[Knowledge, attitude and perception about obstetric fistula by Cameroonian women]. / Connaissance, attitude et perception vis-à-vis des fistules obstétricales par les femmes camerounaises Une enquête clinique conduite à Maroua, capitale de la province de l'extrême Nord du Cameroun.

INTRODUCTION: This study seeks to identify what the women who live in Maroua Cameroon know and think about obstetric fistula. POPULATION AND METHOD: It is a single hospital, cross-sectional, descriptive and comparative study. Ninety-nine women in the maternity service of the Maroua Provincial Hospital were interrogated on obstetric fistula between May and July 2005, by enquirers who were trained health agents using a questionnaire which required both closed and open answers. RESULTS: The women who had no previous knowledge of it were generally the illiterate (41.7% compared to 18.8%). More than a third of the women who had an idea of the fistula do not know that there is a surgical treatment for it. Whether they had the previous information on fistula or received it from us, one-tenth of the women suggested that suicide was the solution to fistula where as one-third of the women suggested that a patient suffering from fistula should be isolated. CONCLUSION AND INTERPRETATION: Illiteracy contributes significantly to the lack of knowledge of this affection. The population has a poor perception and a strong negative attitude towards obstetric fistula as they see isolation or suicide as the solution to it.

Analysis of p53 antibodies in patients with various cancers define B-cell epitopes of human p53: distribution on primary structure and exposure on protein surface.

p53 antibodies have been found in sera of patients with breast and lung carcinomas and in children with B-lymphomas. We report here the presence of p53 antibodies in sera of patients with 11 different types of cancer. The frequency of seropositives for p53 varied among the different types of cancer, but a correlation with the frequency of p53 gene alteration was established. Using a powerful peptide enzyme-linked immunosorbent assay, we demonstrated that the immune response of patients with p53 antibodies was restricted to a small subset of peptides localized in the amino and carboxy termini of p53, whatever the type of cancer. Given the similarities of the patterns of immune responses in patients with p53 antibodies and animals hyperimmunized with human p53, we propose that the p53 humoral response is the result of a self-immunization process which is itself the consequence of p53 protein accumulation in tumor cells.

Accumulation of 5 alpha-reduced androgen glucosiduronates associated with impaired removal in young male hemodialysis patients.

Hypothalamic-pituitary gonadal function is commonly altered in dialysis patients. Even though an improvement in general status and well-being has been noted after recombinant human erythropoietin supplementation, no significant changes were observed in the sex hormone profile. Pituitary gonadal axis as well as 5 alpha-reduced androgen glucosiduronates (i.e. 5 alpha-androstane,3 alpha,17 beta-diol and androsterone) profiles were studied in 23 young male stable dialyzed patients and compared to an age-matched group of healthy subjects. 5 alpha-Reduced androgen glucosiduronates are products of peripheral testosterone (T) metabolism and seem to be a useful tool in assessment of the male androgen status. Their polarity facilitates their urinary excretion, and their clearance is similar to the glomerular filtration rate in healthy men. We observed 1) a pituitary-Leydig cell dysfunction supported by normal serum estradiol and T levels, low free T, and increased LH levels; 2) an alteration of the dehydroepiandrosterone (DHEA) sulfate-DHEA interconversion, reflected by a dramatic decrease in DHEA while DHEA sulfate levels remained in the normal range; 3) an accumulation of 5 alpha-reduced androgen glucosiduronates, whose removal was impaired as shown by their very low sieving coefficients (< 0.012). Taken together, the above observations are consistent with alteration of spermatogenesis with respect to dialysis duration in which earlier elevated baseline serum LH levels indicate a primary defect in Leydig cell function.

Percentage of free serum prostate-specific antigen: a new tool in the early diagnosis of prostatic cancer.

