemical composition and calcium oxalate saturation of renal urine. MATERIAL AND METHODS: Urine specimens were directly collected from the bladder and the kidney, of 11 stone formers and 11 control subjects under general anesthesia. The type of crystals present in urine as well as their size, number by cubic millimeter and state of aggregation were determined. In addition, calcium, magnesium, sodium, chloride, phosphate, citrate, oxalate, pyrophosphate and uric acid were measured in order to evaluate the calcium saturation status (EQUIL V program). RESULTS: Calcium oxalate crystals were detected in 3 stone formers (27%) and 2 control subjects (18%) in vesical urine and in 4 stone formers (36%) and 3 control subjects (27%) in renal urine. Only 2 stone formers presented with simultaneous renal and vesical crystalluria. Subjects of the two groups with and without renal crystalluria were compared in terms of chemical composition and calcium oxalate saturation of renal urine. Crystalluric subjects (n = 7) had significantly higher uricosuria (p = 0.02), calciuria (p = 0.04), magnesiuria (p = 0.04) and calcium oxalate molar product (p = 0.05) than noncrystalluric (n = 15); calcium oxalate saturation was similar (p = 0.5). CONCLUSIONS: Beyond theorical considerations on lithogenesis, our observations and in particular the apparent discrepancy between renal and vesical crystalluria pose the problem of the clinical interest of the evaluation of calcium oxalate crystalluria based on freshly voided urine in the assessing the lithogenic risk or in the follow-up of patients who are particularly prone to stone recurrence.

[Prognosis in pT3b infiltrating tumors of the bladder treated by adjuvant chemotherapy]. / Pronostic des tumeurs infiltrantes de vessie de stade pT3b traitées par chimiothérapie adjuvante.

OBJECTIVE: To evaluate the prognosis of stage pT3bM0 invasive urothelial bladder tumours treated by cystectomy alone or combined with adjuvant chemotherapy according to the MVAC protocol (methotrexate, vinblastine, adriamycin and cisplatin). MATERIAL AND METHODS: From 1987 to 1996, 90 patients with stage pT3M0 urothelial bladder tumours were treated with isolated cystectomy (n = 69) or followed by MVAC chemotherapy (n = 21). Lymph node stage was N0 (n = 55), N+ (n = 29) or Nx (n = 6). Essentially selected because of their good general status, patients treated with chemotherapy had a lymph node stage N0 (n = 7) or N+ (n = 14). Chemotherapy had to be suspended in 2 cases and with a fatal outcome during treatment in 4 cases, due to tumour progression, surgical complication or bone marrow aplasia. RESULTS: 65 deaths have occurred with a follow-up of 2 to 120 months (m = 15), including 2 postoperative deaths, 39 cancer deaths and 14 intercurrent deaths. The 1-year, 2-year and 5-year actuarial survival rates were 70%, 48% and 19% for stage N0 and 54%, 25% and 3% for stage N+, respectively, with corresponding median survivals of 20 and 12 months (p < 0.005). The recurrence rate increased from 40% at stage N0 to 62% at stage N+ (p = 0.05), and the corresponding recurrence-free survivals were 16 months and 7 months (p < 0.02). The median survival without chemotherapy ranged from 11 months at stage N+ to 20 months at stage N0 and, with chemotherapy, from 19 months at stage N+ to 67 months at stage N0. The median recurrence-free survival with and without chemotherapy, was 43 months and 17 months at stage N0 and 12 months and 7 months at stage N+. CONCLUSION: The prognosis after cystectomy for stage pT3b bladder cancer is severe, especially in the presence of lymph node involvement. Adjuvant chemotherapy according to the MVAC protocol tends to improve survival, especially recurrence-free survival, and appears beneficial at stage N0. However, the value of this adjuvant treatment, which is associated with a high specific morbidity appears to be more relative at stage N+.

[The value of retrograde ureterorenoscopy in the treatment of bulky kidney calculi]. / Intérêt de l'urétérorénoscopie rétrograde dans le traitement des volumineuses lithiases rénales.

