Management of female pelvic organ prolapse-Summary of the 2021 HAS guidelines.

When a patient presents with symptoms suggestive of pelvic organ prolapse (POP), clinical evaluation should include an assessment of symptoms, their impact on daily life and rule out other pelvic pathologies. The prolapse should be described compartment by compartment, indicating the extent of the externalization for each. The diagnosis of POP is clinical. Additional exams may be requested to explore the symptoms associated or not explained by the observed prolapse. Pelvic floor muscle training and pessaries are non-surgical conservative treatment options recommended as first-line therapy for pelvic organ prolapse. They can be offered in combination and be associated with the management of modifiable risk factors for prolapse. If the conservative therapeutic options do not meet the patient's expectations, surgery should be proposed if the symptoms are disabling, related to pelvic organ prolapse, detected on clinical examination and significant (stage 2 or more of the POP-Q classification). Surgical routes for POP repair can be abdominal with mesh placement, or vaginal with autologous tissue. Laparoscopic sacrocolpopexy is recommended for cases of apical and anterior prolapse. Autologous vaginal surgery (including colpocleisis) is a recommended option for elderly and fragile patients. For cases of isolated rectocele, the posterior vaginal route with autologous tissue should be preferentially performed over the transanal route. The decision to place a mesh must be made in consultation with a multidisciplinary team. After the surgery, the patient should be reassessed by the surgeon, even in the absence of symptoms or complications, and in the long term by a primary care or specialist doctor.

Robot-assisted laparoscopic cystectomy with non-continent urinary diversion for neurogenic lower urinary tract dysfunction: Midterm outcomes.

OBJECTIVES: The aim of this study was to assess midterm functional outcomes and complications of robot-assisted laparoscopic cystectomy with non-continent urinary diversion in patients with neurogenic lower urinary tract dysfunction. MATERIALS AND METHODS: We performed a retrospective single center study including all patients who underwent robot-assisted laparoscopic cystectomy with non-continent urinary diversion between January 2008 and December 2018 for neurogenic lower urinary tract dysfunction. Perioperative data, early and late complications, reoperation rate, renal function, and patient satisfaction (PGI-I) were evaluated. RESULTS: One hundred and forty patients were included (70 multiple sclerosis, 37 spinal cord injuries, 33 others) with a median follow-up of 29 months (12-49). The main indication for surgery was an inability to perform intermittent self-catheterization (n = 125, 89%). The early complication rate (<30 days) was 41% (n = 58), including 72% (n = 45) minor complications (Clavien I-II) and 29% (n = 17) major complications (Clavien III-V). Three patients died in the early postoperative period. Late complications appear in 41% (n = 57), with 9% (n = 13) being ureteroileal anastomotic stricture. The overall reintervention rate was 19% (n = 27), mainly for lithiasis surgery. Pre- and postoperative renal function were comparable. Most of patients reported an improvement in their quality of life following their surgery (PGI-I 1-2). CONCLUSION: Robot-assisted laparoscopic cystectomy with non-continent urinary diversion may be of particular interest in patients with neurogenic lower urinary tract dysfunction who are unable to benefit from conservative treatment, as it provides midterm protection of the upper urinary tract and an improvement in quality of life.

Adjustable continence balloons in postprostatectomy incontinence: Outcomes and complications.

