[Vertebral osteoporosis induced by corticoids and cyclosporine ina a patient with Still disease]. / Osteoporosis vertebral inducida por corticoides y ciclosporina en una paciente con enfermedad de Still.

We report on a 29-year-old patient who received high doses of prednisone and cyclosporine for the treatment of Still disease. She consulted about dorsolumbar pain leading to physical disability. She presented multiple vertebral fractures, decreased lumbar bone mineral density in the rank of osteoporosis, high bone turnover, and associated hypercalciuria. Cyclosporine and corticoids induced severe changes in bone and mineral metabolism. All patients in treatment with these drugs should undergo radiology, bone densitometry and biochemical determinations of mineral metabolism at the beginning of therapy. Treatment with high doses of intravenous pamidronate (225 mg in 3 months), calcitonin (200/400 IU daily), tiazide (25 mg/daily), and kinesiotherapy mitigated the pain quickly and she recovered motility. We discuss this approach of treating osteoporosis with corticoids and immunosuppressors according to the present knowledge of bone biology.

[Perineoscrotal gangrene: report of 51 cases. Diagnostic and therapeutic features]. / Gangrène périnéoscrotale: à propos de 51 cas. Aspects diagnostiques et thérapeutiques.

OBJECTIVE: To approach the treatment of Fournier's gangrene. So, pathophysiology and etiology are recalled. METHODS: The authors present 51 cases of Fournier's gangrene treated from 1989 to 1998, their age ranged from 19 to 89 years. Data were collected on admission signs and symptoms, physical examination. Aggressive surgical debridement of all necrotic tissues was performed, Intravenous antibiotics and resuscitation fluid were also administered. RESULTS: All patients were male. In 20 cases (39%), there was no identifiable cause, and in 31 cases (61%), the etiology of gangrene was urethral (33%), anorectal (28%) and unknown (19%). The average hospital stay was 30 days. Three cases underwent unilateral orchidectomy, six colostomy and in 17 cases, a suprapubic catheter was inserted. Mortality was high (18%) and essentially associated to debilated state and toxi-infectious context. CONCLUSION: Fournier's gangrene is a true urologic emergency potential lethal, which requires aggressive antibiotic and surgical treatment.

[Role of ureteroscopy in the treatment of lithiasis of the pelvic ureter. Apropos of 52 cases]. / Place de l'urétéroscopie dans le traitement de la lithiase de l'uretère pelvien. A propos de 52 cas.

Between July 1990 and December 1995, 52 patients with lower ureteral calculi were treated by rigid ureteroscopy in the "B" Urology department of Avicenne Hospital. The use of ureteroscopy facilitated Dormia extraction (58%) or ultrasonic lithotripsy fragmentation (17%) or removal of the stone with the two procedures (21%). The overall success rate was 92.3% with a 2% retreatment rate. Complications were rare (3 of 52: 5.8 percent). The mean hospital stay was 3.3 days. Based on our findings, we conclude that rigid ureteroscopy for lower ureteral stone removal is effective with low morbidity and shorter hospital stay.

[Urogenital tuberculosis. Apropos of 40 cases]. / La tuberculose uro-génitale. A propos de 40 cas.

The authors report a series of 40 cases of genitourinary tuberculosis diagnosed and treated in the department of urology "B" of Avicenne hospital over a 7-year period. The objective of this study is to define the various diagnostic and therapeutic aspects of this disease. The patients were predominantly males (62.5%) with a mean age of 40 years. 25% of cases reported a history of extra-urinary tuberculosis. The very polymorphous clinical presentation is dominated by signs of cystitis (45%). Intravenous urography is frequently suggestive of the diagnosis based on the appearance and multiplicity of the lesions. The radiological lesions most frequently encountered were silent kidney (19 cases) and small tuberculous bladder (11 cases). The definitive diagnosis was established by pathological examination in 38 cases (biopsies, operative specimens, prostatic resection chips) and/or by demonstration of AFB in 2 cases (urine, pus). Tuberculostatic treatment was administered to all patients, either alone (5 cases) or, more usually, in combination with surgical and/or endo-urological treatment (35 cases), reflecting the magnitude and severity of the destructive and scar lesions.

[Bladder exstrophy in the adult: therapeutic features. Report of 3 cases]. / L'exstrophie vésicale chez l'adulte: aspects thérapeutiques. A propos de trois cas.

