Staghorn calculi treated by percutaneous nephrolithotomy: risk factors for recurrence.

Since 1985 our primary mode of therapy for staghorn calculi has been by percutaneous nephrolithotomy. Between January 1985 and June 1988 we have treated 57 cases using this method. We reviewed the rate of recurrence at a minimum of one-year follow-up and observed a 17 percent recurrence rate. Factors identified that were associated with an increased rate of recurrence were: positive urine cultures during follow-up (55% recurrence vs 12%); stone remnant greater than 5 mm (27.3% recurrence vs 13.8%); and stone complexity (25% recurrence for complex or complete staghorn vs 9.7% for noncomplex or partial staghorn). By identifying these risk factors we think that stone recurrence can be reduced and, with close follow-up, detected earlier to permit less invasive therapy if needed.

Electromyographic study of bulbocavernosus muscle in 15 patients with postmicturition dribbling.

Fifteen patients with postmicturition dribbling were studied with cystourethroscopy and electromyography of the bulbocavernosus muscle. In all patients the bulbocavernosus reflex and activity of the muscle during and after micturition were normal. No abnormality was found to explain the clinical symptoms.

Safety and effectiveness of Lithostar shock tube C in the treatment of urinary calculi.

Over 14 years of clinical use of extracorporeal shockwave lithotripsy (SWL), great technical modifications resulted in the development of many second-generation lipthotripters. The Siemens Lithostar machine, with its standard shockwave tube, was introduced in 1986. The objective of this study was to assess the safety and effectiveness of the newly proposed Lithostar shock tube C in the treatment of urinary calculi. Between July 1992 and August 1993, 319 patients (214 males and 105 females, average 49.7 years) with 433 renal or ureteral stones or both were treated at five centers in Canada and the United States. Most of the stones (72%) were located in the kidneys, while 28% were located in the ureters. Most (81%) of the treated sides (side = kidney and ureter) presented with single stones, 11% presented with two stones, and 8% presented with three or more stones. The average stone burden was 13.6 mm. The average duration of treatment for the whole population of patients was 39.3 minutes using an average number of shockwaves of 3633 in a minimum and maximum energy setting of 0.11 and 3.82, respectively. The majority of treatments (92%) were performed without anesthesia. Fragmentation was achieved in 93.5% of treatments, with a 3-month stone-free rate of 62.5% and a success rate (stone free or fragment < 5 mm) of 72%. Auxiliary procedures were necessary in conjunction with 108 treatments, and most of them were in form of catheter/stent placement. Treatment applied on a separate occasion to different stones but in the same collecting system (either a kidney or a ureter) were considered retreatments.(ABSTRACT TRUNCATED AT 250 WORDS)

Long term follow-up of intravesical Bacillus Calmette-Guerin for the treatment of bladder transitional cell carcinoma.

OBJECTIVE: To review the long-term follow-up, in terms of recurrence and progression, of transitional cell carcinoma of the bladder treated with intravesical BCG with the following indications: CIS, Ta and T1. MATERIALS AND METHODS: Ninety-two patients who had received complete course of BCG between 1987 and 1993 were included in the study and followed for an average of 59 months (range 12 to 102). RESULTS: The recurrence and progression were looked at. Patients treated with BCG for Carcinoma in situ, 11 of 19 (53%) remained tumor-free after 1 or 2 courses of BCG for the duration of the follow-up (mean 4.9 years, range 1.5 to 8.5 years). For patients treated for recurring tumors, 17 of 50 (34%) had no recurrences after 1 or 2 courses of BCG with the same follow-up. When facing multiple tumors, 10 of 23 (43%) patients did not experience recurrences. Therefore, in the 92 patients treated, 38 presented no recurrences after 1 or 2 courses of BCG, for a success rate of 41%. In terms of progression, of the 19 patients treated with BCG for CIS, 4 (21%) went on to develop muscle invasive disease. Of the 50 patients treated for recurrent tumors, 2 (4%) eventually developed lamina propria invasion (initial lesion was a Ta tumor), 4 (8%) carcinoma in situ and 7 (14%) muscle invasive disease, for an overall progression rate of 26% in this group. Of the 25 patients treated for multiple tumors, 1 (4%) developed CIS and 3 (12%) presented with muscle invasive disease, for an overall progression rate of 16% for the duration of the follow-up. Therefore, 21 of 92 (23%) patients had progression of their disease following BCG therapy. No prognostic factors for recurrence or progression could be identified in these tumors. CONCLUSION: When indications warrant its use, BCG is effective in reducing recurrences and limiting progression in TCC of the bladder. Recurrence within 2 years of treatment is, however, a sign of poor prognosis and other therapeutic options should be sought.