OBJECTIVE: The objective of this study was to assess the mid-term efficacy and safety of adjustable continence therapy (ProACT™) for the treatment of male stress urinary incontinence (SUI) after radical prostatectomy (RP). PATIENTS AND METHODS: Single-center retrospective study including male patients implanted with ProACT™ periurethral balloons for SUI after RP between 2007 and 2017, mainly with flexible cystoscopic guidance. Efficacy was assessed using a composite endpoint with subjective (patient's impression of improvement (PII), using a 0-100 numeral rating scale) and objective outcomes (decrease in daily pad use). Postoperative success was defined as a PII ≥ 80%, associated with the use of 0-1 pad daily. Improvement was defined as a PII ≥ 50% and a decrease ≥50% in the number of daily pads used. RESULTS: Two hundred men with a median age of 68 (64-73) years were included. Seventeen percent (n = 34) had had prior radiotherapy and 15.5% (n = 31) had had prior SUI surgery. The median follow-up was 43 (19-71) months. The severity of SUI was as follows: mild in 119 (59.5%), moderate in 48 (24%), and severe in 33 patients (16.5%). Severe SUI and a history of prior radiotherapy were associated with a lower success rate (p = 0.033 and p < 0.0001). The overall reoperation rate was 34%, with 5.6% (n = 11) requiring a third implantation. Of the patients, 29.4% (n = 58) required an artificial urinary sphincter to treat SUI. At the last follow up, among the overall population, the success rate was 40.1% and the median PII was 18.3%. For patients in whom the balloons were still in place (n = 132), the cumulative success and improvement rate was 78%, with a median PII of 72%. CONCLUSION: The minimally invasive ProACT™ device provides a clear beneficial continence outcome in patients with SUI after radical prostatectomy. Severe SUI or prior radiotherapy were associated with a lower success rate in our study.

Management of post-operative urinary incontinence after midurethral sling explantation for pelvic or perineal pain.

INTRODUCTION AND HYPOTHESIS: The objective was to report the management of post-operative urinary incontinence after midurethral sling (MUS) revision for chronic pelvic pain (CPP), and to report functional outcomes. METHODS: From November 2004 to February 2018, a total of 89 women who underwent removal or section of MUS for CPP, were enrolled. Patients were divided into the transobturator tape (TOT) group (50 patients) and the tension-free vaginal tape (TVT) group (37 patients); 2 patients had had both slings implanted. We report the rate of stress urinary incontinence (SUI) recurrence, the rate of de novo urge urinary incontinence (UUI), the need for subsequent SUI or UUI surgery, and functional outcomes (pain and continence). RESULTS: Median follow-up was 41.4 months [0.9-138.8]. SUI recurrence or de novo UUI occurred in 52 cases (58.4%): 19 (51.3%) patients in the TVT group, 31 (62%) in the TOT group, and both patients (100%) who underwent total removal of both slings. Among patients with SUI recurrence or de novo UUI, 39 (75%) had pain relief after sling removal. Seventeen patients (32.6%) refused any treatment, 14 (26.9%) were cured with conservative therapy, and 21 (40.3%) underwent SUI or UUI surgery. One patient had de novo pelvic pain after reoperation. The overall continence rate for all patients who underwent sling revision was 82% (73 out of 89) at the last follow-up. CONCLUSION: After MUS revision for CPP, post-operative UI may occur in 58.4% of patients, of which, one-fourth may be managed with conservative measures only. Forty percent of them had redo surgery with a low risk of pain recurrence and a high rate of urinary continence.

Outcomes of pregnancy and delivery in women with continent lower urinary tract reconstruction: systematic review of the literature.

INTRODUCTION AND HYPOTHESIS: The aim of this systematic review of the literature was to pool all the existing data regarding pregnancy and delivery in women with neurogenic bladder or bladder exstrophy who had undergone previous lower urinary tract reconstruction (LUTR). METHODS: We conducted a systematic review of the literature from PubMed/MedLine, ClinicalTrials.gov and the Google Scholar database, from 1972 to July 2020. Fifty articles were included, of which 25 contained data that could be pooled (229 women representing 292 pregnancies). RESULTS: Ninety-eight women had bladder exstrophy (43%), 58 had spinal dysraphism (25%), 14 had spinal cord injury (6%), and 59 presented other pathological conditions. Of these, 138 have had an augmentation cystoplasty (61%), 42 (18%) had a continent cutaneous urinary diversion, and 31 had an artificial urinary sphincter (14%). During their pregnancy, 97 women (33%) experienced at least one febrile urinary tract infection. Thirty-one women (11%) required ureteral stenting or nephrostomy placement for upper urinary tract dilatation. Forty-six pregnancies ended with premature delivery (16%). Delivery mode was by C-section for 108 patients (62%) and vaginal delivery for 104 (36%). Twenty complications were reported during delivery (mainly urological), of which 19 occurred during C-section. Nine women experienced postpartum urinary incontinence (4%); in 5 of then this was due to urinary fistulae secondary to complicated C-section. CONCLUSIONS: Pregnancy and vaginal delivery are possible for women with LUTR who have no obstetric or medical contraindications, except for some particular cases of bladder exstrophy. However, these high-risk pregnancies and deliveries should be managed by a specialist multidisciplinary team.

