[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.

Polyamine contents in current foods: a basis for polyamine reduced diet and a study of its long term observance and tolerance in prostate carcinoma patients.

Polyamine contents were assessed by mass spectrometry in 233 current foods and beverages. In order to reduce gut polyamine uptake, a polyamine reduced diet (PRD) and partial intermittent intestinal tract decontamination (PIITD) with neomycin or nifuroxazide was proposed as nutritional therapy to 33 prostate carcinoma patients, 30 of whom with hormone refractory prostate cancer (HRPC). Mean PRD observance was 22 +/- 19 (median: 16; range: 3-72) months. 10, 8 and 3 patients were respectively on PRD for more than 30, 36 and 64 months. No diet toxicity was observed. 8 patients had moderate intestinal intolerance due to PIITD which was interrupted. No significant differences in body weight, blood counts or serum protein levels were observed during the follow-up of patients under PRD. Performance status and pain scores were relatively stable during the trial with improved pain scores at 6 months. A PRD associated with intermittent PIITD is a safe and well observed nutritional regimen and long term observance is possible.

Polyamine deprivation: a new tool in cancer treatment.

The fact that tumors require polyamines for growth has been demonstrated in vitro and in vivo and widely reported. This finding led to the use of polyamine biosynthetic enzymes as targets for antitumor drug design. Highly efficient in vitro selective inhibitors of ornithine decarboxylase such as DFMO do not produce important antitumoral effects in vivo, due to the ability of tumor cells to uptake extracellular polyamines. A new strategy was developed, combining a systematic blockade of all endogenous and exogenous sources of polyamines in vivo. Sources of exogenous polyamines were eliminated by administration of a polyamine-free diet to the animals and decontamination of their gastrointestinal tract. Important antitumoral effects were obtained with this polyamine deprivation and are presented with two experimental models of tumors (Lewis lung carcinoma, Mat Lylu prostatic carcinoma). Biological parameters, modified in cases of cancer, were restored to normal values in treated animals: blood counts and NK cytotoxic activity. Number of metastases was significantly reduced. Given that in man cancer treatment remains unsatisfactory due to incomplete cell kill, development of resistance to treatment and secondary effects of chemotherapy, we chose to investigate the potential interest of polyamine deprivation in this field. By combining clinically applied cytotoxic drugs with polyamine deprivation, we observed an improvement of their antitumoral efficiency: a considerable retardation of tumor growth paired with a marked increase in life-span of the treated animals. Our observations confirm that polyamines absorbed from exogenous sources, mainly food and gastrointestinal tract, play an important role in tumor growth control. Furthermore, the study shows that polyamine deprivation represents an important potential therapeutic tool in improved management of cancer treatment.

A case of myospherulosis occurring in the perirenal adipose tissue.

The authors report a case of spontaneous myospherulosis that developed in the right perirenal adipose tissue, presented like an abscess, in an 82-year old man of the A, Rh+ blood group. The patient had a history of chronic lymphocytic leukaemia. Fine needle aspiration and histological examination of the renal cyst allowed the observation of 4- to 7-micron spherules (or endobodies) enclosed in saccular structures (or parent bodies) and accompanied by a foreign body-type response. The walls of the parent bodies were negative for PAS, Gomori's methenamine silver and Giemsa's stain. Immunohistochemical study was positive with anti A antibody specific of A1/A2 blood group and with anti glycophorin A antibody. The authors reviewed the literature concerning this rare lesion: it usually occurs in subcutaneous fat or in the paranasal sinuses, nose and middle ear but, up to now, no previous case has ever been reported in the urinary tract. The only case of visceral myospherulosis previously reported occurred in a cystic teratoma of the ovary. The reported case is also peculiar by the unusual thickness of the parent bodies. The authors also discuss the mechanism of the disease and suggest that, in the present observation, myospherulosis could have been induced by the rupture of a preexisting cyst in the perirenal adipose tissue.

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)

[Extracorporeal lithotripsy for urinary calculi: a non invasive technique? Report of 150 patients treated with the Nova lithotriptor]. / La lithotripsie extra-corporelle pour calcul urinaire: une technique non invasive? A propos de 150 patients traités avec le lithotripteur Nova.