Bladder exstrophy is a malformation which the incidence is estimated at 3.3 per 100,000 births. It is usually treated in the first hours of life. The authors report three cases of bladder exstrophy treated in adult life with continent urinary diversion such as Benchekroun continent ileocaecal bladder (CICB). After a literature review on the management of bladder exstrophy, they studied clinical and therapeutical particularities of the bladder exstrophy in adulthood.

[Psychological, sexual and social aspects of bladder exstrophy in adulthood. Analysis of 3 cases]. / Aspects psychologiques, sexuels et sociaux de l'exstrophie vésicale chez l'adulte. Analyse de 3 cas.

Rare congenital malformation, bladder exstrophy is usually treated soon after birth. Based on three cases report of bladder exstrophy in adulthood (two men and one women aged from 21 to 25 years), the authors emphasize the importance of psychological, sexual, and social disorders caused by this affection treated at this age. Urinary problems were excluded of this study. The authors stress the necessity of an early management of this malformation, if possible at birth in order to minimize these consequences.

[Benign prostatic hypertrophy: clinical and therapeutic aspects. Review of 1,280 cases]. / L'hypertrophie bénigne prostatique: aspects cliniques et thérapeutiques. A propos de 1,280 cas opérés.

Between 1989 and 1996, 1,280 patients aged 41 to 100 years were operated for BPH. 70% of patients were treated at the stage of complications such as acute urinary retention, haematuria, bladder stones or renal failure. 549 patients (42.9%) were treated by transvesical prostatectomy (TVP), 668 patients (52.18%) underwent transurethral resection (TURP) and only 63 (4.92%) were treated by bladder neck incision (BNI). Early postoperative complications essentially consisted of infections: wound infection (15%), followed by vesico-cutaneous fistula (2%), epididymo-orchitis (0.7%) and urinary tract infection (1.5%). Late post-operative assessment revealed retrograde ejaculation in 100% of cases after transvesical surgery, 80% of cases after TURP and almost no cases (4%) after BNI. The permanent urinary incontinence rate was 1.18% after TURP and 1.0% after transvesical surgery. The shortest mean postoperative stay was 5 days in the BNI group versus 12.5 days after transvesical surgery. Finally, the postoperative mortality, essentially due to septic shock and myocardial infarction, was (0.8%). The BPH complication rate is proportional to the delay in diagnosis and management. Transurethral resection remains the most effective treatment with the lowest morbidity.

[Major renal trauma: report of 18 cases]. / Les traumatismes rénaux majeurs: à propos de 18 cas.

The authors report a retrospective study concerning 18 patients having major renal trauma. The patients study group was comprised of 11 males (61%) and seven females (39%) with a mean age of 23 years. The etiologic agents were traffic accident (eight cases), falls (five cases) and stab wounds (five cases). Gross hematuria was present in all the patients. After radiologic investigations the renal injuries were classified according to the American Association for Surgery of Trauma. Two patients were in stage V, seven in stage IV and nine in stage III. Three patients were operated in emergency for hemodynamic instability, two had a total nephrectomy and one a partial nephrectomy. Five patients underwent surgery between the 5th and 7th day, three had a suture of the renal parenchyma under a nephrostomy, one a partial nephrectomy and the third a total nephrectomy. Two patients had only a urinary drainage by placement of an ureteral stent in order to diminish the urohematoma. Eight patients were treated conservatively and all were in stage III. The mean retreat was 16 months. There was no mortality and among the eight patients who underwent surgery, none had complications, aside from two wound infections. The patients who were managed conservatively had good progression; they all had a control by computed tomography which showed that the urohematoma had decreased. None of the patients developed hypertension or infection of the urohematoma.

[Complex vesicovaginal fistula. Report of 55 cases]. / Fistules vésicovaginales complexes. A propos de 55 cas.

OBJECTIVE: To specify the clinical and therapeutic peculiarities of complex vesico-vaginal fistulas. MATERIAL AND METHODS: 55 cases of complex vesico-vaginal fistulas are reported. After the clinical diagnostic all the patients had an intravenous excretory urogram. The fistulas were classified according to the Benchekroun classification. RESULTS: The mean age was 34 years (17-70 years). The diagnostic was made clinically in all the patients. Thirteen patients had an abnormal intravenous excretory urogram. The treatment was made by a vaginal way in 45 patients, by an abdominal way in three patients and by a mixed way in two patients. Four patients had an urinary diversion and one refused the treatment. Among the 50 patients whose fistula was treated, 44 (88%) were continent whom 26 (52%) after one operation, 15 (30%) after two operations and three (6%) after three operations. CONCLUSION: The complex vesico-vaginal fistulas as all the vesico-vaginal fistulas are diagnosed clinically. The intravenous excretory urogram is indispensable to search an associated ureteral lesion. The treatment is surgical and usually needs the interposition of a vascularised graft.

