Intra-operative electron radiotherapy as a conservative treatment for infiltrating bladder cancer.

The intent of this feasibility study was to evaluate the use of intra-operative electron radiotherapy (IOERT), after transurethral resection (TUR), combined with external beam radiation with concurrent chemotherapy for the conservative treatment of infiltrating bladder cancer. From November 1988 to June 1998, 27 patients with histologically proven non-metastatic infiltrating bladder cancer were included in this protocol. The treatment consisted of: TUR, external beam irradiation (x18 MV:48 Grays (Gy)/24 fractions/5 weeks), with concurrent chemotherapy (cisplatin 30 mg/day for 3 days-two cycles during irradiation), followed by control cystoscopy and cystotomy with IOERT (e 9 MeV:15 Gy). 14 patients received two cycles of neoadjuvant methotrexate, vinblastine and cisplatin (MVC) and folinic acid chemotherapy. Patients were evaluated for toxicity, local control and survival. The 5-year overall and cystectomy-free survival rates were 53.3% +/-11.1% and 48.1%+/-11.4%, respectively. 4 patients developed infiltrating intravesicular recurrence (3 were treated by salvage cystectomy), and an additional patient developed a superficial recurrence. 2 patients subsequently developed regional recurrence in pelvic nodes and 10 patients were found to have distant metastases. The protocol was found to be feasible and associated with acceptable toxicity. Early and late toxicities consisted of 3 cases of bladder mucosal necrosis or ureteral stenosis which resolved with medical management. These preliminary results indicate that IOERT combined with TUR and neoadjuvant external beam radiation with concurrent chemotherapy is feasible. It could be considered as an alternative therapy for infiltrating carcinoma of the bladder, especially in patients unfit for radical surgery, and is well adapted to treat lesions of the fixed portion of the bladder.

Ureteropelvic invagination procedure for endopyelotomy (Gelet technique): review of 51 consecutive cases.

Between 1990 and 1995, we performed 51 endopyelotomies on 38 cases of primary and 13 of secondary obstruction of the ureteropelvic junction (UPJ) using the ureteropelvic invagination technique. Of the 51 patients in the series, 49 have been followed for a minimum of 3 months postoperatively (mean follow-up 16 months). Overall, success was achieved in 38 (77.5%). Endoscopic endopyelotomy was successful in 11 of 13 cases (84.5%) with secondary strictures. When the technique was used for the treatment of primary UPJ stricture, the success rate was only 75% (27 of 36). The presence of a crossing vessel was identified as the cause of failure in five cases of primary strictures; hence, we advocate the use of angiography to identify crossing vessels preoperatively. We recommend the use of the ureteropelvic invagination technique as the first-line therapy for primary hydronephrosis in adults in the absence of a crossing vessel.

Accuracy of the manometric diagnosis of Hirschsprung's disease.

In a 3-yr period, 229 examinations were carried out in infants and children. These were sub-divided into five groups according to age. There were 10 false positive and 8 false negative results, an overall not unreasonable record of 7.8% errors. However, in the neonatal group, there were as many as 26% errors and thus the test in this group was considered to be highly inaccurate. The older the infant or child, the less errors in diagnosis occurred. Possible reasons for errors are pointed out and comparisons are made with other series.

Surgical treatment of high imperforate anus with definition of the puborectalis sling by an anterior perineal approach.

An operative technique in which the sling of the puborectalis muscle is seen through an anterior perineal approach in the treatment of high imperforate anus is described. The operation has been performed, on children with previous colostomies, and on older children with unsuccessful previous abdomino-perineal pull-through procedures. While our series of patients is still small, 24 children, operated upon sufficiently long ago for follow-up purposes, have generally shown good to excellent functional results.

Place of luteinizing hormone releasing hormone agonists in the treatment of prostatic cancer.