Treatment of Urinary Urgency Incontinence Using a Rechargeable SNM System: 6-Month Results of the ARTISAN-SNM Study.

PURPOSE: Sacral neuromodulation is a guideline recommended treatment of urinary dysfunction and fecal incontinence in patients in whom conservative treatments have failed. Historically sacral neuromodulation has been delivered using a nonrechargeable device with an average life span of 4.4 years. Surgery is required to replace the implanted neurostimulator due to battery depletion. Implantation of a long-lived implanted neurostimulator can eliminate the need for replacement surgeries, potentially reducing patient surgical risks and health care costs. The Axonics r-SNM System™ is a miniaturized, rechargeable sacral neuromodulation system designed to deliver therapy for at least 15 years. The ARTISAN-SNM (Axonics® Sacral Neuromodulation System for Urinary Urgency Incontinence Treatment) study is a pivotal study using rechargeable sacral neuromodulation therapy to treat urinary urgency incontinence. Six-month results are presented. MATERIALS AND METHODS: A total of 129 eligible patients with urinary urgency incontinence were treated. All participants were implanted with a tined lead and the rechargeable sacral neuromodulation system in a nonstaged procedure. Efficacy data were collected using a 3-day bladder diary, the validated ICIQ-OABqol (International Consultation on Incontinence Questionnaire Overactive Bladder quality of life) questionnaire and a participant satisfaction questionnaire. Therapy responders were identified as participants with a 50% or greater reduction in urinary urgency incontinence episodes compared to baseline. We performed an as-treated analysis in all implanted participants. RESULTS: At 6 months 90% of participants were therapy responders. The mean ± SE number of urinary urgency incontinence episodes per day was reduced from 5.6 ± 0.3 at baseline to 1.3 ± 0.2. Participants experienced a clinically meaningful 34-point improvement on the ICIQ-OABqol questionnaire. There were no serious device related adverse events. CONCLUSIONS: The Axonics r-SNM System is safe and effective with 90% of participants experiencing clinically and statistically significant improvements in urinary urgency incontinence symptoms.

Stratification of Patients With Interstitial Cystitis/Bladder Pain Syndrome According to the Anatomical Bladder Capacity.

OBJECTIVE: To compare the data of score symptoms (Interstitial Cystitis Problem Index, Interstitial Cystitis Symptom Index, Pelvic Pain and Urgency/Frequency Patient Symptom Scale and SF-36quality of life), voiding diaries, urodynamic studies, and cystoscopy under general anesthesia according to the anatomical bladder capacity for patients with interstitial cystitis/bladder pain syndrome (IC/BPS). MATERIAL AND METHOD: Single-centre descriptive observational epidemiological study based on retrospective review of 134 patients managed for IC/BPS between January 2010 and December 2016. Patients were stratified into 2 groups according to anatomical bladder capacity measured under general anesthesia: ≤400 mL (n = 40) and >400 mL (n = 94). RESULTS: Patients with an anatomical bladder capacity less than 400 of mL presented significantly different results for voiding diary data: higher total frequency (P = .0023) especially at night (P = .0008), lower functional bladder capacity (P = .0082) and lower maximum bladder capacity (P = .0001); urodynamic data: earlier onset of painful urge during bladder filling (P = .0002), lower maximum bladder filling capacity (P = .0001) and lower compliance (P = .0067); and the findings of cystoscopy under general anesthesia: more Hunner's lesions (P = .00013). These patients presented poorer Pelvic Pain and Urgency/Frequency Patient Symptom Scale symptom scores (P = .0176) but associated with better overall quality of life as assessed by SF-36 (P = .0295). CONCLUSION: The anatomical bladder capacity, measured under general anesthesia, can be used objectively to define 2 distinct groups of patients with symptoms of IC/BPS.