[Hepatitis C viruses antibodies. Prevalence and their influence on morbidity-mortality in renal transplant recipients, in the last two years of the kidney transplantation program in La Plata city]. / Anticuerpos contra el Virus de la Hepatitis C--anti HCV. Prevalencia e influencia sobre la morbimortalidad en los pacientes sometidos a trasplante renal, en los dos ultimos años del programa de trasplante renal de la ciudad de La Plata.

UNLABELLED: A small series of 34 renal transplanted patients (RTx) were studied, 18 males and 16 females in order to know the prevalence of Anti HCV in this type of patients and their influence on early morbi-mortality. The follow-up mean was 8.44 months SD 6.7, and Age 38.32 SD 13.97. All patients were under the same immunosuppressive scheme, and rejection episodes were treated with methilprednisolone pulses. The results were: 7 (20.6%) Anti HCV seroreactives (R) (EIA II Abbott and Immunoblotting of synthetic Peptides LIA TEK Organon Teknika); and 27 (79.4%) non-serorectives (NR), 14 patients received grafts from cadaveric donor; 4 (57.1%) Anti HCV (R), and 10 (37.0%) Anti HCV (NR). 20 patients have received grafts from lived-related donors: 3 (42.9%) Anti HCV (R), and 17 (63.0%) Anti HCV (NR). 6 (85.7%) of the 7 patients Anti HCV (R) had hepatitis history: 2 chronic hepatitis, 4 acute hepatitis (2HBV) and 2 no A no B (NANBV) and 6 (22.2%) of the 27 Anti HCV (NR). The mean time of hemodialysis treatment before transplantation in the Anti HCV (R) group was of 63.0 months SD27.0, and it was significantly superior (P < 0.05) to the Anti HCV (NR) group with 27.3 months SD 20.7. There were no significant differences between the Anti HCV (R) and (NR) patients with regard to rejection episodes, post-transplant hepatopathies, and survival of graft and patient. CONCLUSIONS: 1) Anti HCV prevalence is of 20.6%. 2) Time of hemodialysis prior to transplantation and an hepatitis history during hemodialysis came out to be significantly higher in Anti HCV (R) RTx. 3) Morbi-mortality is no modified by the presence of Anti HCV during a mean follow-up period of 8.44 months.

[The York Manson approach in the treatment of prostato-rectal fistulae]. / La voie de York Mason dans le traitement des fistules prostato-rectales.

The York Mason approach appears to be one of the most suitable techniques for the treatment of prostato-rectal fistulas, as it provides a maximum chance of success with no morbidity, as no cases of anal incontinence have been reported to date. The authors report a case of prostato-rectal fistula secondary to transurethral resection of the prostate for benign prostatic hyperplasia treated by the YORK MASON posterior trans-anosphincteric approach.

[Urogenital tuberculosis. Experience in 10 years]. / Tuberculose uro-génitale. Expérience de 10 ans.

OBJECTIVE: To review the clinical, imaging and therapeutic aspects of urogenital tuberculosis. MATERIAL AND METHODS: From April 1989 to April 1999, 57 patients with urogenital tuberculosis were reviewed in our department. This series consisted of 32 males and 25 females with a mean age of 40 years (range: 18 to 72 years). RESULTS: The most frequent clinical symptoms were irritative symptoms (47.3%). Fever, anorexia and weight loss were rare (11%). 16% of patients had an isolated genital lesion. 14% presented with renal failure (mean serum creatinine: 18 mg/l). Only 3 cases (5.2%) presented with bacilluria. Urography showed abnormalities in 80% of cases. The most frequent abnormality was a non-functioning silent kidney in 23 cases (40.3%). The positive diagnosis was based on bacteriological (5 cases) and histological data (52 cases). Treatment consisted of antituberculous chemotherapy in all patients, in combination with surgery (75%), and/or endourological procedures (26.3%). Nephrectomy is still indicated for non-functioning tuberculous kidneys in order to prevent the development of hypertension, abscess and fistulas. CONCLUSION: The diagnosis of urogenital tuberculosis is difficult and often late. A surgical or endourological procedure is often necessary to preserve renal function and to improve quality of life.

