Update of the SFMV (French society of vascular medicine) guidelines on the conditions and safety measures necessary for thermal ablation of the saphenous veins and proposals for unresolved issues.

Venous insufficiency is a very common disease affecting about 25% of the French population (if we combine all stages of its progression). It is a complex disease and its aetiology has not yet been fully elucidated. Some of its causes are well known, such as valvular dysfunction, vein wall defect, and the suctioning effect common to all varicose veins. These factors are generally associated and together lead to dysfunction of one or more of the saphenous veins. Saphenous vein dysfunction is revealed by ultrasound scan, a reflux lasting more than 0.5 seconds indicating venous incompetence. The potential consequences of saphenous vein dysfunction over time include: symptoms (heaviness, swellings, restlessness, cramps, itching of the lower limbs), acute complications (superficial venous thrombosis, varicose bleeding), chronic complications (changes in skin texture and colour, stasis dermatitis, eczema, vein atresia, leg ulcer), and appearance of unaesthetic varicose veins. It is not possible to repair an incompetent saphenous vein. The only therapeutic options at present are ultrasound-guided foam sclerotherapy, physical removal of the vein (saphenous stripping), or its thermal ablation (by laser or radiofrequency treatment), the latter strategy having now become the gold standard as recommended by international guidelines. Recommendations concerning thermal ablation of saphenous veins were published in 2014 by the Société française de médecine vasculaire. Our society has now decided to update these recommendations, taking this opportunity to discuss unresolved issues and issues not addressed in the original guidelines. Thermal ablation of an incompetent saphenous vein consists in destroying this by means of a heating element introduced via ultrasound-guided venous puncture. The heating element comprises either a laser fibre or a radiofrequency catheter. The practitioner must provide the patient with full information about the procedure and obtain his/her consent prior to its implementation. The checklist concerning the interventional procedure issued by the HAS should be validated for each patient (see the appended document).

Conservative treatment of bladder carcinoma by partial cystectomy and interstitial iridium 192.

From 1971 to 1984, 85 patients with bladder carcinoma were treated conservatively at the Henri Mondor Hospital by a combination of short course of pre-operative external pelvic irradiation, iliac node dissection, partial cystectomy, and iridium 192 implantation. There were 79 transitional cell carcinomas (G1: 12, G2: 25, G3: 36, Gx: 6) and 6 squamous cell carcinomas. By clinical stage, based on endoscopic resection, there were 43 T1, 30 T2, 5 T3, and 7 Tx. After partial cystectomy the pathologic stage distribution was: 41 pT1, 31 pT2, and 13 pT3. Crude disease-free survival at 5 years is 72% for T1 tumors and 55% for T2, but overall only 16% of patients died of bladder carcinoma. Local failures were seen in 11.5% of T1 and 0% of T2 tumors, and second bladder tumors developed at a distance from the treated site in 11.5% of T1 and 7% of T2. There is a non significant trend for intravesical recurrences (both local failures and second tumors) to occur more frequently for G1 tumors (25%) than for G2 (16%) or G3 (7%). At 5 years 95% of disease-free survivors have a functioning bladder. Regional or distant metastases occurred in 54% of patients with pT3 tumors and 10% of those with pT1 or pT2; within each stage there was no apparent influence of grade on metastatic risk. The four patients with histologically positive iliac nodes received additional post-operative external pelvic irradiation; three died of metastases and one is disease free at 10 years. No abdominal scar recurrences were seen. Late complications occurred in 6% of the population. For T1 tumors we suggest modification of the described protocol, eliminating the pre-operative irradiation and the lymph node dissection. If there is no doubt as to the pathologic stage after complete endoscopic resection, iridium 192 implantation delivering a dose of 60 Gy, without partial cystectomy, may be sufficient management. By contrast, for T2 tumors, all elements of the protocol seem important to obtain optimal results.

Treatment of bladder tumors by iridium 192 implantation. The Créteil technique.