Prolonged administration of a luteinizing hormone releasing hormone agonist causes a transient increase in serum testosterone concentrations, lasting a few days, followed by a long-lasting decrease in the serum testosterone concentrations, luteinizing hormone releasing hormone agonists inducing a chemical castration equivalent to surgical castration. The effect is observed whatever the agonist employed, side-effects being limited to loss of libido, impotence and hot flushes. Moreover, chemical castration is reversible and may be repeated; therefore, this new therapy appears to be of considerable interest in the treatment of prostatic cancer. The indications for luteinizing hormone releasing hormone analogues, however, are limited to metastasized adenocarcinomas which represent the stage of the disease most frequently encountered (about 75% of the cancers treated). They constitute a method of treatment that is only palliative. The use of agonists competes directly with orchidectomy but it is costly and demanding, and it derives its indications from the fact that it is reversible, does not mutilate and is devoid of toxicity.

[Adjuvant radiotherapy after radical prostatectomy. Apropos of a series of 73 patients in Lyons (France)]. / La radiothérapie adjuvante après prostatectomie radicale. A propos d'une série lyonnaise de 73 patients.

PURPOSE: Descriptive analysis of adjuvant radiation therapy after radical prostatectomy. MATERIALS AND METHODS: From 1986 to 1993, 73 patients (median age, 64.5 years; Gleason score > or = 7 : 36 pts; T1:22; T2:40; T3:11) were included into the study. On the operative specimen, the cancer grades were pT2:5 (involvement of the apex), pT3:67, pT4:1, pN1-2:8. Radiation therapy was performed after a mean resting period of 112 days. The target volume was the prostatic area. The technique used was a four-field box with an 18 MV-X photon beam. The dose was 50 Gy/20 fractions/5 weeks. No hormonal treatment was administered, except for 5 patients for a short duration. RESULTS: The median follow up was 46 months. One anastomotic local failure was salvaged by trans-urethral resection, three distant metastatic failures. Out of 72 patients with a PSA < 3 ng/mL at the end of radiotherapy, 13 showed an isolated elevation. The 5-year overall survival rate was 93%. The event-free survival was 72% after 5 years. Pathological differentiation and Gleason score were significantly correlated with the survival. There was no complication related to radiotherapy. CONCLUSION: Elective adjuvant radiation therapy for pT3 prostate adenocarcinoma after radical prostatectomy provides a good local control with minimal morbidity.

[Ectopic deposits of Tamm-Horsfall protein. A psuedo-tumoral lesion]. / Dépôts ectopiques de protéine de Tamm-Horsfall. Lésion pseudo-tumorale.

Three cases of unusual deposits of Tamm-Horsfall protein in peripelvic and perirenal fat tissue are reported. A renal tubular rupture leads to the deposition of this protein. In the first case, the association of the deposits with epithelial structures, raised the possibility of a bladder carcinoma infiltration. These deposits simulated on the X-ray examination, a pelvis neoplasm in our second patient and a tuberculosis in the third case. However the particular microscopic appearance of Tamm-Horsfall protein, its intense staining with the periodic-acid-Schiff, and its positivity with a specific antibody led to the diagnosis.

[Radical prostatectomy]. / Prostatectomie radicale.

Radical prostatectomy can cure cancer of the prostate if the malignancy is localized within the gland and the patient has a life expectancy sufficiently long enough to appreciate efficacy. The expectations raised by this technical progress, particularly since the number of diagnosed cases is constantly on the rise, should however be tempered by questions concerning indications and therapeutic efficacy, pathology findings in surgical specimens, factors of prognosis and certain doubts about the quality of life, therapeutic alternatives and cost evaluation. 10-year survival after radical prostatectomy is 85% for localized (pT1 and pT2) forms and prostate specific antigen levels provide an easily accessible means of detecting recurrence. However, due to the insufficient sensitivity of imaging techniques, preoperative staging is generally underestimated compared with pathology reports. Postoperative incontinence is the major factor in quality of life after prostatectomy and has been estimated to concern from 0% to 26% of the patients. No comparative data is available to evaluate alternative treatment such as external radiotherapy. These observations emphasize the uncertain nature of current indications for radical prostatectomy and the importance of further research.