The NOVA apparatus is an electrohydraulic lithotriptor not yet available in France. The authors present an evaluation of the first 150 patients treated with this machine. 92.2% of the 185 stones treated were fragmented. 141 patients were reviewed at 1 month and, if necessary, 3 months after the first session; 4/24 patients and 1/3 patients were not reviewed after their second and third treatment session, respectively. Evaluation of the 177 sessions performed (16% of second sessions and 2% of third sessions), 69.11% of patients did not have any residual stones. The success rate was 52% for renal stones; 96% for stones of the lumbar ureter and 50% for pelvic stones. The morbidity was low (10% of renal colic, 5% of obstructive stone) but in combination with second treatment sessions, it generated a risk of being rehospitalised after the first session of 26%. When the procedures performed under anaesthesia before and after ECL (apart from repeated sessions) are added, the risk of this supplementary anaesthetic for a given patient is 18.66%. Lastly, the risk of undergoing another anaesthetic after the 1st ECL was 33%. These data indicate the limits of the "noninvasive" nature of a modern and effective lithotriptor.

[Bladder replacement and continent diversion: what about metabolic complications?]. / Remplacement de vessie et dérivation continente: qu'en est-il des complications métaboliques?

During the past several years there has been increasing interest in refunctionalizing patients who have undergone radical extirpative surgery for pelvic malignancies and patients with dysfunctional bladders. To accomplish this, intestinal segments have been successfully employed in a variety of configurations. Independent of their optimal urosurgical implementation these procedures are not without potential complications, a significant portion of which involve metabolic derangements. Besides first follow-up results of patients with bladder substitution or continent urinary diversion, analysis of experimental investigations and functionally comparable clinical conditions enables an insight into potential following physiopathological interrelationships. These concern, besides the problem of chronic metabolic acidosis, disorders of bile acid and vitamin B12 metabolism as well as the potential induction of a secondary hyperoxaluria with subsequent oxalate concrement diathesis. Furthermore, there may be a malabsorption of calcium and vitamin D with development of intestinal osteopathy due to the reduction of absorptive surface. Apart from these problems of enteral loss and deficiency manifestations, several case reports and investigations suggest that bone demineralization can occur as a consequence of chronic metabolic acidosis and patients are at risk of skeletal demineralization. The pathogenesis of this association has yet to be clarified. These physiopathological interrelationships must be considered in medical attendance of patients with intestinal substitute bladders and continent supravesical pouch systems over many years. As these procedures become more popular, it becomes important to identify any metabolic changes that may occur as their consequence.

[Diagnostic value of recording nocturnal erections]. / Valeur diagnostique de l'enregistrement des érections nocturnes.

The recording of tumescence and rigidity during nocturnal erections is considered to be the reference examination to differentiate between the organic or psychogenic origin of erectile dysfunction. However, its diagnostic value is more doubtful in the absence of normal rigidity values. 170 consecutive patients were submitted to this type of recording (RigiScan, Dacomed, USA). With the exception of patients suffering from multiple sclerosis, all patients with erectile dysfunction considered to be psychogenic obtained a rigidity > or = 60%. 59% of these patients were detected by this method (sensitivity: 59%, specificity: 87%). In contrast, no conclusion can be drawn from a pathological nocturnal recording (32% of psychogenic patients) and finally, in view of the aetiologies of this series, this examination was considered to be useful in 29% of patients.

[The diagnostic value of erythrocyte polyamines (EPA) in prostatic adenocarcinoma (PA): apropos of 100 patients]. / Intérêt diagnostique des polyamines érythrocytaires (PAE) dans l'adénocarcinome prostatique (AP): à propos de 100 patients.

Spermidine and spermine are ubiquitous polyamines which are intensely metabolised in the prostate. Polyamines are involved in the processes of proliferation and differentiation of normal and neoplastic cells. As the erythrocyte levels of these polyamines are correlated with the intratumoral levels, we assayed EPA in 45 controls, 66 patients with benign prostatic hypertrophy and 100 patients with prostatic cancer. Erythrocytic polyamines are markers of proliferation and prostatic metastases and can be used to distinguish between hormone-sensitive and hormone-resistant patients. Although non-specific, polyamines constitute circulating markers of the state of tumour proliferation of a given patient and definitely have a prognostic value which needs to be evaluated by further studies.