[Usefulness of prostate-specific antigen in the diagnosis of lymphatic metastases in cancer of the prostate]. / Utilité de l'antigène prostatique spécifique pour prédire la présence de métastases ganglionnaires dans le cancer de la prostate.

PSA has become the most important tumor marker in prostate cancer and has increased its usefulness from simply being a marker of treatment response, to one of early detectible/screening, and more recently as an aid in staging. Lymph node status in patients with prostate cancer is extremely important in terms of prognosis and treatment. We therefore undertook this study to evaluate the predictive value of PSA in determining lymph node status in an attempt to limit the number of lymph node dissections. The study consists of 240 consecutive cases of prostate cancers having pre op PSA levels, negative bone scans and known lymph node status (determined by lymphadenectomy). Results showed that the risk of node positive disease highly correlated with PSA levels and poorly correlated with clinical stage and histologic grade. There was no minimal PSA level under which nodes were consistently negative. With PSA under 10, 7.7% of lymphadenectomies revealed at least one positive node (2 cases had PSA's of 3). When PSA was between 10 and 20, 17% had positive nodes, with PSA between 20 and 50, 21% were node positive, and 53% positivity when PSA was over 50. The combination of low grade tumors with PSA under 20 identified a subgroup of patients with consistently negative nodes. We therefore conclude that PSA levels may be of use in predicting lymph node status but cannot, at present, be used to replace lymphadenectomy.

[Perineal retraining in urinary stress incontinence]. / La rééducation périnéale dans l'incontinence urinaire d'effort.

Twenty patients suffering from urinary stress incontinence were treated by perineal reeducation. The assessment included a medical and urological questionnaire, a physical examination, a urine analysis and culture, a cystoscopy, urinary flow and cystometry, a urethral pressure profile and a subjective evaluation of the perineal musculature. The 20 patients selected had documented stress incontinence, had never been operated on for incontinence and had a stable bladder at urodynamic assessment. Treatment was identical for all patients and included 12 biofeedback and electrostimulation sessions over a 4 to 6 week period. The questionnaire, urodynamic and perineal assessment were repeated at the end of treatment. No complication occurred. Micturition frequency decreased in all patients. Clinical correction of incontinence was observed in ten patients, improvement in nine and no change in one for an overall cure or improvement rate of 95%. The urethrocystocele evaluation did not change. Perineal evaluation and urodynamic parameters were only slightly improved. At follow-up evaluation 6 to 9 months post treatment, a 75% cure or improvement rate was still present. Perineal reeducation is a non morbid and effective modality to correct urinary stress incontinence. Its long term efficacy and its use for other types of incontinence has to be demonstrated.

[Ureteroscopy versus in situ extracorporeal shockwave lithotripsy in the treatment of calculi of the distal ureter]. / Urétéroscopie versus lithotripsie par onde de choc extracorporelle in situ dans le traitement des calculs du tiers distal de l'uretère.

In a retrospective study from a unique center (St. Luc Hospital, Montreal) stone clearance of 88 consecutive distal ureteral calculi (below pelvic brim) treated by extracorporeal shock wave lithotripsy in situ were compared to a group of 94 distal ureteral calculi treated by ureteroscopy during the same period. Our results show 84% success rate for ureteroscopy which is clearly superior than 58% stone clearance rate at 3 month follow-up for ESWL Success rate was influenced by stone size in the ESWL group but not in the ureteroscopy group. This study reveals similar success rate for calculi smaller than 6 mm but for larger calculi, success rate of ureteroscopy is significantly superior.