The technique and results of a treatment protocol for bladder cancer combining low dose pre-operative external beam irradiation followed by external iliac nodal dissection, limited partial cystectomy and curietherapy with iridium 192 are described. In 55 patients treated from 1971 to 1979, 37/45 (67%) are alive NED at 5 years--23/31 pT1, 10/14 pT2, 4/10 pT3--with 9/55 bladder recurrences at 5 years--7/31 pT1, 1/14 pT2, 1/10 pT3. Only two patients (total cystectomy) have not retained a functional bladder. These favorable results have been obtained in a carefully selected population; our indications for the technique being T1, T2, T3a tumors with a total surface area not exceeding 5 cm, not involving the bladder neck and unifocal or in some cases plurifocal, but closely grouped. The advantages and precise details of each stage of the technique will be described and compared with large series in which radium 226 is utilized and results of curietherapy will be compared with other modalities of treatment employed under similar circumstances for similar patient groups. We feel that curietherapy has certain advantages over other methods in the treatment of bladder cancer and that an afterloading technique employing iridium 192 wires permits the curietherapy to proceed under optimal conditions, allowing combination with partial cystectomy, optimal placement of sources, precise radiographic control and dosimetry, dose reduction in many cases, optimal conditions of radioprotection and widening of the indications for the technique.

Treatment of malignant bladder tumors by iridium-192 wiring.

Small tumors of the mobile portion of the bladder may be treated by means of interstitial irradiation by iridium-192 wiring. Twenty-six tumors (mostly T1, but also T2 and T3) were treated by this procedure. Good results are attained in 89 per cent of 19 cases followed over three years. This method has the benefit of avoiding irradiation to the surgeon's hands, and of delivering to a specific site a dose of 6,000 rads. No bladder contraction was observed.

Immediate and long-term results of superior mesenteric vein-inferior vena cava shunt for portal hypertension in children.

Experience with 46 superior mesenteric vein-inferior vena cava shunts in children is reported, with postoperative follow-up of from 2 to 15 yr. The first procedure used as an end-to-side implantation of the vena cava into the right side of the superior mesenteric vein or portal vein after ligating the cava above the iliac vessels (16 cases). In the next 30 children, the vena cava was lengthened using the left or right common iliac vein, thus obtaining better anastomosis and reversed portal flow. Patency may be definitely assumed when the esophageal varices have disappeared within 3 mo; this was observed in 33 children. Results are nearly the same with superior mesenteric vein-inferior vena cava shunt, splenorenal shunt and portacaval shunt when the respective veins of the portal system are more than 1 cm in diameter. When it is less, the superior mesenteric vein-inferior vena cava shunt is more successful than others; this is the case in children under 7 yr of age. No serious trouble was observed after the interruption of the venous circulation of the limbs and pelvis when a superior mesenteric vein-inferior vena cava shunt was performed when the patients were less than 15 yr of age.

[Volumetrics: an indispensable complementary test in lymphology]. / La volumétrie: un examen complémentaire indispensable en lymphologie.

In patients with lymphedema, the volume of the affected limb is rarely measured in routine practice or may only be appreciated by a method giving a result in centimetres, an incorrect unit for volume quantification. Measurement of limb volume allows early diagnosis of lymphedema, long before the clinical signs appear. Two methods exhibit excellent reproducibility: the water displacement method which is the gold standard, with an accuracy of 0.7% and reproducibility of 1.3%, and the perimetric method, which has a good intraclass coefficient of correlation of 0.99. The water displacement method is the gold standard because it is the only one that gives the exact volume of the limb, including its extremity (hand or foot), but it has the drawback of requiring water. The perimetric method has two drawbacks: it does not include the hand or foot in the volume measure, and therefore gives an approximate volume of the affected limb, and it requires a computer to calculate the cone volumes. Taking, as an example of limb volume measurement, the case of patients operated for breast cancer, a difference between the post and pre postoperative volumes of < or = 100 mL is reassuring, a difference > 100 and < or = 250 mL requires regular surveillance, and a difference exceeding 250 mL is an indication for drainage and elastic compression. When the preoperative limb volume is unknown, the volume of the ipsilateral limb can be used.