Artificial Urinary Sphincter in Male Patients with Spina Bifida: Comparison of Perioperative and Functional Outcomes between Bulbar Urethra and Bladder Neck Cuff Placement.

PURPOSE: We evaluated the perioperative and long-term functional outcomes of bladder neck and peribulbar cuff placement of an artificial urinary sphincter in a population of adult male patients with spinal dysraphism. MATERIALS AND METHODS: We retrospectively analyzed the French spina bifida network database. Patients who underwent implantation of an artificial urinary sphincter from January 1985 to November 2015 were selected and stratified into 2 groups according to cuff location, that is bladder neck vs bulbar urethra. Explantation-free and revision-free device survival was estimated by the Kaplan-Meier method and compared with the log rank test. Cox regression models were created to assess prognostic factors of artificial urinary sphincter device failure. RESULTS: A total of 65 patients were included in study. Most patients were not wheelchair bound. The cuff was implanted around the bulbar urethra at 46 procedures (59%) and around the bladder neck in 32 (41%). In the peribulbar and bladder neck groups median revision-free device survival was 11.7 and 14.3 years, respectively (p = 0.73). Median explantation-free device survival was 18.5 and 24.5 years, respectively (p = 0.08). On multivariate analysis clean intermittent catheterization was the only predictor of artificial urinary sphincter device failure. Cuff location had no influence. At the last followup satisfactory continence was similar in the 2 groups (83% vs 75%, p = 0.75). CONCLUSIONS: In male patients with spinal dysraphism morbidity and functional outcomes were similar for bladder neck and bulbar urethra cuff placement but with a trend toward longer survival without explantation in the bladder neck group. Clean intermittent catheterization was the only predictor of shorter device survival on multivariate analysis.

Feasibility, Morbidity, and Functional Results of Supratrigonal Cystectomy with Augmentation Ileocystoplasty by Combined Robot-Assisted Laparoscopy and Mini-Laparotomy Approach.

OBJECTIVES: Evaluation of the feasibility, morbidity, learning curve, and functional results of robotic supratrigonal cystectomy with augmentation ileocystoplasty (RSCAI). MATERIALS AND METHODS: RSCAI was performed in 19 patients between 2012 and 2016. Thirteen patients (66.4%) presented refractory detrusor overactivity or impaired compliance and 6 patients (31.6%) had painful bladder syndrome. A combined robot-assisted laparoscopy and mini-laparotomy approach was performed. Early (<30 days) and late (>30 days) complications were reported according to the Clavien-Dindo classification. Functional results were analyzed according to the surgical indication. RESULTS: Mean total operating time was 288.7 ± 92.1 minutes. Mean intraoperative blood loss was 147.4 ± 144.8 mL. Mean length of hospital stay in the surgical ward was 9.4 ± 3.7 days. Mean duration of bladder drainage was 23.3 ± 4.1 days. For surgeons who regularly performed robot-assisted laparoscopy, the learning curve of this technique, as assessed by the operating time, required almost five operations. No major (Clavien-Dindo >2) early (0%) or late (0%) postoperative complication was observed. Early minor complications were observed in 47.4% of cases, usually consisting of pyelonephritis (21.1%). Late minor complications (10.5%) were Clavien-Dindo grade I. Mean follow-up was 13.6 ± 10.1 months. The majority of patients (94.7%) obtained functional improvement of their disease in terms of pain, functional bladder capacity, or bladder compliance. CONCLUSION: Our RSCAI technique is a reliable technique with no early or late major postoperative complications reported in this series. This technique allows patients to be operated by minimally invasive surgery with very satisfactory long-term functional results.

Comparison of the morbidity and mortality of cystectomy and ileal conduit urinary diversion for neurogenic lower urinary tract dysfunction according to the approach: Laparotomy, laparoscopy or robotic.