[Cystic lymphangioma in the adrenal gland: a case report]. / Le lymphangiome kystique de la surrénale: à propos d'une observation.

Cystic lymphangioma of the adrenal gland are rarely encountered tumoural formations with no clinical expression. Pre-operative diagnosis is difficult. Echography and CT scan are essential exploratory techniques, diagnosis is histological. Usually surgical exploration is indicated due to uncertain diagnosis. We report a new case of cystic lymphangioma of the adrenal gland and a review of recent literature.

[Recanalization of pelvic ureter in prostatic neoplastic obstruction: endoscopic and radiologic approach]. / Reperméabilisation de l'uretère pelvien pour obstacle néoplasique prostatique: approche endoscopique et radiologique.

UNLABELLED: Obstruction of the lower ureter by pelvic cancer requires a palliative treatment. Percutaneous derivation is often performed as an emergency. If obstruction is limited to the peri-meatic area (a few mm or a cm) resection of the ureteral orifice can be enough to catheterize the obstructed ureter. Stenting of the ureter can be done even if the obstruction is longer, using the extra vesical repermeabilization. METHODS: A guide wire is passed via the nephrostomy, and ureteral stent is passed over the guide wire. Dye additionned with methylene blue is injected tovisualize the lower extremity of the ureter. A regular resectoscope is placed transuretraly, and resection is conducted using X ray localisation with a C arm and several incidences. The tissue resected first is usually extravesical, in the adipous perivesical tissue. Dissection of this area can be performed bluntly with the tip of the resectoscope until the ureter is reached. At this time, the resectoscope is used to open the lower extremity of the ureter, localized with the C arm. It is important to open widely the ureter, so as to be sure to catheterize easily this opening with a ureteral catheter. A double J can then be passed easily. Tunnel of several cm can be performed using this technique. RESULTS: Seven patients with pelvic cancer with obstruction of the last cm of the pelvic ureter were included in this series. They were recurrent prostate cancer already treated with hormone therapy, stage T3, T4. All procedures were performed under rachianesthesia or general anesthesia according to general status. After this procedure normal miction were obtain in all patients and nephrostomies were removed. This technique is possible for extended pelvic obstruction. Blunt dissection with the endoscope is usualy blood less. This palliative procedure can be done in patients with poor general condition and allows for a better quality of life than nephrostomy or urinary diversions.

[Endoscopic treatment of intermittent vesico-ureteral reflux in women. Apropos of 40 cases]. / Traitement endoscopique du reflux vésico-urétéral intermittent chez la femme. A propos de quarante cas.

UNLABELLED: To evaluate the clinical efficacy of endoscopic treatment of intermittent vesicoureteric reflux in adult females. METHODS: Forty women presenting with recurrent urinary tract infection related to intermittent vesicoureteric reflux, underwent subureteric Teflon injection according to the O'Donnell procedure (mean volume of Teflon 1 cc). Thirty patients required one injection, while nine patients needed two injections. Meatostomy or urethral dilatation were associated in 29 cases (72.5%). RESULTS: No complication occurred. Clinical results were evaluated using a questionnaire. The mean follow-up was 33.5 months (range 12-72), complete disappearance of infection was obtained in 31 out of 40 cases (77.5%). Recurrent urinary infection occurred in 9 cases. After complementary Teflon injection, urinary infection disappeared in 5 patients and finally a complete cure was obtained in 36 out of 40 cases (90%). CONCLUSION: Intermittent vesicoureteric reflux could be easily cured by an endoscopic procedure. This minimally invasive technique is simple and well adapted to this relatively benign disease.

[Renal autotransplantation in the treatment of renovascular hypertension]. / Autotrasplante renal en el tratamiento de la hipertensión renovascular.

Surgery plays an important role in the treatment of renovascular Hypertension (RVHT). 123 RVHT carrier patients were treated by means of 101 single autotransplants (11 double autotransplants) and 34 autotransplants preceded by extracorporeal replacement of the branches of the renal artery (1 bilateral case). Taken all round, the patients improved either totally or partly (93.5%). In lesions involving multiple branches of the renal artery, replacement of these by a hypogastric autologous arterial transplant is regularly the only technique possible to save the kidney.