Prostate-specific antigen (PSA) is a protease able to bind to serum antiproteases as alpha 1 antichymotrypsin (ACT). Free PSA (FPSA) corresponds to the fraction of total PSA (TPSA) which is unbound to ACT. Specific detection of the FPSA seems to be a valuable tool in the distinction between prostatic cancer (PCa) and benign prostatic hyperplasia (BPH). Our aim was to evaluate retrospectively the FPSA/TPSA ratio in comparison to TPSA or FPSA determination, using two new immunoradiometric assays (PSA-RIACT and FPSA-RIACT, CIS bio international, Gif Sur Yvette, France) in the early diagnosis of PCa. 256 men, with TPSA levels between 0.7 and 44.7 ng/ml (median age = 69 years), including 164 sera obtained from patients with BPH and 92 sera from patients with untreated PCa were assayed. All diagnoses were histologically confirmed and patients tested before any adjuvant treatment. The evaluation of the median FPSA/TPSA ratio in the two groups showed significantly different values (BPH group: 24.2%, PCa group: 12.1%, P < 0.0001). By R.O.C. (Receiver-Operating-Characteristics) analysis, we show that the FPSA/TPSA ratio is the method of choice for discriminating BPH and PCa, since the area under curve is the greatest for the FPSA/TPSA ratio curve, as compared to the TPSA or FPSA curves (P < 0.0001). The best accuracy (number of true positive + true negative/total = 82.4%) was obtained with a FPSA/TPSA ratio < or = 15% with high odds ratio (20.5; confidence interval (CI): 11.2; 37.7). Of interest, similar results were also confirmed even in the subpopulation with serum TPSA levels between 2.5 and 10 ng/ml (161 patients including 99 BPH and 62 PCa). We thus confirm that combined serum measurement of FPSA and TPSA is of particular interest in the early diagnosis of PCa for patients with non-suspicious digital rectal examination and a TPSA value between 2.5 and 10 ng/ml. In those patients, biopsy should be reserved to the cases with FPSA/TPSA below 15%, which allows significant odds ratio (12.8; CI: 5.2; 31.4). Otherwise, to avoid the risk of missing any PCa, usual follow-up with combined TPSA and FPSA determination would be required with the same criteria of biopsy (i.e. FPSA/TPSA ratio < or = 15% when TPSA value is between 2.5 and 10 ng/ml; or TPSA > 10 ng/ml).

The role of laser-induced autofluorescence spectroscopy in bladder tumor detection. Dependence on the excitation wavelength.

We assessed the ability of laser-induced autofluorescence spectroscopy to distinguish neoplastic urothelial bladder lesions from normal or nonspecific inflammatory mucosa. Three different pulsed laser excitation wavelengths were used successively: 308 nm (xenium chloride excimer laser), 337 nm (nitrogen laser) and 480 nm (coumarin dye laser). The excitation light was delivered by a specially devised multifiber catheter connected to a 1-mm core diameter silica monofiber introduced through the working channel of a standard cystoscope with saline irrigation. The captured fluorescence light was focused onto an optical multichannel analyzer detection system. Performance of this device was evaluated in 25 patients after obtaining consent and immediately before transurethral resection of a bladder tumor. Spectroscopic results were compared with histological findings. At 337- and 480-nm excitation wavelengths, the overall fluorescence intensity of bladder tumors was clearly decreased compared to normal urothelial mucosa regardless of tumor stage and grade. At the 308-nm excitation wavelength, the shape of the tumor spectra, including carcinoma in situ, was markedly different from that of normal or nonspecific inflammatory mucosa. No absolute intensity determinations were required in this situation, since a definite diagnosis could be established based on the fluorescence intensity ratio at 360 and 440 nm. This spectroscopic study could be particularly useful in designing a simplified autofluorescence imaging device for detection of occult urothelial neoplasms.

Intraoperative localization of renal calculi by real-time ultrasonography.

Experimental and intraoperative experiences in ultrasonographic localization of calculi are reported. With a small high-resolution real-time probe, we localized 1-mm calculi introduced in ex situ cadaver kidneys. During 13 operations all calculi of various sizes and nature were localized 11 times. This method seems to have many advantages: it is easy to use, it localizes calcific and noncalcific small calculi bidimensionally, and it shortens operative time.

Correlations between radiography, ultrasonography, computed tomography and pathologic findings in prostatic disease.