OBJECTIVES: To evaluate and compare the morbidity and mortality of cystectomy-ileal conduit urinary diversion in patients with neurogenic lower urinary tract dysfunction according to the surgical approach, and to evaluate predictive factors of early and late morbidity. METHODS: This was a single-center retrospective study based on 65 patients operated between May 2005 and December 2011. The surgical approach consisted of: laparotomy (n = 11), laparoscopy (n = 14) and robotic (n = 40). Evaluation of early (<30 days) and late (>30 days) morbidity and mortality was carried out according to the Clavien-Dindo classification. RESULTS: The operating time was longer (P = 0.007) and the mean time to return of bowel function was shorter (P = 0.012) in the robotic group. The early complication rate for the overall population was 41.5%: minor complications in 32.3% of cases and major complications in 9.2% of cases. A tendency towards a lower minor complication rate was observed in favor of robotic surgery (P = 0.08), with a reduction of the postoperative hemorrhagic complication rate (P = 0.03). The late complication rate for the overall population was 43.1%: minor complications in 20% and major complications in 23.1%. A lower surgical revision rate under general anesthesia was observed in favor of robotic surgery (P = 0.03). No predictive factor of early and late morbidity was identified. CONCLUSION: Robotic cystectomy-ileal conduit urinary diversion in patients with neurogenic lower urinary tract dysfunction is feasible and safe. Its morbidity in experienced hands seems to be limited and comparable with laparoscopy or open surgery.

Validation of voiding diary for stratification of bladder pain syndrome according to the presence/absence of cystoscopic abnormalities: a two-centre prospective study.

OBJECTIVE: To assess the value of the voiding diary in the management of patients with bladder pain syndrome for predicting the presence or absence of cystoscopic abnormalities. PATIENTS AND METHODS: From November 2009 to March 2011, 54 consecutive patients (39 women and 15 men) with bladder pain syndrome, as defined by the European Society for the Study of Interstitial Cystitis/Bladder Pain Syndrome (ESSIC) criteria, were prospectively enrolled in this two-centre study. All patients completed a home voiding diary on 3 consecutive days, which included analysis of voiding frequency, voided volume and severity of pre- and post-voiding pain. The variables were evaluated on a numeric pain scale (NPS). All patients then underwent standardized cystoscopy under anaesthesia. Patients were stratified into two groups: a group with or a group without cystoscopic abnormalities. Voiding diary variables were compared using Student's t-test. RESULTS: Cystoscopic abnormalities were found in 33 patients. The group of patients with cystoscopic abnormalities had significantly more severe frequency (P = 0.034), especially nocturnal frequency (P = 0.009), a significantly lower mean voiding volume and lower sd from the mean (P = 0.011 and P = 0.014), and a significantly lower mean post-voiding NPS score (P = 0.039). CONCLUSION: On analysis of the voiding diaries, we found that different patient profiles were associated with the cystoscopic appearance of the bladder. A clinical voiding score was proposed to predict the cystoscopic appearance of the bladder on the basis of the voiding diary in bladder pain syndrome but needs to be validated on an independent population.

Female urinary incontinence and artificial urinary sphincter: study of efficacy and risk factors for failure and complications.

BACKGROUND: The artificial urinary sphincter (AUS) has become a commonly used therapy for severe urinary incontinence (UI) due to intrinsic sphincter deficiency (ISD). OBJECTIVE: To evaluate retrospectively the efficacy and risk factors for failure and complications of AUS implantation in women with nonneurologic UI. DESIGN, SETTING, AND PARTICIPANTS: From May 1987 to December 2009, 215 women with ISD were treated by AUS implantation, with a mean age of 62.8 yr and a mean follow-up of 6 yr (standard deviation: 5.6 yr). Previous surgical procedures to treat incontinence had been performed in 88.8% of the patients. Urodynamic assessment was required. Patients using only 0 or 1 pad at the end of follow-up were considered continent. The patient's level of satisfaction was evaluated by a global analogue scale and clinical interview. INTERVENTION: All women had AUS implantation. MEASUREMENTS: Patients were evaluated for continence rate, risk factors for failures, and complications. RESULTS AND LIMITATIONS: At the end of follow-up, 158 patients (73.5%) were continent, and 170 (79%) were satisfied. The redo rate was 15.3% after a mean interval of 8.47 yr for the first redo procedure. Fifteen explantations (7%) were performed. The only risk factor for intraoperative complications (10.7%) was smoking (p<0.004). Six patients (2.8%) were lost to follow-up. AUS failed to treat incontinence in 51 patients (23.7%) due to defective manipulation in 27.4% of the cases. On multivariate analysis, risk factors for failure were age >70 yr (odds ratio [OR]: 2.46), a history of the Burch procedure (OR: 2.28), or pelvic radiotherapy (OR: 4.37) (p<0.05). CONCLUSIONS: The place for this safe and long-lasting effective technique in the treatment of UI due to recurrent sphincter deficiency is confirmed. Screening for these risk factors should allow better patient selection.