OBJECTIVE: To assess the value of retrograde endoscopic lithotripsy for very large pyelocaliceal stones. MATERIAL AND METHODS: Eighteen patients between the ages of 28 and 80 years (mean : 52) and presenting a staghorn renal calculus (n = 7) or with a maximal diameter greater than or equal to 20 mm (n = 11) were initially managed by rigid or flexible retrograde ureterorenoscopy, with ballistic (Lithoclast) or electrohydraulic (Riwolith) stone fragmentation. In 16 cases (89%), an additional extracorporeal shock-wave lithotripsy (ESWL) session was performed immediately after the endoscopic procedure. Early complications consisted of 3 cases of bacteraemic discharge rapîdly responding to medical treatment and 1 death from septic shock on the 8th postoperative day. Twelve patients (67%) were subsequently treated by ureteroscopy (n = 4) or ESWL (n = 11). RESULTS: 17 patients were evaluated after this therapeutic procedure, with a follow-up of 3 to 6 months (mean : 4). Stone elimination was complete for 8 patients (47%), 3 of whom initially presented a staghorn calculus. A residual stone was observed in 9 cases (53%), with a maximal diameter < 5 mm in 7 cases (41%). One patient (5%) underwent secondary percutaneous nephrolithotomy. CONCLUSION: Technological progress has clearly facilitated the ureteroscopic approach to very large pyelocaliceal stones, but fragmentation and stone elimination remain problematical. This unconventional approach constitutes a potential field of technical progress, but does not represent a really efficient alternative to PCNL at the present time.

[Piezoelectric extracorporeal lithotripsy of calculi of the median ureter (EDAP LT 02)]. / La lithotitrie extra-corporelle piézo-électrique des calculs de l'uretère moyen (EDAP LT 02).

OBJECTIVE: To evaluate the performance of in situ piezolectric extracorporeal shock-wave lithotripsy (ESWL) in the middle part of the ureter. MATERIAL AND METHODS: 36 consecutive patients presenting with stones of the middle part of the ureter were treated by in situ piezoelectric ESWL (EDAP LT 02). The maximal dimensions of the stones ranged from 5 to 14 mm (m = 7.8). Moderate or severe ureterohydronephrosis was present in 19 cases (53%) and a double J stent had been previously implanted in 6 cases (17%). The ESWL sessions were performed in the ventral supine position without any anaesthesia or systematic premedication, but an IM injection of 100 mg of pethidine was administered during poorly tolerated treatments. RESULTS: The stone was located easily in 23 cases (64%) and with greater difficulty in 13 cases (36%), as an intraoperative intravenous injection of contrast agent was performed in 6 cases (17%). The number of sessions per patient ranged from 1 to 2 (m = 1.16). The complete sucess rate was 75%, with a 64% success rate after a single ESWL session. The performances were statistically independent of stone dimensions and the degree of obstruction of the urinary tract. The complication rate was 5.5%, but no ancillary endoscopic or percutaneous treatment was required. CONCLUSION: In situ piezoelectric ESWL allows effective management of most stones of the middle part of the ureter. However, the treatment of stones with a maximal diameter < 5 mm, especially poorly radiopaque stones, can raise problems of localization. Very large or impacted stones, especially when complicated by urinary tract infection, should be preferably treated by first-line ureteroscopy.

Management of major blunt renal lacerations: surgical or nonoperative approach?