[Prostatic leiomyosarcoma (report of 2 cases)]. / Léiomyosarcome prostatique (à propos de deux cas).

The authors report 2 cases of prostatic leiomyosarcoma. The first patient was not operated because of a severely debilitated state and died a fortnight after admission to hospital. The second patient underwent cystoprostatectomy with ilio-obturator lymph node dissection. Resection margins and lymph node dissection were negative and no further treatment was required. With a 10-year follow-up, the clinical and radiological assessment was normal. The diagnostic and therapeutic aspects of this rare prostatic tumour are discusses.

[Ureteral replacement with non-modelled isoperistaltic ileoplasty]. / Remplacement urétéral par iléoplastie isopéristaltique non modelée.

OBJECTIVES: To study the long-term morbidity and efficacy of ureteroileoplasty in a retrospective series of 18 patients. MATERIALS AND METHODS: 12 men and 6 women with a mean age of 50 years underwent ureteroileoplasty with unilateral replacement in 15 patients and bilateral replacement in 3 patients. A total of 21 units renoureteral units were repaired by this technique. The pelvic ureter was replaced in 16 renoureteral units, the lumbar ureter was replaced in 1 case and the entire ureter was replaced in 4 cases. The commonest ureteral lesions were strictures secondary to ureteroscopy or ureterolithotomy (40%). All patients had normal renal function, except for one patient with serum creatinine of 224 mumol/l. RESULTS: With a mean follow-up of 25 months (range: 3 to 64 months) all ureteroileoplasties were patent with no major morbidity. Only the patient with preoperative renal failure developed hyperchloraemic acidosis with deterioration of her renal function. CONCLUSION: In the absence of renal failure, ureteroileoplasty is an operation with low morbidity achieving good medium-term results.

[Treatment of urethro-rectal fistulas. Apropos of 5 cases]. / Traitement des fistules uréthro-rectales. A propos de 5 cas.

Urethro-rectal fistulas, consisting of prostato-rectal fistulas and fistulas communicating between the bulbo-membranous urethra and the rectum, are rare, easily diagnosed diseases, which essentially raise a problem of choice of surgical technique. Although the predominant aetiology is currently iatrogenic, many other less frequent aetiologies can also be responsible. Treatment is usually surgical with a large number of possible incisions. In the light of 5 cases, the authors review the various surgical techniques allowing cure of these fistulas, and indicate the advantages and disadvantages or each one.

[Vesico-uterine fistula. Report of 10 cases]. / Fistules vésico-utérines. A propos de dix observations.

OBJECTIVE: To study the aetiopathogenics, diagnostic and therapeutic aspects of this pathology. MATERIALS AND METHODS: The authors report a series of 10 vesico-uterine fistulas observed over à 10 years period. The mean age was 32 years(30-40). The fistulas were secondary to cesarian section in 6 cases and to abnormal delivery in 4 cases. The symptomatology was an urinary leakage from the vagina in 6 cases, an isolated cyclic hematuria in 3 cases and the association of the two signs in one case. The diagnostic was established on clinical examination in 8 cases. Intraveinous urography was performed in all the patients and visualised the uterine cavity in only 8 cases. In the 2 remaining cases a retrograd cystography was performed and demonstrated the opacification of the uterine cavity. The treatment was surgical in 9 cases. One patient who had a menuria has refused the operation. RESULTS: The diagnostic of the vesico-uterine fistulas is often based on clinic examination but often necessitate recourse to complementary examinations mostly in the menouria forms. The intraveinous urography does not establish the diagnostic in all the cases but is an indispensable complementary investigation because it permits searching for an associated ureteral injury. With a mean recoil of one year the results judged on the disappearance of the clinic signs was good in all the patients. CONCLUSION: The vesico-uterine fistulas are often secondary to cesarian section or abnormal delivery. Their treatment is surgical but is above all preventive by the improvement of the obstetric taking care and avoiding the vesical injuries in the course of the cesarian section.