[Bilateral adrenal pheochromocytomas in von Hippel-Lindau disease]. / Phéochromocytomes surrénaliens bilatéraux au cours de la maladie de von Hippel-Lindau.

The pheochromocytoma is a medullo-adrenal tumor which develops at the cost of the chromaffin cells. It appears in 11-19% of cases of von Hippel-Lindau's disease (VHL), is often bilateral, and the symptomatology is often crude: arterial hypertension is frequently isolated and unstable, and the classic triad of headache, palpitations and sweating is quite rarely observed. We report four observations of bilateral pheochromocytomas in patients with von Hippel-Lindau's disease (three with phenotype IIA and one with phenotype IIB). The tumor was bilateral during the diagnosis in three cases; in the fourth patient, the attack on the contralateral adrenal gland came two years after the first adrenalectomy. All the patients had undergone an adrenalectomy by open surgery after a short preparation of 48 hours; replacement therapy was begun in each patient. Morbidity was low, and the patients submitted to a prolonged follow-up in order to screen for the onset of future lesions of VHL.

[Percutaneous resection of benign renal cysts]. / Resección percutánea de los quistes renales benignos.

Six patients carrying bulky renal cysts located in the kidney lower pole were treated by percutaneous resection of the cystic wall. No complications were observed during the peri and postoperational period. In all cases disappearance of symptoms was observed, and the total success rate (absence of residual cavity) recorded was 4/6, two cases presenting persistence of a small residual cavity which originated one case of relapse. The paper presents the technique used, and the indications and possible therapeutic actions for the treatment of simple kidney cysts are discussed.

[Role of celioscopy in the treatment of lymphocele after transplantation]. / Place de la coelioscopie dans le traitement des lymphocèles après transplantation.

Lymphoceles can be observed after renal transplantation. Sometimes lymphoceles can cause symptoms (renal insufficiency, pain). In these cases they require surgical treatment. From january 92 to december 1993 seven patients with complicated lymphoceles were treated. Simple drainage with injections of polyvidone iodine was used in 4 cases without effect. Surgical drainage was performed in 5 cases with complete disappearance of the pouch (on open surgical procedure, four celioscopic procedures). Celioscopic marsupialization of lymphoceles after transplantation is a method of choice and is preferred to open surgery for lymphoceles which develop internally.

[Long term results of endoscopic treatment of reflux in hemodialysis patients waiting for transplantation]. / Résultats à long terme du traitement endoscopique du reflux chez les hémodialysés en attente de transplantation.

Between January 1986 and April 1988, 13 patients (mean age: 35 years) waiting for renal transplantation (mean duration of haemodialysis: 46 months) were treated by means of O'Donnell's technique. Vesico-ureteric reflux was unilateral in 6 patients and bilateral in 7 patients (20 refluxing ureteric units). Reflux was classified as Grade II for 7 ureters, Grade III for 8 ureters and Grade IV for 5 ureters. The volume of Teflon injected ranged from 1 to 4 cm3 and 6 patients received repeated injections. No complications were observed. Complete resolution of reflux was obtained in 9 patients (69%), i.e. 15 ureteric units (75%). Reflux persisted in 4 patients (31%), i.e. 5 ureteric units (25%). Three nephro-ureterectomies were performed in 2 patients with persistent high grade reflux, but 2 patients with Grade I reflux after endoscopic treatment were not operated. All patients were transplanted after endoscopic treatment (mean interval between correction of reflux and transplantation: 13 months) and a follow-up cystography was systematically performed after transplantation (mean follow-up after transplantation: 27 months): no recurrence of the reflux was detected (mean follow-up after endoscopic treatment: 40 months). Endoscopic treatment of reflux avoids the need for nephro-ureterectomy in 80% of haemodialysis patients waiting for renal transplantation and presenting with vesico-ureteric reflux.

[Fragmentation of urinary calculi using the Lithoclast EMS. Technique and results]. / Fragmentation des calculs urinaires à l'aide du Lithoclast EMS. Technique et résultats.