[Immediate complications of transurethral resection of the prostate: study of 1000 consecutive cases]. / Complications immédiates de la résection transurétrale de la prostate: étude de 1000 cas consécutifs.

The authors reviewed the charts of 1000 patients who underwent transurethral resection of the prostate. When the 30-day postoperative period was studied, it was found that 139 patients suffered complications and 6 died. Infectious complications (urinary tract in 63 cases and septicemia in 23 cases) were the commonest followed by hemorrhage and urinary retention. The deaths were related to cardiac problems.

[Treatment of the acute phase of urinary retention (author's transl)]. / Traitement de la phase aiguë de la rétention urinaire.

The authors report on a series of 50 consecutive patients, admitted in emergency for complete urine retention of sudden onset. They all presented an enlarged bladder, containing 500 to 2 200 ml of urine. They all underwent vesical drainage through urethral catheterization, without concern for a slow decompression of the bladder. There were six cases of macroscopic hematuria needing no specific treatment. For the authors, there is no justification for slow urinary decompression.

[Usefulness of intravenous urography in the evaluation of benign prostatic hypertrophy]. / Utilité de l'urographie intraveineuse dans l'évaluation de l'hypertrophie bénign de la prostate.

Intravenous pyelography performed in 500 patients as part of the evaluation for benign prostatic hypertrophy revealed an incidence of upper tract abnormalities in 25.2% of cases. Amongst the 179 patients with haematuria and/or pyuria, the incidence of abnormalities rose to 31.2%. The incidence of significant abnormalities such as calculi, polycystic kidneys and renal neoplasm was 3%, comparable to the general population. In the light of these findings and in view of the cost of the investigation, we believe that intravenous pyelography should only be performed in selected cases.

Urinary calculi in pregnancy.

Between January 1975 and March 1980, 19 pregnant patients with urinary calculi were admitted to hospital, they constituted 0.23% of all women delivered at the Hôpital St-Luc during that period. The symptoms were characteristic: pain in the flank and right lower quadrant, hematuria, frequency and dysuria. Noninterventional therapy was successful in 14 patients. Two patients were operated upon during pregnancy without complications. Ultrasonography is a useful diagnostic procedure during the first trimester. Pyelography should be considered only after adequate time has elapsed to allow spontaneous elimination of the calculi and, if used, one exposure before and one 30 minutes after injection of the contrast material well ensure the radiation dose is low enough to avoid causing any fetal abnormality. The authors believe that treatment must be individualized depending on the location and size of the calculus, the degree of obstruction, presence of infection, age of the fetus and condition of the patient. Spontaneous elimination after hydration and analgesia is the ideal, lumbar ureterolithotomy or basket extraction can be considered, although surgical procedures are best postponed until the postpartum period.

[Haemorrhage from an ileal loop bladder secondary to portal hypertension (author's transl)]. / Hémorragie d'un conduit iléal secondaire à une hypertension portale.

Whilst haemorrhage from the stoma is a classical complication of ileal canal, portal hypertension is rarely responsible since only six cases have been reported in the literature before that described here. The responsibility of portal hypertension having been confirmed by umbilico-portography, and a mesenterico-caval shunt was performed. This did not prevent a further bleed 15 months later which led to the discovery of obstruction of the shunt. Despite this there were no further problems up to the time of the patient's death 22 months later as a result of encephalopathy. On the basis of the present case and those already published, the authors discuss the mechanisms and therapeutic possibilities of this rare complication.

[Urological problems related to aorto-bifemoral surgery (author's transl)]. / Problèmes urologiques reliés à la chirurgie aorto-bifémorale.