A total of 20 macroscopically normal or hypertropic prostates were taken from cadavers of men older than fifty, who died of causes other than urologic ones. The samples were studied in vitro by nonscreen x-ray films, ultrasonography, computed tomography, and then by a pathologist. There were 4 normal prostates, 12 with benign prostatic hypertrophy, 3 with carcinoma, and 1 with prostatitis. Conventional radiography which showed only prostatic calcifications was of no pathologic interest. Computed tomography is by no means of diagnostic use in distinguishing between benign prostatic hypertrophy and carcinoma, and should be used only as an alternative in the evaluation of regional extension of prostatic carcinoma. On the other hand, ultrasonography appears to be sensitive to detection of very small nonpalpable nodules. However, its specificity is poor and its use should be restricted as a guide in obtaining biopsy specimens or as a means of evaluating tumor volume.

An experimental model of bulbar urethral stricture in rabbits using endoscopic radiofrequency coagulation.

OBJECTIVES: To develop an experimental model of endoscopic urethral stricture mimicking the human clinical situation. METHODS: Twenty-four New Zealand male rabbits were included. Eighteen animals (study group) underwent videourethroscopy with a pediatric resectoscope, and a 3 to 5-mm-long circumferential electrocoagulation of the bulbar urethra was performed, without postoperative urinary diversion. Six animals underwent the same procedure without application of electrocautery (control group). Each animal was assessed for urethral stricture on day 15 and day 30 by videourethroscopy and voiding cystogram. Among the study group, 8 animals were killed on day 15 and 10 on day 30 for histologic evaluation. All the control animals were killed on day 30 for histologic examination. RESULTS: Nine animals (50%) in the study group developed a significant bulbar stricture (reducing the lumen by more than 50%) at day 15. Histologic examination confirmed the presence of hyalin fibrosis mutilating the urethral wall. No spontaneous improvement of the stricture was observed on day 30. None of the controls developed urethral stricture, and histologic examination showed a normal urethra in each case. CONCLUSIONS: Endoscopic electrocoagulation of the urethral wall provides a reproducible model of stricture in the rabbit.

Hand-assisted laparoscopic live donor nephrectomy in a patient with renal artery aneurysm.

Among the transplantation teams there is an increasing interest in laparoscopic live donor nephrectomy. For technical reasons, the use of the left kidney is recommended. However, considering the shortage of organ donors, it is likely that right-side laparoscopic live donor nephrectomy will need to be considered in selected donors, even those with vascular anomalies. Here we report the first case of right-side live donor laparoscopic nephrectomy in a patient with a renal artery aneurysm. Arteriography showed a 3-cm saccular aneurysm of the main right renal artery located at the bifurcation of the secondary branches and associated with an inferior polar artery coming directly from the aorta. The patient was placed in the lumbotomy position. An 8-cm midline incision was made above the umbilicus to insert the HandPort system (Smith & Nephew S.A., 72019 Le Mans Cedex2, France). Four additional trocars were introduced. Dissection of the renal artery was carried out beyond the level of relieving the aneurysm behind the vena cava. The main and polar arteries were clipped, and the renal vein was stapled. The kidney was removed through the HandPort and perfused cold ex vivo. The warm ischemia time for the kidney was 1 min, and the total operative time was 280 min. Vascular abnomalies were corrected ex vivo. The postoperative course of the donor was uneventful. At 6 months after transplantation, the graft function was normal. The hand-assisted approach is of particular value on the right side where the dissection must be carried out behind the vena cava. The HandPort may save few precious minutes over the sac extraction technique of the standard laparoscopic procedure.

Prostate-specific antigen in prostatic cancer.

In an attempt to establish the value of prostate-specific antigen (PSA) in prostatic cancer, serum PSA measurements were performed in 600 patients, including 75 previously untreated prostatic cancer patients. The mean PSA levels in the benign prostatic hypertrophy (BPH) and cancer groups were highly significantly different, but less difference was found between BPH and localized prostatic cancer. A PSA level above 50 ng/ml was never recorded for BPH, but lower levels can be due to either prostatic cancer or to BPH. Our data suggest that PSA is not a specific marker of prostatic cancer but increased serum PSA levels must draw the physician's attention to the possible presence of prostatic cancer.

Magnetic resonance imaging in patients with penile carcinoma.