The Lithoclast is an endoscopic lithotriptor which uses the ballistic energy produced by a small hand-held apparatus, by the movement of a small metal part (the projectile) driven by a jet of compressed air. The energy is transmitted to a metal rod whose diameter is selected according to the application: 0.8 or 1 mm in the ureter; 2 mm in the bladder and kidney. We have used this apparatus to treat 40 stones in 39 patients (25 ureteric stones, 11 renal stones, 4 bladder stones). Satisfactory fragmentation was obtained for 39 of the 40 stones (97.5%). The apparatus is very easy to use in the kidney and bladder (the risk of urinary tract perforation is very low at this level). The risk of perforation of the ureteric wall by 0.8 mm or 1 mm rods is considerable (12% of cases), but these punctate lesions heal rapidly over a double J stent. Special techniques should be used in the ureter to limit the risk of pushing the stone towards the renal pelvis.

[Treatment of intradiverticular lithiasis by percutaneous methods (19 caliceal diverticuli)]. / Traitement de la lithiase intradiverticulaire par abord percutané (à propos de 19 diverticules calciels).

The main technical procedures in percutaneous nephrolithotomy are the direct puncture of the diverticulum (precise puncture may be required to place the tract directly on to the stone), and treatment duration the diverticulum could be coagulated and a large nephrostomy catheter could be left in place two days. No complication was encountered. One patient refused the treatment after unsuccessful puncture. The nephrostomy tube was left open for two days of drainage. Mean hospital stay was 5 days. Three patients required E.S.W.L because of persistent symptoms. One month after treatment 13 of 18 patients intravenous urography showed obliteration of the diverticulum (72%); Three months after 84% (15/18) of our patients were stone free and 94% (17/18) symptom free. Percutaneous nephrolithotomy should be performed for symptomatic patients, it has low complication rate and should be reserved for patients with persistent symptoms after E.S.W.L.

[The treatment of metastasized kidney cancer. Current data and perspectives]. / Les traitements du cancer du rein métastasé. Données actuelles et perspectives.

Metastatic renal cancer has a poor prognosis because of the limited impact of traditional treatment modalities on this tumour. The few long-term survivals obtained after isolated surgical resection of the primary tumour or its metastases can be attributed to the occasionally unpredictable natural history of this tumour and isolated surgical resection generally does not appear to improve the survival of these patients. Among non-surgical treatments, radiotherapy is purely palliative and hormone therapy has been shown to be ineffective. New therapeutic approaches have been recently developed, suggesting a possible improvement in the prognosis of metastatic renal cancer. A better understanding of the mechanisms of chemoresistance of renal cancer should lead, in the near future, to the use of drugs capable of increasing the efficacy of cytotoxic chemotherapy in this tumour. The results obtained with new forms of immunotherapy open up prospects for combined immunosurgical modalities.

[What is the role of endoscopy in the diagnosis and treatment of tumors of the upper urinary tract?]. / Quelle doit être la place de l'endoscopie dans le diagnostic et le traitement des tumeurs de la voie excrétrice du haut appareil?

17 patients with upper urinary tract tumours were investigated by endoscopy. 3 patients (Group I) with fibrous or fibroepithelial polyps were treated via a retrograde approach and did not develop any recurrences. 2 patients (Group II) developed unexplained haematuria: the diagnosis of high-grade carcinoma was confirmed by endoscopy and they were treated by nephroureterectomy. 12 patients (Group III) with low grade non-invasive urothelial carcinoma, in whom radical surgical was not indicated, were treated conservatively via the percutaneous (13 tumours) or retrograde (1 tumour) endoscopic approach. The local recurrence rate was 33% (4 out of 12 tumours) for a mean follow-up of 22 months. The recurrences were treated by repeated endoscopy in 3 patients, and by nephroureterectomy in 1 patient. Endoscopic treatment of upper urinary tract tumours should be reserved for benign tumours and selected cases of low-grade, non-invasive urothelial carcinoma.