OBJECTIVE: To evaluate changes in the management of major blunt renal trauma since the introduction of computerized tomographic diagnosis and follow-up. MATERIAL AND METHODS: Twenty-three consecutive patients with deep blunt renal lacerations without major pedicle injury or shattered kidney were treated from 1986 to 1995. In group 1 (1986-1989, 12 patients), initial management was conservative, but with open surgery in cases of hemodynamic instability or persistent urinary extravasation. In group 2 (1990-1995, 11 patients), a plain conservative approach was followed and open surgery was reserved for major complications only. RESULTS: In group 1, 6 patients required early renal exploration (4 nephrectomies, 2 renorrhaphies). A persistent urinary fistula led to late nephrectomy in 1 of the renorrhaphy patients. Retroperitoneal hematoma and urinary extravasation spontaneously resolved in 6 cases. Length of hospital stay was significantly lower (p = 0.02) for nonoperated patients. None suffered from hypertension at long-term follow-up (5-8 years, mean 7.2). In groups 2, all 11 patients were treated conservatively, with endoscopic ureteric stenting in 4 cases. Urinary extravasation always resolved, but 9 patients had residual perirenal hematoma at the time of discharge. Length of hospital stay was significantly higher (p = 0.0005) with ureteric stenting. Nine months after trauma, 1 patient suffered from recurrent pyelonephritis. Radiographic follow-up (1-30 months, mean 10.2) revealed minor sequelae in all evaluated patients. CONCLUSION: In most patients with major blunt renal lacerations, a conservative approach is safe. Most extravasation spontaneously resolves and minimally invasive techniques will deal with nearly all complications. In our experience, open surgery usually results in nephrectomy.

Evaluation of the risk of stone formation: study on crystalluria in patients with recurrent calcium oxalate urolithiasis.

OBJECTIVE: The aim of this study was to determine the usefulness of the morning calcium oxalate crystalluria in detecting stone formers particularly prone to recurrence. METHODS: Over a 24-hour period of urine collection, the morning calcium oxalate crystalluria was evaluated as well as the risk of stone formation, established with Tiselius and Parks indices, for 25 recurrent stone formers (group 1) and 25 normal controls (group 2). RESULTS: Morning crystalluria (type, size, number/ml and state of aggregate) and the Tiselius index were comparable in the two groups. Conversely, calciuria as well as the citrate/ calcium ratio and the Parks index varied significantly for stone formers and normal controls. No particular correlation appeared between crystalluria and indices of Tiselius and Parks, calciuria, calcium-oxalate product or calcium/ oxalate and citrate/calcium ratios. CONCLUSIONS: Morning calcium oxalate crystalluria does not enable an efficient characterization of recurrent stone formers. Its discordance with others potential indicators of the risk of stone formation poses the problem of their respective validity and evokes the prevalence of still unknown inhibiting agents in the phenomenon of crystallization.

In situ piezoelectric extracorporeal shock wave lithotripsy of ureteric stones.

OBJECTIVE: To evaluate the efficacy of the EDAP LT 02 lithotripter for the in situ treatment of ureteric calculi. PATIENTS AND METHODS: One hundred consecutive patients presenting with ureteric calculi were treated with in situ piezoelectric extracorporeal shock wave lithotripsy (ESWL) using the EDAP LT 02 lithotripter. There were 49 patients with upper, nine with mid and 42 with lower ureteric stones. The largest diameter of the stones varied from 7 to 21 mm (mean 9.6 mm). Mild or severe hydronephrosis was present in 53 cases. Mid and lower ureteric stones were treated with the patients in the prone position, with no anaesthesia or pre-medication, and upper ureteric stones in the supine position, with intravenous sedation in 44 cases. RESULTS: Localization of the stones was easy in 81 cases and more difficult in 19, but an intravenous pyelogram was only necessary in three cases. The number of sessions per patient varied from 1 to 3 (mean 1.17). Complete success rate was achieved in 75% of patients and partial success (residual stones < or = 3 mm) in 6%. The stone-free rate was statistically affected by stone size but was independent of stone localization or the degree of obstruction. The rate of infective and obstructive complications was 14% and auxiliary treatments were necessary in 5% of patients. CONCLUSION: In situ piezoelectric ESWL with the EDAP LT 02 device is a convenient and efficient method for the treatment of ureteric stones.

[Morbidity of percutaneous biopsy of kidney transplants (Vim-Silverman and Tru-cut needles)]. / Morbidité des biopsies percutanées de transplants rénaux (aiguilles de Vim-Silverman et Tru-cut).

