[Laparoscopic surgical treatment of simple cysts of the kidney]. / Traitement coeliochirurgical des kystes simples du rein.

OBJECTIVE: To demonstrate the efficacy of laparoscopic treatment of symptomatic renal cysts or cysts suspicious of malignancy. MATERIAL AND METHODS: 10 patients (mean age: 58 years) were operated by laparoscopy either for compressive or symptomatic cysts (7 cases), or for cysts suspicious of malignancy (3 cases). The mean cyst diameter was 7.8 cm. All patients were evaluated by preoperative CT scan. There were 8 Bosniak type I and 3 Bosniak type II cysts. RESULTS: The procedure was performed via an intraperitoneal approach (8 cases) or via a retroperitoneal approach (2 cases). The mean operating time was 92 min and the mean hospital stay was 5.4 days. One patient was operated (conversion to lumbotomy) for uncontrolled haemorrhage of the base of the cyst. The 10 cysts were found to be benign histologically. All 10 patients are asymptomatic (mean follow-up: 8.3 months) with disappearance of the cyst on the follow-up CT scan. CONCLUSION: Laparoscopic treatment of renal cysts is feasible and effective. However, this treatment must be reserved for Bosniak type I and II cysts, associated with a low risk of malignancy.

[Renal and adrenal involvement in von Hippel-Lindau disease: clinical features and therapeutic strategies]. / Atteintes rénales et surrénaliennes dans la maladie de von Hippel-Lindau: aspects cliniques et stratégies thérapeutiques.

OBJECTIVES: We report our experience of renal and/or adrenal manifestations of von Hippel-Lindau disease and propose a practical approach. METHODS: Eight patients (mean age: 43 years) presented with predominant renal and adrenal lesions in 6 cases and 2 cases, respectively. RESULTS: All patients are alive with a mean follow-up of 8.1 years. A local recurrence after partial nephrectomy was observed in two cases. Two patients are in renal failure and are treated by dialysis and two patients require hormone replacement therapy for adrenal insufficiency. CONCLUSIONS: The predegenerative nature of simple renal was not observed. Conservative renal surgery is adapted to small renal tumours, with a low cytological grade and without any distant lesions in the same kidney. Radical nephrectomy is reserved for large lesions (greater than 5 cm) with a high cytological grade. The presence of pheochromocytoma must be systematically excluded. Preservation of the adrenal gland in the case of homolateral renal surgery for cancer is recommended. The reliability of the genetic test allows early diagnosis of this disease.

Surgical management of complex renal cysts: a series of 32 cases.

PURPOSE: The differentiation between benign cysts of the kidney and those that require surgical exploration remains difficult. The accuracy of radiological techniques (ultrasound, computerized tomography [CT], angiography, magnetic resonance imaging, cyst puncture and intraoperative pathological examination) is analyzed. MATERIALS AND METHODS: Surgical exploration was performed in 30 patients with 32 asymptomatic renal cysts, and the pathological specimens were compared retrospectively to the radiological findings. The classification of Bosnaik was used to categorize the ultrasound and CT findings. RESULTS: Of our complex renal cysts 41% proved to be malignant. Our results suggest that the radiological techniques are not well suited for characterization of these cysts. None of the Bosnaik types was sufficiently predictive of the lesion. Only a Bosnaik score of 4 (the sum of ultrasound and CT Bosnaik types) was not associated with renal cell carcinoma. According to the radiological findings, 1 patient was under treated (recurrent renal cell carcinoma) and 4 were over treated (radical nephrectomy for benign lesions). CONCLUSIONS: A practical therapeutic strategy is described in which radical nephrectomy is performed when malignant lesions are detected either by preoperative or intraoperative techniques. Conservative surgery is indicated for benign cysts according to the clinical status and risks of nephron sparing surgery.

[Activation of T-lymphocytes in Crohn disease and in ulcerative hemorrhagic rectocolitis. Therapeutic implications]. / Activation des lymphocytes T dans la maladie de Crohn et dans la rectocolite ulcéro-hémorragique. Implications thérapeutiques.