Functional results after tape removal for chronic pelvic pain following tension-free vaginal tape or transobturator tape.

PURPOSE: The incidence of pelvic pain after placement of a suburethral sling for incontinence ranges between 0% and 30%. The management of this chronic pain after suburethral sling placement is complex and to our knowledge no consensus has been reached. We evaluated the functional results after removal of the suburethral tape responsible for chronic pelvic pain. MATERIALS AND METHODS: From November 2004 to August 2009, 32 patients undergoing removal of suburethral tape causing chronic pelvic and perineal pain at our department were prospectively followed. Patients were divided according to the type of suburethral sling into the transobturator tape group (15 patients) and the tension-free vaginal (retropubic) tape group (17 patients). In the TVT group tape removal was performed using transperitoneal laparoscopy in every patient. In the TOT group tape removal was performed via a transvaginal approach possibly associated with a unilateral or bilateral incision in the proximal part of the thigh. Pain was evaluated by a visual analogue scale from 0-no pain to 10-maximal pain. RESULTS: The surgical exploration of suburethral tape responsible for chronic, treatment refractory pelvic pain revealed in most cases an abnormal tape position or excessive tape traction. In the overall population tape removal provided improvement of pain (at least 50% improvement of the visual analogue scale score) in 68% with a mean followup of 10 months. Mean visual analogue scale score was 7.3 +/- 1.5 before surgery and 3.4 +/- 3 after surgery. However, recurrence of incontinence was observed in 22% of cases. No significant difference was demonstrated in terms of functional results according to the type of tape insertion. CONCLUSIONS: The surgical removal of suburethral tape improved pain in 68% of patients but with a risk of recurrence of urinary incontinence in 22%.

[Oncological results of renal cancer with inferior vena cava thrombosis after nephrectomy]. / Résultats de la néphrectomie pour cancer du rein avec avec thrombus tumoral dans la veine cave inférieure.

OBJECTIVE: The objective of this study was to evaluate survival and risk of recurrence in patients undergoing nephrectomy with resection of inferior vena cava tumour thrombus in our department. MATERIAL AND METHODS: From June 1991 to March 2003, 40 patients underwent radical nephrectomy with resection of inferior vena cava tumour thrombus. The upper limit of the tumour thrombus was below the hepatic veins in 21 cases (52.5%) and above the hepatic veins in 19 cases (47.5%), with thrombus in the right atrium in 6 cases (15%). Cardiopulmonary bypass (CPB) was used in 12 patients (30%) RESULTS: With a mean follow-up of 28.5 +/- 36.8 months (range: 0-150), 22 patients (55%) have died. The 2- and 5-year overall survival rates were 45.2% and 38. 7%, respectively. Local and/or metastatic recurrence was observed in 28 patients (70%) after a mean interval of 18 +/- 22.9 months (range: 1-104). Patients with tumour thrombus derived from the left kidney had a higher local recurrence rate than patients with thrombus derived from the right kidney (p = 0.0194). The 2- and 5-year recurrence-free survival rates were 28.3% and 8.9%, respectively. Only stage pN had a statistically significant prognostic value on overall survival, but not on recurrence-free survival. At the end of the study, only 1 patient (2.5%) can be considered to be cured with no disease progression with a sufficient follow-up (52 months) after nephrectomy. CONCLUSION: Nephrectomy with resection of tumour thrombus from the inferior vena cava provides a gain in terms of medium-term survival, but the majority of patients are not cured by this major surgery. Only lymph node status has a prognostic value.