[Precancerous conditions of the prostate]. / Les états pré-cancéreux de la prostate.

Carcinoma in situ, dysplasia, prostatic intra-epithelial neoplasia, duct-acinar dysplasia and large-acinar hyperplasia are various terms describing more or less identical forms of prostatic epithelial atypia. The precancerous nature of these lesions can be demonstrated by: morphological and functional similarities with carcinoma, a younger age than that of carcinoma, a higher incidence in cancerous prostates, an identical zonal distribution and a significant progression of high-grade lesions towards carcinoma. These hypoechoic lesions can be detected or monitored by transrectal ultrasonography. They also secrete PSA at levels intermediate between those of benign prostate and adenocarcinoma. Because of the occasional risk of malignant transformation and a frequent association with carcinoma, these lesions should be regularly monitored by digital rectal examination, PSA assays and possibly by ultrasound-guided biopsies.

[Can we do better than surgery in the treatment of benign prostatic hypertrophy? Results after 10 years in endoscopic resection and adenomectomy in urination and sexual disorders]. / Peut-on mieux faire que la chirurgie dans le traitment de l'hypertrophie bénigne de prostate? Les résultats à 10 ans de la résection endoscopique et de l'adénomectomie sur les troubles mictionnels et la sexualité.

Surgery is considered to be the reference treatment for obstructive benign prostatic hypertrophy (NPH). Transurethral resection of the prostate (TURP) and suprapubic prostatectomy are the operations most frequently performed by urologists. However, little information is available concerning the long-term results of this surgery. In order to assess the long-term efficacy, we recalled 618 consecutive patients operated for benign prostatic hypertrophy between 1979 and 1982 (390 by TURP and 228 by suprapubic prostatectomy (SP). 167 patients were reviewed and investigated, 150 had died and 301 were lost to follow-up. Ten years after the operation, 85% of the patients reviewed had good or satisfactory micturition and 72% of them were satisfied, regardless of the technique used. In 80% of patients, no complementary procedure was required to ensure urinary comfort. However, the effects of this surgery on sexual function were considerable, as one half of patients reporting sexual intercourse before the operation reported a deterioration of sexual function after the operation. Lastly, long-term morbidity affected 10 to 41% of patients and 9 to 12% of them were reoperated. Although, overall, surgery gave excellent results at 10 years, 15% of patients did not derive any benefit from the procedure. It is therefore important, in the future, to more clearly define the indications for surgery and the place of noninvasive treatments. At the present time, young subjects wishing to preserve their sex life may benefit from noninvasive first-line treatments, provided their quality of life is sufficiently altered by the severity of the urinary symptoms.

[Radical prostatectomy and biologic glue]. / Prostatectomie radicale et colle biologique.

Fibrin glue (reconstituted fibrin glue-Tissu-col-Immuno-France) was used in 24 patients following radical prostatectomy with ilio-obturator lymphadenectomy (Group II) to improve haemostasis of the operative field, to decrease or eliminate lymphatic oozing and to promote healing of the urethrovesical anastomosis. The results in terms of duration of drainage, quantity of fluid evacuated by these drains, operative complications and length of hospital stay were compared to those obtained in 24 clinically identical patients operated previously without the use of fibrin glue (Group I). Although fibrin glue is easy to use, ensures a particularly dry operative field at the end of the operation and does not induce any infectious complications (abscess, hepatitis), it increases the cost of the operation (5 ml vial = 2,500 FF) and the use of this product does not reduce the drainage time (Group I: 7 +/- 4.6 days; Group II: 8.5 +/- 5.4 days) the volume of blood or lymphatic discharge (Group I: 500 +/- 570 ml; Group II: 660 +/- 825 ml) or the length of hospital stay (Group I: 16.5 +/- 4.8 days; Group II: 17.4 +/- 5.5 days). These results argue against the routine use of fibrin glue in radical prostatectomy.

[Testicular microlithiasis: ultrasonographic diagnosis and semiologic value]. / Microlithiases testiculaires: diagnostic échographique et valeur sémiologique.