The aim of the study was to determine the role of pre-operative magnetic resonance imaging (MRI), with and without contrast enhancement, in patients with penile carcinoma. Nine patients with a penile cancer were studied. The staging of the tumours was performed by clinical examination, MRI and surgery, according to the TNM classification. Six patients had primary tumours, of clinical stage T1 (n = 1) and T2 (n = 5). Three other patients had been previously treated and presented with a local recurrence of clinical stage T2. Surface-coil MRI was performed at 0.5 T with T1 weighted sequences before and after gadolinium-DOTA, and T2 weighted sequences. MRI results were compared with the clinical and surgical findings. T1 weighted sequences did not clearly demonstrate the margins of the tumours. T2 weighted sequences were the more useful in five patients, whereas contrast enhanced T1 weighted sequences allowed better delineation of the lesions in only three patients. Therefore, an imaging protocol should include spin echo T2 weighted sequences. Clinical examination correctly staged six of nine tumours; MRI, seven of nine tumours and the combination of both examinations, eight of nine tumours. MRI provided good evaluation of tumoral invasion into the penile shaft.

Laparoscopic fibrin glue ureteral anastomosis: experimental study in the porcine model.

Laparoscopic suturing is still difficult and time-consuming. The aim of this study, using the porcine model, was to evaluate the feasibility, safety, and efficacy of laparoscopic fibrin glue ureteral anastomosis without stay sutures for approximating the ureteral ends. In five pigs, after bilateral cystoscopic insertion of a 7F ureteral catheter, each upper ureter was laparoscopically dissected free and transected with scissors. The ureteral ends were then approximated with two atraumatic grasping forceps, and the fibrin glue was applied over the anastomotic site using a specially designed catheter (Duplocath). After waiting 5 minutes for the sealant to adhere, the forceps were removed, and the anastomotic site was examined for any early disruption. The ureteral stents were then pulled back to the distal ureter, and retrograde ureteropyelography was accomplished bilaterally in order to assess the immediate patency of the anastomoses. The animals were sacrificed and the ureteral anastomoses surgically removed for histologic examination. The operative time after insertion of the trocars averaged 15 minutes for each anastomosis, and no early disruption was observed after withdrawal of the grasping forceps. Immediate ureteral fluoroscopic patency was achieved in all 10 ureteral anastomoses, without leakage in 8 and with minimal leakage in 2. Histologic examination revealed a mild inflammatory reaction in the serosa with no modifications of the mucosa or the muscularis. Subsequently, two pigs were subjected to the same procedure bilaterally and not sacrificed. These two animals died with enormous urinomas on postoperative days 6 and 8. In each case, the anastomotic site was completely disrupted on one side, while the other side remained grossly patent. However, histologic examination of these latter anastomoses revealed no real coaptation of the ureteral ends, while demonstrating complete eversion of the mucosa. In conclusion, fibrin glue ureteroureterostomies, although easy to accomplish, are not safe enough to be used without stay sutures in laparoscopic surgery.

Experimental study of Wallstent self-expandable metal stent in ureteral implantation.

In regard to the risk of stent obstruction, there are persistent controversies concerning the use of the Wallstent self-expandable metal stents in the ureter. Only a few clinical trials have been published to date, and, from a technical point of view, no success predictors have been identified. In an experimental study using a pig model, we have shown that neither the length of the stent (5 or 10 cm) nor an initial 1-month intubation had any influence on the outcome of the stents. Among the eight implantations studied (four 5-cm and four 10-cm stents), only one 5-cm stent was perfectly patent at 35 days. In all the remaining stents, after 35 or 90 days, constant failure was related to distal narrowing at the edge of the stent, with no difference between the 5- and 10-cm stents or between the intubated and the nonintubated stents. This distal narrowing, probably attributable to a functional discrepancy between an adynamic stented ureter and a normal underlying ureter, demands extreme caution in human applications when the ureter is normally peristaltic.

Ureteral and bladder lesions after ballistic, ultrasonic, electrohydraulic, or laser lithotripsy.