OBJECTIVES: To evaluate the morbidity of renal transplant biopsies performed after simple ultrasonographic identification of the transplants, using a Vim-Silverman or Tru-cut needle. METHODS: From January 1987 to April 1991, 360 renal transplant biopsies were performed after simple ultrasonographic identification of the transplants, using a Vim-Silverman (n = 204) or Tru-cut (n-156) needle. In 221 transplants, these biopsies were performed because of a rise of serum creatinine (n = 319) or proteinuria (n = 17) or were even performed systematically (n = 24). One to 5 (mean = 1.6) transplant biopsies were performed systematically and the interval between renal transplantation and biopsy varied between 3 days and 11 years. RESULTS: 290 biopsies (80.6%) allowed the analysis of a minimum of 3 glomeruli (mean = 9.3). The yield of the Vim-Silverman needle was significantly greater than that of the Tru-cut model (p = 0.02). 147 biopsies (50.7%) demonstrated acute or chronic rejection, 57 (19.7%) revealed cyclosporin nephrotoxicity, 41 (14.1%) showed acute tubular necrosis and 14 (4.8%) showed glomerulopathy, while 31 (10.7%) were strictly normal. The morbidity of these biopsies was reflected by 37 complications (10.3%), including 30 minor and 7 major complications (2 cases of haemoperitoneum, 4 cases of obstructive anuria and 1 arteriovenous fistula). However, only one case required transplantectomy. These problems were significantly more frequent following inadequate biopsies (< 3 glomeruli, purely medullary, extra-renal). CONCLUSION: Despite the considerable risk of iatrogenic lesions, these biopsies were justified by their potential diagnostic and therapeutic benefit. The prophylaxis of complications of this procedure is based on strict respect of blood pressure and haematological criteria and on real-time ultrasound monitoring of the biopsy and miniaturization of the trocars. The treatment of severe complications has been greatly improved by the development of endourology and interventional radiology, but surgery, and especially transplantectomy, is still occasionally required.

[Pelvic endometriosis of urinary and digestive sites. Apropos of 7 cases]. / Endométriose pelvienne de localisation urinaire et digestive. A propos de sept observations.

Seven cases of pelvic endometriosis of the urinary or digestive tracts are reported: 4 cases of vesical endometriosis, 1 case of ureteral involvement, 1 rectal case and 1 sigmoid location. The authors point out the difficulty of the clinical preoperative diagnosis--in despite of cyclic troubles--and underline the interest of complementary explorations performed at the time of periods: ultrasound, cystoscopy, rectosigmoidoscopy and coelioscopy. The MR imaging, showing high intensity a T1-weighted images and prominent high intensity on T2-weighted images, is very suggestive of an endometrial lesions. A joint medical and surgical treatment is required. Endoscopic excision, endoprosthetic tube, excision-suture, resection-anastomosis and a complementary medical treatment using Danazol. Decapeptyl or progestational agents have to be proposed. Per-operative microscopy is advised as routine procedure in order to avoid excessive surgery.

[Pelvic endometriosis with urinary and digestive involvement. Apropos of 7 cases]. / Endométriose pelvienne de localisation urinaire et digestive. A propos de sept observations.

Seven cases of pelvic endometriosis of the urinary or digestive tracts are reported: 4 cases of vesical endometriosis, 1 case of ureteral involvement, 1 rectal case and 1 sigmoid location. The authors point out the difficulty of the clinical preoperative diagnosis--in despite of cyclic troubles--and underline the interest of complementary explorations performed at the time of periods: ultrasound, cystoscopy, rectosigmoïdoscopy and coelioscopy. The MR imaging, showing high intensity a T1-weighted images and prominent high intensity on T2-weighted images, is very suggestive of an endometrial lesions. A joint medical and surgical treatment is required. Endoscopic excision, endoprothetic tube, excision-suture, resection-anastomosis and a complementary medical treatment using Danazol, Decapeptyl or progestational agents have to be proposed. Per-operative microscopy is advised as routine procedure in order to avoid excessive surgery.