Testicular microlithiasis corresponds to calcifications in the lumen of seminiferous tubules. This rare condition, primarily diagnosed histologically, is usually discovered on scrotal ultrasonography. The characteristic appearance combines multiple microscopic hyperechoic areas disseminated bilaterally throughout the testicular parenchyma. The coexistence of microlithiasis and testicular neoplasms has been described and raises the problem of the therapeutic approach following incidental discovery on scrotal ultrasonography performed for other reasons. The authors report a case of testicular microlithiasis discovered on ultrasonography performed after testicular trauma.

[Dose adaptation during training of intracavernous self-injections of prostaglandin E1]. / Adaptation de la dose lors de l'apprentissage des auto-injections intracaverneuses de prostaglandine E1.

OBJECTIVE: Dose adaptation in self-administered intracavernous PGE1 injections is poorly defined in learning protocols and its degree of difficulty depends on the aetiology of the erectile dysfunction. The authors tried to standardize this phase by studying the results and complications of a protocol using an identical initial dose of PGE1 regardless of the aetiology of erectile dysfunction. MATERIAL AND METHODS: 101 patients consulting for erectile dysfunction participated in a learning protocol of self-administered intracavernous PGE1 injections, consisting of 3 injections systematically starting with 10 micrograms of PGE1, following assessment of the aetiology. RESULTS: For an efficacy of 58.4%, 79.2% and 88.1% after one, two or three injections, respectively, the prolonged erection rate (> or = 6 hours) was 2.7% after the first injection and 0% after the other injections. However, erection durations of 2 to 6 hours have frequently been reported in neurological patients. Discontinuations during the learning phase were only observed in patients presenting with tumescence without rigidity after one injection (5.4%) or two injections (21%). CONCLUSION: In the light of these results and to minimize prolonged erections and discontinuations, while ensuring efficacy, PGE1 dose adaptation can be simply performed by starting with 10 micrograms in all patients except for neurogenic patients (5 micrograms) with an increase to 20 or 30 micrograms in the case of failure.

[General practitioners' approach to urination disorders in men over the age of 50. A survey of 250 physicians in Brittany]. / Le médecin généraliste face aux troubles mictionnels de l'homme de plus de 50 ans. 250 médecins interrogés en Bretagne.

A questionnaire was set to 250 general practitioners in the Brittany region, to determine the impact of information campaigns concerning benign prostatic hyperplasia (BPH) and prostatic cancer on their everyday approach to disorders of micturition in men over the age of 50 years. 225 questionnaires were interpretable. 75% of general practitioners systematically investigated the presence of disorders of micturition. In the presence of such symptoms, 76% of general practitioners conducted further investigations to exclude prostatic cancer. 89% of general practitioners performed first-line digital rectal examination, and 34% of them systematically performed this examination once a year. The investigations most frequently performed after digital rectal examination concerned the state of urine (50%) but only 30% of general practitioners used reagent dip-sticks and 43% ordered urine cultures. Other investigations consisted of transrectal ultrasonography (31%) an PSA assay (26%). 3% of PSA assays were ordered before digital rectal examination. Renal and vesical ultrasonography occupied 5th place, although distension of the upper urinary apparatus was a source of concern for 51% of general practitioners. In the presence of symptomatic BPH, general practitioners readily prescribed medical treatment (96%). They assessed the results of this treatment on the course of disorders of micturition (95%), digital rectal examination (91%), and PSA (50%). General practitioners are familiar with disorders of micturition after the age of 50 years. However, 25% of them do not systematically question patients about these symptoms. Digital rectal examination is now performed more frequently, although systematic examination of the prostate is rare (34%). PSA assay is not the doctor's first priority (3rd place in the list of examinations). Two examinations are rarely used and should be developed: reagent dip-sticks (30%) and renal and vesical ultrasonography (5th place). Only 4% of general practitioners did not prescribe any treatment in the case of uncomplicated BPH, which is not in line with current recommendations. There is certainly a need for better information of general practitioners, but this information is only valid when a consensus has been reached among urologists.

[Percutaneous surgery for lithiasis: results and perspectives. Apropos of 390 operations]. / La chirurgie percutanée pour lithiase: résultats et perspectives. A propos de 390 interventions.