Four techniques of intracorporeal lithotripsy are now available: ballistic, ultrasonic, electrohydraulic, and laser. Their therapeutic efficacies have generally been evaluated and compared, but very few data have been available on their relative risks of iatrogenic trauma to the urothelial wall. We conducted a comparative analysis of this risk by testing the pig ureteral and bladder wall with the EMS Lithoclast, Olympus ultrasonic lithotripter, Walz Lithotron EL 23, and Versa Pulse Ho:YAG Coherent Laser. We measured the number of shockwaves or the energy required to perforate the ureter and bladder by delivering shocks perpendicular to the walls. Ureteral perforation was impossible with the 1.0-mm Lithoclast transducer and the 1.5-mm ultrasound transducer. Perforation was induced after 250 shocks with the 0.8-mm Lithoclast transducer, after 110 shocks with the 3F electrohydraulic electrode, and after 0.02 kJ with the laser. Bladder perforation was impossible with the 2.0-mm Lithoclast device and the 3.4-mm ultrasound transducer but was induced after 0.04 kJ had been delivered with the laser. We evaluated the iatrogenic risk under normal conditions of use by delivering the shocks tangentially to the ureteral wall and perpendicular to the bladder wall. We sacrificed animals on days 0, 1, and 6. The immediate histologic lesions induced by the Lithoclast and the ultrasound lithotripter were similar, consisting of a moderate reduction of the epithelial layers or intraepithelial detachments. Electrohydraulic shocks induced almost complete abrasion of the urothelium, and the laser induced extensive lesions of partial or complete necrosis of the urothelial wall.(ABSTRACT TRUNCATED AT 250 WORDS)

Outcomes of non-self-expandable metal prostheses in strictured human ureter: suggestions for future developments.

The success of metal stents in the urethra led us to implant flexible metal stents unilaterally in the ureter in four patients. Radiographic and endoscopic controls during follow-up showed an obstruction in three cases. We describe the different aspects of these unfavorable outcomes and propose changes to be made in metal stents for use in the upper urinary tract.

Percutaneous implantation of subcutaneous prosthetic ureters: long-term outcome.

PURPOSE: We have used an extra-anatomic subcutaneous alloplastic ureteral replacement initially to bypass ureteral obstruction secondary to advanced pelvic malignancies in patients with a short life expectancy. Following the encouraging preliminary results, our list of indications has broadened to include complex benign ureteral strictures. We herein report the long-term outcome. PATIENTS AND METHODS: A series of 35 subcutaneous prosthetic ureters were implanted percutaneously in 27 patients (19 unilateral and 8 bilateral) to bypass extrinsic ureteral obstructions. The nature of obstruction was neoplastic in 22 patients and benign in 5. A composite prosthesis, consisting of two coaxial tubes--internal pure smooth silicone covered by coiled e-PTFE--has been designed to serve as the ureteral replacement. This tube is inserted percutaneously into the renal pelvis, tunnelled subcutaneously, and introduced through a small suprapubic incision in the bladder. All patients were followed to date or until death from tumor. The mean follow-up was 6.3 months for the deceased patients and 47 months for the surviving ones, the longest follow-up being 84 months. RESULTS: No operative or immediate postoperative deaths were observed. Initial difficulty in placing the prosthesis was encountered in 5 of the 27 patients (19%). Secondary parietal complications occurred in 8.5% of cases (3/35). The prosthetic ureter had to be removed in one patient because of skin erosion. Return to a standard percutaneous nephrostomy was needed in two patients because of local tumor progression with bladder fistulae. Five patients are alive with the prosthesis in place and a follow-up as long as 84 months without encrustation, infection, obstruction, or skin problems and with normally functioning kidneys. CONCLUSION: The subcutaneous urinary diversion using a silicone-PTFE prosthesis is an efficient and minimally invasive way to bypass malignant or complex benign obstructions of the ureters that otherwise would necessitate permanent nephrostomy drainage.

Percutaneous extra-anatomic nephrovesical diversion: preliminary report.

We propose a new approach to total ureteric replacement based on the use of a new spiraled composite tube. This tube is inserted percutaneously into the renal pelvis, then tracked subcutaneously and introduced into the bladder via a short incision. The tube is maintained in place by anchoring its spirals along the subcutaneous tract, and only the two silicone extremities are in continuous contact with the urine. We have used this technique for total replacement of the ureter in one renal transplant patient with a follow-up of 8 months and no complication. A longer follow-up is obviously necessary, but this new, minimally invasive approach, using a newly designed tube, would appear to give a new lease of life to an old, abandoned principle.

Randomized comparison of transurethral electroresection and holmium: YAG laser vaporization for symptomatic benign prostatic hyperplasia.