Carcinoma medular de tiroides: estudio multicéntrico. Presentación y evolución en 219 pacientes / Medullary Thyroid Carcinoma: Clinical Presentation and Outcome in 219 Patients

Ante la baja frecuencia del carcinoma medular de tiroides (CMT), en el Departamento de Tiroides de SAEM nos propusimos realizar un estudio de cohorte, observacional, retrospectivo y multicéntrico. Se incluyeron 219 pacientes con diagnóstico histológico de CMT. El 65 % fueron mujeres, la edad promedio fue de 39 ± 20 años (1 a 84 años); 44-% de los casos fueron familiares. Las formas de presentación más frecuentes fueron nódulo tiroideo (58 %) y pesquisa genética por antecedente familiar (22 %). Si bien la citología tiroidea fue diagnóstica de CMT en el 39 % de los casos, fue determinante de indicación quirúrgica en el 79 %. En el 47 % de los pacientes el diagnóstico de CMT se obtuvo previamente al tratamiento quirúrgico inicial por punción aspiración con aguja fina (PAAF), estudio genético o nivel de calcitonina (CT)). El 65 % se presentó en estadios avanzados (TNM III y IV). El estudio del protoncogen RET se realizó en 162 pacientes (74 %). En el 49 % se observó mutación siendo la más frecuente (76 %) en el codón 634. La forma hereditaria más frecuentemente observada fue el síndrome de neoplasia endocrina múltiple (NEM) 2A (57 % de los casos familiares), seguida por carcinoma medular familiar (25 %) y NEM 2B (13 %). Los casos familiares tuvieron menor edad al diagnóstico y mayor frecuencia de diagnóstico prequirúrgico. Los casos índice tuvieron mayor edad al momento del diagnóstico, mayores niveles de antígeno carcinoembrionario (CEA) y CT prequirúrgicos, mayor proporción de estadios III y IV y mayor porcentaje de evidencia de enfermedad al momento de la última consulta que aquellos detectados por pesquisa. En 143 pacientes (65 %) se obtuvieron registros completos de seguimiento en los que se analizaron los factores relacionados con la evolución. La mediana de seguimiento fue de 44 meses: fallecieron 21 pacientes (14,6 %) y 122 (86 %) viven; 76 de estos (54 %) se encuentran libres de enfermedad. El grupo con evidencia de enfermedad se presentó en estadios más avanzados. Resultaron factores de mayor riesgo para evidencia de enfermedad: sexo masculino, CMT esporádico, niveles elevados de CT prequirúrgicos, estadio IV y presencia de metástasis. Los niveles de CT posquirúrgicos fueron menores en aquellos pacientes que en la evolución final no presentaron evidencia de enfermedad. El principal factor pronóstico de la evolución de los pacientes con CMT fue el estadio de presentación, determinando la importancia del diagnóstico precoz con el fin de poder implementar un tratamiento quirúrgico curativo en estadios menos avanzados.(AU)

Due to the low frequency of medullary thyroid cancer (MTC), an observational, cohort, retrospective multicenter study was conducted at the Thyroid Department of the Endocrine and Metabolism Argentine Society (SAEM). We included 219 patients with histologically proven MTC, with a mean age of 39 ± 20 yr (range 1-84 years). Sixty five percent were women and 44% were familial cases. The most common presentations were thyroid nodule (58 %) and genetic screening due to family history (22 %). In 39 % of patients, diagnosis of MTC was made by fine needle aspiration, but cytology led to surgery in 79 %. In 47 % of patients, MTC was diagnosed by cytology, calcitonin (CT) levels or genetic studies prior to initial surgery. Sixty five percent of patients had advanced stages of the disease (TNM III or IV) at diagnosis. Proto-oncogene RET was studied in 162 patients (74 %). In 49% a mutation was reported, most frequently in codon 634 (76 %). Regarding hereditary forms of MTC, MEN 2A was the most frequent (57%), followed by familial MTC in 25 % and MEN 2B in 13 % of cases. Familial cases were younger subjects and had more frequently a pre-surgery diagnosis. Index cases were older, with higher CEA and CT levels, presented in more advanced stages and had more frequently evidence of disease at final assessment than patients who were diagnosed by genetic screening. Follow-up records of 143 patients were analyzed (65%); median time was 44 months; 21 patients died (14.6 %) and 122 survived (86 %), 76 showed no evidence of disease (NED) (54 %). High risk factors for evidence of disease at the final evaluation were: male gender, sporadic MTC, higher CT pre-surgery levels, stage IV and metastasis. Post surgery CT levels were lower in patients with NED. Stage at initial diagnosis was the main prognostic factor in patients with MTC, determining the importance of early detection for performing curative surgery in less advanced stages.(AU)