[Extracorporeal shockwave lithotripsy. A brief review of the types of equipment currently in use]. / La lithotripsie extra-corporelle par ondes de choc (LECOC). Revue abrégée des types d'appareils actuellement en usage

Presentation of the main lithotriptors used in 1996: Dornier HM3 and 4, Edap-Technomed Sonolith, Storz Modulith, Siemens Lithostar, Wolf. Comparison of the efficacy coefficients of these apparatuses.

[Cancer of the penis. 1989]. / Cancer du pénis.

Cancer of the penis is the rarest male genital tract tumour, accounting for only 1% of all cancers in men. It is highly lymphophilic. Complex diagnostic problems are posed by both the primary tumour and lymph nodes. The prognosis depends on the degree of lymphatic spread. This cancer occurs in uncircumcised men with poor personal hygiene. The diagnosis is based on biopsy of all persistent lesions on the glans. In every case, treatment requires complete removal of the prepuce. Small noninvasive cancers can be treated by application of radioactive iridium wire. Inguinal lymph node biopsy is performed on a palpable node. Small cancers with lymph node involvement requires extensive inguinal lymph node dissection. Adjuvant irradiation is only indicated when the tumour has extended beyond the lymph node capsule. Cancer invading the corpora cavernosa has a poor prognosis (T3). It justifies large amputation of the penis with perineal urethrostomy and extensive lymph node dissection in the presence of positive nodes. Advanced cancers with unresectable lymph nodes (inguinal and iliac) and/or metastases (pulmonary) require combination chemotherapy with MTX-cisplatin-bleomycin.

[Contribution of suprapubic ultrasound in prostatic hypertrophy]. / Apport de l'échographie par voie sus-pubienne dans les hypertrophies prostatiques.

After describing the technique, the authors recall the ultrasound anatomy of the prostate with the symmetrical echoes given by the seminal vesicles, the vas deferens and the ejaculatory ducts, which often allow a distinction to be made between the cranial and caudal portions of the prostate. Calculation of the volume (normally under 20 cm3) measures the enlargement (useful in determining the choice of approach), using the formula (Formula: see text) Ultrasound also often gives some idea of the nature of the lesion. The main distinction between an adenoma and a carcinoma is the fact that the adenoma is normally confined to the cranium. Carcinomas are generally asymmetrical, and their structure is non-echogenic, giving coarse echoes. Chronic prostatis, on the other hand, leads to the existence of symmetrical hyper-echogenic areas, sometimes calcified. The main contribution of suprapubic ultrasound is the information it provides concerning the repercussions on the urinary tract (residue, straining bladder, repercussions on the kidney). It can also be used to monitor developments.

[Modification of the infectious state following surgical treatment of primary vesicorenal reflux in adults. Apropos of a series of 17 patients]. / Modification de l'état infectieux aprés traitement chirurgical du reflux vésico-rénal primitif de l'adulte. A propos d'une série de dix-sept patientes.

Seventeen adult female patients with primary vesico-renal reflux were treated surgically (6 nephrectomies, 5 reimplantations and 3 ureteropelvic anastomoses). The risk of severe upper tract infection was eliminated in all seventeen cases, but lower urinary tract infection persisted in two cases.

[Renal oncocytoma. Apropos of 9 cases]. / Oncocytome rénal. A propos de neuf cas.

The authors report nine cases of renal oncocytoma which were observed in a series of 220 consecutive renal cell carcinomas. They share the general view concerning the clinical latency of these tumors which are rarely hematuric, and concerning the favorable prognosis, despite signs of locoregional malignancy. On the other hand, they do not share the opinion that arteriography or CT scan can provide a reliable preoperative differential diagnosis with the normal type of renal cell carcinoma.

[Demonstration of specific antibodies against diethylstilbestrol during treatment of prostatic cancer]. / Mise en évidence d'anticorps spécifiques anti-diéthylstilboestrol au cours du traitement du cancer prostatique.