The authors reviewed, from a urological standpoint, the records of 400 patients undergoing aorto-bifemoral bypass between 1967 and 1980. Stenosing or aneurysmal lesions of the renal arteries were present in 106 patients, i.e. 26.5% of cases. 7% of the patients had previous pathology (2 lithiasis, 4 hydronephrosis and one non-functioning kidney). All the operations consisted of a bypass inserted posterior to the peritoneum and ureters. 39 patients (9.7%) underwent simultaneous surgery on the renal artery or vein, or the kidney, Amongst a total of 12% deaths, 1.5% were of renal causes. The postoperative urological morbidity was 24.9% being dominated by infectious lesions (16%) and ureteric lesions (5%). The majority of ureteric lesions took the form of progressive distension of the excretory apparatus. The presence of an indwelling urethral catheter was considered to be the most important factor in infection. The authors feel that it is essential to visualise the urinary tract at the time of angiographic investigation of aortoiliac disease. Amongst 18 cases of progressive dilatation of the upper urinary tract after such vascular surgery, only 3 underwent operation. Nevertheless, intravenous urography is an essential part of postoperative surveillance after surgery of this sort. Only 15% of their patients had undergone IVU and amongst them 18 were found to have a hydronephrosis.

Long-term followup of initial Ta grade 1 transitional cell carcinoma of the bladder.

PURPOSE: We evaluate the long-term outcome of initial Ta grade 1 transitional cell carcinoma. MATERIALS AND METHODS: A total of 152 patients with initial Ta grade 1 bladder tumor were followed for a mean of 76 months (range 6 to 241). Recurrence was defined as positive findings on cystoscopy or biopsy. Progression was defined as an increase in tumor grade or stage. RESULTS: Tumor recurrence in 83 of 152 patients (55%) was noted within 12 months of followup in 38 patients (46%), between 12 and 24 in 11 (13%), and between 24 and 60 in 22 (27%). A significant number of recurrences (12, 14%) were diagnosed more than 60 months after the first tumor. Of 83 patients with recurrence 31 (37%) had progression, including 21 to grade 2 and 2 to grade 3 disease. Carcinoma in situ was diagnosed in 3 patients and 5 had muscle invasive disease. Progression occurred more than 24 months after initial diagnosis in 20 patients and more than 60 months after first tumor event (2 had carcinoma in situ and 2 had muscle invasive disease) in 12. CONCLUSIONS: Ta grade 1 bladder transitional cell carcinomas have a high recurrence rate and progression is not uncommon. These findings warrant close long-term followup, even when in some settings the trend is to discontinue followup after 5 years without any abnormal findings.

Randomized, prospective, controlled study comparing radical prostatectomy alone and neoadjuvant androgen withdrawal in the treatment of localized prostate cancer. Canadian Urologic Oncology Group.

PURPOSE: A prospective, multicenter, randomized study was done to test the hypothesis that neoadjuvant androgen withdrawal decreases the incidence of positive margins following radical prostatectomy for localized prostate cancer. MATERIALS AND METHODS: Observations were made of 213 patients randomized to undergo radical prostatectomy alone (101) or to receive a 12-week course of 300 mg. cyproterone acetate daily followed by surgery (112). Groups were similar at baseline in terms of clinical stage, serum prostate specific antigen and Gleason score. Of 192 patients available for efficacy analysis 9 had stage T1b, 8 stage T1c, 63 stage T2a, 36 stage T2b and 76 stage T2c disease. RESULTS: One or more positive surgical margins were found in 59 of 91 patients (64.8%) in the surgery only group compared to 28 of 101 (27.7%) in the cyproterone acetate group (p = 0.001). Patients who received preoperative therapy had a statistically significantly lower rate of apical margin involvement than those who did not (17.8 versus 47.8%, respectively, p < 0.0001). There was no statistically significant difference in surgical (p = 0.8645) or postoperative (p = 0.173) complications between the 2 groups. CONCLUSIONS: Neoadjuvant androgen withdrawal with a 12-week course of 300 mg. cyproterone acetate daily results in a lower rate of positive margins without adversely affecting postoperative recovery. The impact on patient survival will be determined by long-term followup.