[Morbidity and mortality of renal cancer with inferior vena cava extention according to various types of surgical management]. / Morbidité et mortalité des cancers du rein avec thrombus tumoral dans la veine cave inférieure en fonction du type de la prise en charge chirurgicale.

OBJECTIVE: The objective of this study was to evaluate the mortality and morbidity of patients operated for renal cancer with inferior vena cava extension according to the surgical management and the upper limit of the tumour thrombus. underwent radical nephrectomy with resection of neoplastic venous thrombus extending into the inferior vena cava. The upper limit of the tumour thrombus was below the hepatic veins in 21 cases (52.5%) and above the hepatic veins in 19 cases (47.50%) with invasion of the right atrium in 6 cases (150). RESULTS: Cardiopulmonary bypass (CPB) was used in 12 patients (30%). The transfusion rate was 87.5%. In the group of 19 patients with thrombus extending above the hepatic veins, the transfusion rate was lower in patients operated by CPB (p=0.008). Intraoperative embolism occurred in 3 patients (7.5%): 2 cases of thrombotic embolism and 1 case of gas embolism, always in patients operated without CPB. The early mortality was 7.5% from haemorrhagic complications. The early morbidity was 47.5%. No significant difference was observed between groups of patients operated with or without CPB in terms of morbidity (p=0.836) or mortality (p=0.896). CONCLUSION: The management of patients with renal cancer and inferior vena cava extension is complicated and requires a multidisciplinary approach. Patients operated under CPB for tumours extending above the hepatic veins have a lower transfusion rate and a lower embolic complication rate with no increase of mortality and morbidity.

Surgical care, morbidity, mortality and follow-up after nephrectomy for renal cancer with extension of tumor thrombus into the inferior vena cava: retrospective study since 1990s.

OBJECTIVES: The aim of our survey was to evaluate surgical care, morbidity, mortality and follow-up of patients who had undergone surgical exeresis of a renal cancer with extension of tumor thrombus into the inferior vena cava. PATIENTS AND METHODS: Between June 1991 and March 2003, 40 (5.4%) patients were operated on for an enlarged nephrectomy with thrombectomy. The upper limit of the tumor thrombus was below the sus-hepatic veins in 21 (52.5%) patients and above the sus-hepatic veins in 19 (47.5%) patients with six (15%) located in the right atrium. RESULTS: Cardiopulmonary bypass (CPB) was used for 12 patients (30%). A per-operative embolism was noted for three (7.5%) patients: two cases of cruoric embolism and one case of gaseous embolism, systematically occurring in patients operated on without CPB. Early mortality was 7.5% (three patients) attributable to hemorrhagic complications. Overall survival at 2 and 5 years was 45.2% and 38.7%, respectively. Disease-free survival at 2 and 5 years was 28.3% and 8.9% respectively. Only the pN stage had a statistically significant prognosis value for overall survival but not for disease-free survival. At the end of the study, only one (2.5%) patient could be considered free of the disease with sufficient follow-up after the surgery. CONCLUSION: Patients with renal cancer and tumor extension in the inferior vena cava need multidisciplinary cooperation to adapt a good surgical strategy, particularly with the use of CPB. However, the rate of patients free of disease after such surgery was low.

[Therapeutic management of ureteric strictures in renal transplantation]. / Prise en charge thérapeutique des sténoses urétérales en transplantation rénale.

OBJECTIVE: Ureteric strictures, with a reported incidence ranging from 2% to 7.5%, are the most frequent urological complication of renal transplantation. This article reports the results of open surgery and percutaneous or endoscopic techniques used to treat these strictures, based on a single-centre retrospective series of renal transplantations. PATIENTS AND METHODS: From January 1990 to December 2002, in a series of 1787 consecutive renal transplantations performed in our centre, 74 were complicated by ureteric stricture (4.1% of cases). Strictures occurred at the ureterovesical implantation in 82.4% of cases and during the first year in 88% of cases. The mean time to management of the stricture after transplantation was 9 months (range: 6 days-120 months). Criteria of success were defined by regression or even resolution of ultrasound signs of dilatation associated with stabilization of serum creatinine obtained by the external urinary diversion. Surgical or percutaneous revisions (particularly repeated changes of double J stents) were considered to be treatment failures. RESULTS: 44 strictures (59.5% of cases) were treated by open surgery and 30 (40.5%) were treated by a first-line endoscopic or percutaneous technique. In our hands, open surgical techniques (ureteropelvic anastomosis: 80% of success (n=5), ureterovesical reimplantation: 82% of success (n=11), ureteroureteric anastomosis: 100% of success (n=4)) gave better results than endourological techniques (endoscopic electrical incision: 61.5% of success (n=13), double J stent: 61.5% of success (n=13), balloon catheter dilatation: no success (n=4)). CONCLUSION: Classical open surgical revision remains the reference treatment for ureteric strictures in renal transplantation for our team.