OBJECTIVE: To evaluate the safety and efficacy of holmium:YAG laser vaporization v transurethral electroresection (TURP) for benign prostatic hyperplasia. PATIENTS AND METHODS: Thirty-six patients were randomized. Two laser procedures (60 to 80 W) were performed for one TURP. Symptom Score, peak flow rate, potency, and ejaculation status were measured at baseline and at 1, 3, 6, and 12 months. RESULTS: The mean operative time was 75 minutes for laser and 56 minutes for TURP (P = 0.0407). With a mean laser energy delivered of 103.6 kJ, hemostasis was satisfactory during vaporization. The mean catheterization time was 1.7 and 2.1 days in the laser and TURP group, respectively. For the laser and TURP groups, the mean AUA Score improved from 20 preoperatively to 7 and from 24.1 to 5, respectively, at 12 months. The mean peak flow increased from 8.4 to 19.5 mL/sec and from 7.6 to 16.8 ml/sec, respectively, at 12 months. These results are not statistically different. No significant initial dysuria occurred. No significant difference between the groups appeared in potency or ejaculatory status during the follow-up. One patient in the laser group (Day 5) and two in the TURP group (2nd and 6th month) had to undergo a second procedure to relieve obstruction. CONCLUSION: Although taking slightly longer to accomplish, holmium:YAG laser vaporization of BPH provides early results very similar to those of TURP with a shorter catheterization time and no initial dysuria or pain.

New experimental model of ureteropelvic junction obstruction allowing easy access for percutaneous surgery.

To assess the usefulness of an experimental model of ureteropelvic junction (UPJ) obstruction designed to facilitate subsequent percutaneous surgery, a right UPJ obstruction was created in 10 pigs by an open retroperitoneal surgical approach. With the pig in the left lateral decubitus position, a 0.038-inch Terumo guidewire was inserted via a 1-cm longitudinal upper-third ureterotomy and advanced up and down so as to bridge the UPJ from the flank to the urogenital opening. A UPJ obstruction was then induced by securing two 2-0 chromic gut ties, separated by an interval of 1 cm, over the Terumo guidewire and a 6F ureteral catheter, which was removed immediately after this procedure. After closure of the ureterotomy, the kidney was anchored horizontally to the muscle wall, and the Terumo guidewire was coiled subcutaneously in the flank and fixed to the urogenital opening. Each pig developed marked hydronephrosis, diagnosed by ultrasonography, after a mean interval of 8.3 days. Retrograde ureteropyelography confirmed this pronounced dilation of the right collecting system above a tight UPJ stricture (mean length 1.17 cm). Subsequent percutaneous access to the UPJ over the Terumo guidewire in the lateral decubitus position was facilitated by the almost-horizontal plane of dilation (mean operating time 14 minutes). Pathologic examination of the UPJ revealed mild periureteral fibrosis, but the muscle layer and urothelium remained normal. We have developed a reliable and reproducible model of secondary UPJ obstruction especially designed for percutaneous surgery. This model should provide a better understanding of current endoscopic techniques such as endopyelotomy and could help to promote new treatment concepts such as percutaneous endoscopic pyeloplasty.

[Genetic alterations in localized cancers of the prostate: identification of a common region of deletion on the chromosome 18q]. / Altérations génétiques dans les cancers localisés de la prostate: identification d'une région commune de délétion sur le chromosome 18q.

Prostate cancer is one of the most common malignancies in men. Few authors have attempted to identify consistent genetic alterations at the molecular level in adenocarcinoma of the prostate, but those most frequently reported are loss of heterozygosity (LOH) involving chromosome arms 8p, 10q, 16q, and 18q and inactivation of the TP53 tumor suppressor gene. In order to determine if alterations frequently found in other adenocarcinomas (breast, ovarian, colorectal), including losses of genetic material from chromosome arms 1p, 3p, 7q, 8p, 11p, 17p, 17q, and 18q, are also involved in prostate cancer, we examined 20 localized early-stage prostate tumors. We detected no mutations of the TP53 gene. Allelic losses were found from 7q (33%), 8p (50%), 10q (20%), and 18q (33%). Furthermore, as the first step toward isolating tumor suppressor genes on 18q, we used six polymorphic markers and identified a small common deleted region between the chromosome 18 centromere and the D18S19 locus.