Percutaneous nephrolithotomy (PCNL) has radically changed the treatment of renal stones. The indications for this technique have been modified by the development and refinement of extracorporeal lithotripsy (ECL). The authors present their experience of 390 PCNL performed between 1984 and 1991, for solitary stones in 75% of cases. There were only 11 cases of failed puncture (3.8%). The overall morbidity was 18% with only 4.4% of major complications, i.e. life threatening or requiring reoperation. There were two deaths (0.5%). Stones were completely eliminated in 80.25% of patients, after a second operation (PCNL or other technique) in 32 cases (11%). 45 staghorn calculi were treated with 11% of complications and a 51% complete cure rate. The mean hospital stay was 6 days (2 to 30). PCNL is a safe and reliable technique. Its indications have decreased (6.5% of our patients treated for renal stones), but it still retains a place in the therapeutic approach to patients with renal stones.

[Acquired experience in anesthesia and perioperative intensive care in percutaneous nephrolithotomy. Current approach in the endoscopic treatment of lithiasis and pyelo-ureteral junction anomalies]. / Expérience acquise en anesthésie et réanimation péri-opératoire dans la néphrolithotomie percutanée. Attitude actuelle dans le traitement endoscopique de la lithiase et de l'anomalie de la jonction pyélo-urétérale.

Percutaneous endoscopic treatment of the kidney retains a place in the treatment of renal stones (percutaneous nephrolithotomy--PCNL) and ureteropelvic junction abnormalities (endopyeloplasty). It requires anaesthesia ensuring surgical comfort and safety for the patients despite changes in position and the prolonged ventral supine position. The operation carries certain iatrogenic risks related to caliceal irrigation in patients with more or less documented episodes of infection and carries risks of haemorrhage and effraction of adjacent organs. 282 patients treated by PCNL between 1984 and 1991 were reviewed in order to define the respective indications for general anaesthesia and peridural anaesthesia and to determine the modalities, to evaluate the risk and severity of absorption of irrigation fluid and to assess the risk of infection by defining the indications for prophylactic antibiotics. General anaesthesia, using etomidate and propofol via an infusion pump, ensures surgical comfort, anaesthetic safety and better control of intraoperative complications. The renewed interest in this technique must be counterbalanced by the growing incidence of anaphylactic reactions related to anaesthetic drugs. Operations lasting more than 2 hours, raised intracaliceal pressure, the initially exclusive use of glycine for irrigation induce haemodilution complications, possibly aggravated by glycine intoxication. Repeated surgery is preferable with the use of an Amplatz tube as often as possible and physiological saline, except when required by the operation. Patients with a history of urinary tract infection or infected stones should receive prolonged and effective antibiotics before, during and after the operation. Prophylactic antibiotics are reserved for those patients with no history of infection. These principles equally apply to percutaneous nephrolithotomy and endopyeloplasty.

[Medical treatment of prostate cancer]. / Traitement médical du cancer de la prostate.

Hormone dependence of prostate cancer is well known. In 80% of cases with metastases, hormone suppression leads to the reduction of tumour volume and related disorders. However the treatment is generally palliative because malignant process recurs after about around 16 months. Mean survival is less than 3 years in these forms. Lack of response come always together with a poor prognosis, and there is 90% mortality at 2 years. Advanced prostatic cancer should not be treated with hormones if the patient has few symptoms and his quality of life is satisfactory. Symptomatic forms require hormone manipulation. Orchidectomy or LH-RH are recommended. Total androgen ablation (combined treatment) leads rapidly to more relief of symptoms, but its drawbacks and especially high cost indicate that its use should be weighed individually. Estramustine is not a first-lune treatment. Presently, there is no criteria to predict response to treatment.

Hypofertility in males due to a secretion anomaly of the seminal vesicles and its treatment.

Between 1981 and 1986, 5,000 males with infertility were treated. Eight (0.16%) of them had hypospermia, a decrease in seminal fructose, asthenospermia without oligospermia considered as a secretion anomaly of the seminal vesicles. Artificial Insemination with the Husband's sperm (AIH) combined with vesiculo-prostatic plasma from a vasectomized donor was performed successfully in 3 couples. In this series, failures were associated with an important fertility factor in the female. AIH combined with vesiculo-prostatic plasma from a vasectomized donor is considered as an effective treatment of male hypofertility caused by vesicular dysfunction.