Antibodies against diethylstilboestrol were detected in prostatic cancer patients treated with diethylstilboestrol (DES). Direct radioimmunoassay (DRIA) was performed in 109 patients divided into three groups: a control group of 33 patients (group I), a group of 38 patients treated by DES and free of cardiovascular complications (group II), and a group of 38 patients treated by DES with cardiovascular complications (group III). Antibody count was significantly higher in group III than in the two other groups (p less than 0.05). These results suggest that DES antibodies may play a role in estrogen-associated cardiovascular toxicity. For this reason, DES should not be used in patients with a positive assay.

[Use of a resorbable mesh in the conservative treatment of a ruptured human kidney allograft]. / Utilisation d'un treillis résorbable dans le traitement conservateur de la rupture d'allogreffe rénale humaine.

A new surgical technique is proposed to preserve severe ruptured renal allografts requiring surgical exploration. Renal corsetage using an absorbable mesh provided a continuous external compression for these friable and fragile kidneys. Two cases treated successfully with this method are reported.

[The value of the serum level of the prostate-specific antigen in prostatic pathology]. / Intérêt du dosage sérique de l'antigène spécifique prostatique dans la pathologie prostatique.

Development of serum assays for prostate-specific antigen (PSA) has provided physicians with a new marker for carcinoma of the prostate. PSA was compared to prostate acid phosphatases (PAP), the reference serum marker, in 162 patients including 54 patients with carcinoma of the prostate (CP), 84 patients with benign hypertrophy of the prostate (BHP), and 24 controls free of prostate disorders. PSA appeared more sensitive but less specific than PAP. Results showed that PSA is not suitable for routine screening in the population at large where BHP is common. In BPH, the rise in PSA concentrations parallels the size of the hypertrophy. However, in patients with CP, PSA seems more sensitive than PAP for evaluating tumor spread and response to treatment. The prognostic bearing of increased levels in patients with apparently localized carcinomas remains to be elucidated.

[Cystoplasty using a resorbable polyglactin prosthesis covered by a free peritoneal flap]. / Cystoplastie utilisant une prothèse résorbable de polyglactine doublée d'un lambeau libre péritonéal.

The bowel is not always suitable for cystoplasty. The use of a vicryl mesh lined with a peritoneal flap was investigated as material for partial replacement of the bladder. The procedure was performed on 20 rats divided into two groups. A partial cystectomy was first performed, then a cystoplasty was done using either a free peritoneal flap (group 1) or a vicryl mesh combined with a peritoneal flap (group 2). The results were evaluated using intravenous pyelography, macroscopic examination and histological analysis within one month. In group 1 (7 cases), there was one urinary fistula. In group 2 (13 cases), no fistula was observed but stones occurred in three cases. The histological analysis revealed good reconstruction of urothelium in both groups. Partial resorption of vicryl was observed at one month with organization of neo-muscular fibers. The vicryl prosthesis was well accepted and, when covered by a peritoneal flap, provided a strong and water-tight material for bladder replacement. The vicryl mesh increased the risk of stone formation in the presence of urinary tract infection.

[Percutaneous nephrolithotomy in 1984. Technics, results, indications]. / La néphrolithotomie percutanée en 1984. Techniques, résultats, indications.

Percutaneous nephrolithotomy - PCNL - was made possible by technological progress, with the introduction of nephroscopes, lithotomy forceps, and mechanical, ultrasonic or electrohydraulic lithotriptors. The procedure includes four stages. First needle puncture of the inferior or middle calyx. Secondly, dilatation of the pathway and creation of a tunnel. Thirdly, investigation of the collecting system. And, finally, extraction of the stone. The results of 302 published cases show a success rate of 87 per cent, a complete failure rate of 13 per cent, and residual stones in 10 per cent of cases. The complication rate is 7 per cent, with hemorrhage and sepsis in roughly equal proportions. A few other complications are occasionally reported, such as colic wounds, perirenal collections, traumas of the ureteropelvic junction, pneumothorax, or a stone left in the lumbar wall. There was one case of death. The hospitalization period is the same as for lombotomy, but the return to work is more rapid. The best indications are pelvic and inferior calyceal stones (with a success rate of over 80 per cent). Despite their enthusiasm for this procedure, the authors feel that is still remains to be seen or whether it will in turn be superseded by ultrasound lithotripsy.