[Complications of Bricker ileal conduit urinary diversion: analysis of a series of 246 patients]. / Complications des urétérostomies cutanées trans-iléales selon Bricker. Analyse d'une série de 246 patients.

OBJECTIVE: The objective of this retrospective study was to evaluate the mortality and early and late morbidities of Bricker ileal conduit urinary diversion. PATIENTS AND METHODS: Between January 1990 and December 2002, 246 Bricker ileal conduit urinary diversion was performed in our centre in 164 males (67%) and 82 females (33%) with a mean age of 64 years (range: 9 to 90 years). Bricker diversion was performed in 73.6% of cases for underlying tumour (prostate, bladder, cervical, colon cancer), and in 26.4% of cases for benign disease (neurogenic bladder radiation bladder bladder exstrophy, incrusting cystitis). Cystectomy was associated with Bricker diversion in 62.2% of cases. The mean follow-up was 24 months (range: 1 to 151 months). The following parameters were studied: mortality and early and late medical or surgical, urological and gastrointestinal complications. RESULTS: The postoperative mortality was 6.9% (17 deaths, 16 in patients in whom Bricker diversion was performed for cancer). The early morbidity was marked by gastrointestinal complications (ileus, fistula, evisceration) in 46 cases (1.7%), 25 of which required re-operation. A medical complication was observed in 41 patients (16.7% of the series), responsible for 60% of the postoperative mortality (10 of the 17 deaths). A urinary fistula was observed in 7 patients (2.8%). The late morbidity consisted of parietal complications (incisional hernia, peristomal hernia, stricture of the stoma) in 18.3% of cases. Urological complications consisted of acute pyelonephritis (11%), ureteroileal stricture (4.9%) and urinary stones (4.9%). CONCLUSION: Bricker ileal conduit urinary diversion is associated with considerable mortality, especially in cancer patients. Early complications are essentially gastrointestinal, while late complications tend to be parietal or urological.

[Ventriculo-ureteric shunt without associated nephrectomy for the treatment of hydrocephalus]. / Dérivation ventriculo-urétérale sans néphrectomie associée pour hydrocéphalie.

The authors report the case of a 51-year-old patient with hydrocephalus following posterior fossa surgery (cerebellar astrocytoma) treated by ventriculo-peritoneal shunt, then ventriculo-atrial shunt. After repeated valve revisions (diffuse peritoneal loculation, intracardiac thrombus responsible for dyspnoea and recurrent pulmonary embolism, shunt infections), another mode of shunting was required. The authors opted for ventriculo-ureteric shunt comprising ureteric reimplantation into a psoas bladder, without associated nephrectomy, which appears to constitute an alternative in the case of difficult surgical management of hydrocephalus or after failure of other modes of ventricular shunting.

[Mixed epithelial and stromal tumour of the kidney]. / Tumeur mixte epithéliale et stromale du rein.

The authors report the case of a patient with mixed epithelial and stromal tumour, a rare, recently described entity, as only 40 cases have been reported, mixed epithelial and stromal tumours are essentially observed in women during the perimenopausal period with a history of treatment with oestrogen-progestogens or gynaecological surgery. No clinical or radiological arguments can differentiate these tumours from other renal tumours. Histological examination reveals a tumour with an epithelial component and a stromal component presenting the characteristics of ovarian stroma and expressing oestrogen and progesterone receptors. The prognosis of these tumours is usually very favourable, although caution is advised in view of the limited number of published cases and a recent report of a malignant case.