Inflammatory bowel disease (IBD) encompasses two forms of intestinal inflammation: ulcerative colitis and Crohn's disease. Besides abnormalities of immunoglobulins production and complement activation, T lymphocytes play an important role in pathogeny of these diseases. Although T-cells number is increased in intestinal mucosa of such patients, CD4/CD8 ratio of T lymphocytes subsets is normal in mucosa. Activated T-cells expressing interleukin-2 receptors (CD25) are increased in lamina propria from patients with IBD. Cytokines induce abnormal expression of class II antigens of major histocompatibility complex by epithelial cells which may act as antigen presenting cells to CD4 T-cells. Better understanding of pathogenic mechanisms in IBD might justify new immunosuppressive therapeutics to treat these patients.

[Simultaneous allotransplantation of the adrenal gland and the kidney]. / Allotransplantation simultanée de la surrénale et du rein.

Thirteen months after a bilateral nephrectomy for a synchronous bilateral renal cell carcinoma involving both adrenal glands, a 46 years-old man underwent a simultaneous adrenal and kidney allotransplantation. The left renal allograft was harvested together with a ipsilateral adrenal gland using a common aortic patch. Maintenance immunosuppression was based on azathioprine, antilymphocyte globulin cyclosporine and prednisolone. Kidney allograft function remained stable for 5 years until the patient died from multifocal pancreatic metastases. Clinical, biochemical, radiological and histological arguments demonstrated the function of adrenal allograft. To our knowledge, it is the first report of a simultaneous kidney and adrenal gland allotransplantation in a therapeutic intent. An adrenal gland allotransplantation is only justified when the adrenal insufficiency exists with an end stage organ failure requiring transplantation and therefore immunosuppressive drugs.

Endoscopic treatment of vesicoureteric reflux in transplanted kidneys.

Twenty-one patients underwent endoscopic subureteric injection of Polytef paste for the correction of secondary vesicoureteric reflux (VUR) in transplanted kidneys. Ureteroneocystotomy was performed in renal transplants using an extravesical technique in 19 patients and the Leadbetter-Politano technique in 2 cases. Success was achieved in only 6 patients, including the 2 ureters reimplanted according to the Leadbetter-Politano technique. No significant complication relating to the technique was observed. Despite the low success rate (30%), endoscopic treatment of VUR in transplanted kidneys is justified as a first attempt in view of the morbidity of VUR and the difficulties of repeated surgical reimplantation in this population.

[Veno-occlusive disease after liver transplantation. Association of acute cellular rejection and toxicity of azathioprine]. / Maladie veino-occlusive après transplantation hépatique. Association d'un rejet aigu cellulaire et de la toxicité de l'azathioprine.

Azathioprine vascular hepatotoxicity has been described mainly after renal transplantation. We report a new case in a patient who developed veno-occlusive disease of the liver 3 weeks after liver transplantation; regression of lesions were observed after discontinuation of azathioprine therapy. In this case, azathioprine hepatotoxicity may have been enhanced by a previous episode of severe, acute rejection prevailing in the hepatic veins. After liver transplantation, the diagnosis of azathioprine hepatotoxicity is difficult but should be suspected in the presence of non-inflammatory small hepatic veins lesions. Early withdrawal of the drug is mandatory for complete recovery.

[Endoscopic treatment of vesico-ureteral reflux after reimplantation of the ureter (transplants excluded)]. / Traitement endoscopique du reflux vésico-urétéral après réimplantation de l'uretère (greffes exclues).

O'Donnell's technique was used to treat 9 refluxing ureteric units after surgical reimplantation of the ureter in 8 patients (mean age: 45 years) between May 1986 and January 1991. The reimplantation was performed according to Cohen's technique in 5 cases (including ureteric remodelling in one case), Leadbetter's technique in 2 cases (including ureteric remodelling in one case), the Campos Freire technique in 1 case and a direct reimplantation in 1 case (with Boari). The reflux was grade II for 1 ureter, grade III for 54 ureters, grade IV for 2 ureters and grade V for 1 ureter. A single injection was performed in 5 patients and multiple injections were required in 3 patients. An associated bladder neck incision was performed in 2 male patients. No complications were observed. Correction of reflux was obtained for 8 ureteric units, i.e. 87% success with a mean follow-up of 28 months. The failure corresponded to the case of grade V reflux in a megaureter reimplanted with remodelling. The authors recommend that endoscopic treatment of reflux be performed as first-line treatment for reflux of reimplanted ureters because of the simplicity and efficacy of this technique.