[Conservative treatment of bladder epitheliomas by partial cystectomy and iridium-192 curietherapy]. / Traitement conservateur des épithéliomas vésicaux par cystectomie partielle et endocuriethérapie par iridium 192.

From 1971 to 1979, 55 patients were treated for bladder cancer at the Henri-Mondor Hospital using a treatment protocol combining low dose pre-operative external beam radiation followed by iliac node dissection, limited partial cystectomy (or sometimes for T1 tumors, a trans-urethral resection) and curietherapy with iridium 192. The 5 year disease free survival was 37/55 (67%). The rate of local recurrences plus second tumors within the bladder was 16% (9/55). These results are compared with other conservative modalities of treatment of bladder cancer.

[Results of treatment of superficial vesical tumors by transurethral resection alone and transurethral resection followed by an intravesical instillation of Calmette-Guerin bacillus]. / Résultat du traitement des tumeurs superficielles de la vessie par résection transuréthrale seule et résection transuréthrale suivie d'instillation endovésicale de bacille Calmette-Guérin.

Superficial bladder tumors treated at the Henri Mondor Hospital from 1984 through 1988 were analyzed for recurrence and progression using the following prognostic parameters: stage (TNM classification, 1978), grade (G1, G2, G3), size, number of tumors, and tumor malignancy index as defined by the Besançon group. Forty-five patients were treated with transurethral resection alone (TUR group) whereas 30 had TUR followed by the prophylactic instillation of fresh Calmette-Guérin bacillus in the bladder (BCG group). In TUR patients, parameters predictive of progression included grade G3, multiple tumors, stage T1, recurrence within 6 months of TUR, and a tumor malignancy index above 455. None of these criteria were predictive of a response to BCG. Results obtained in the BCG group were comparable to those reported in the literature and confirmed the efficacy of BCG instillations to prevent recurrence and progression of superficial carcinomas of the bladder.

[Atraumatic microsurgical nephrotomy. Experimental study on canine kidney (author's transl)]. / La néphrotomie atraumatique microchirurgicale. Etude expérimentale sur le rein de chien.

Microsurgical transversal section and repair of canine kidney was presented as a model to study the condition required for an atraumatic nephrotomy. The investigation was carried out by two methods. In a first series five kidneys were injected by coloured resins after transection and microsurgical repair. Results were evaluated by cast examination of vascular net work. In a second series, transection and repair were made by an "ex-situ" procedure on seven dogs. The repaired kidney was autotransplanted in the opposite fossa iliaca. Long term renal function was evaluated after controlateral nephrectomy, by arteriography, biologic data and DMSA Tc 99 m scintiscan. The good results showed that microsurgery is useful in atraumatic nephrotomy and now a new tool in intrarenal access.

[Quality standards for ultrasound assessment of the superficial venous system of the lower limbs. Report of the French Society for Vascular Medicine]. / Standards de qualité pour la pratique des examens écho-Doppler dans l'exploration du réseau veineux superficiel des membres inférieurs. Rapport de la Société française de médecine vasculaire (SFMV).

The quality standards of the French Society for Vascular Medicine for the ultrasound assessment of the superficial venous system of the lower limbs are based on the two following requirements: technical know-how (mastering the use of ultrasound devices and the method of examination); medical know-how (ability to adapt the methods and scope of the examination to its clinical indications and purpose and to rationally analyze and interpret its results). AIMS OF THE QUALITY STANDARDS: To describe an optimal method of examination in relation to the clinical question and hypothesis; to achieve consistent practice, methods, glossary terminologies and reporting; to provide good practice reference points and to promote a high quality process. THEMES OF THE QUALITY STANDARD: The three levels of examination. Their clinical indications and goals. The reference standard examination (level 2) and its variants according to clinical needs. The minimal content of the examination report, the letter to the referring physician (synthesis, conclusion and management suggestions) and iconography. Commented glossary (anatomy, hemodynamics, semiology). Technical basis. Ultrasound devices settings. We discuss of use of Duplex ultrasound for the assessment of the superficial veins of the lower limbs in vascular medicine practice.