[Magnetic resonance imaging for delineation of prostate in radiotherapy: monocentric experience and review of literature]. / Imagerie par résonance magnétique et délinéation de la prostate en radiothérapie : expérience monocentrique et revue de la littérature.

PURPOSE: To assess the benefits of magnetic resonance imaging (MRI) in the dosimetric treatment planning for prostate radiotherapy. PATIENTS AND METHODS: Ten consecutive patients have been enrolled. They were treated for a low risk prostate adenocarcinoma. A rigid superimposition was performed between MRI and scan slides obtained at time of virtual simulation, then prostate volume was delineated by four to five physicians, on TDM slides and on MRI/TDM superimposition. For each treatment plan, we assessed the impact of MRI in terms of planned treatment volume (PTV) position, individual variability of prostate delineation and doses delivered to the critical organs. The prescribed dose was 74 Gy in 37 fractions to the PTV. RESULTS: PTV delineated on TDM (V(TDM)) were 1.15 (SD 3.71) larger than volumes delineated on MRI. Prostate apex was 4.6 mm (SD 2.87) lower on TDM than on MRI. Posterior limit of the prostate was in mean 4 mm more posterior on TDM. The variability between physicians in terms of prostate delineation was lower using MRI. For apex, these variations were 6.8 mm using TDM, versus 3.3 mm using MRI. Mean rectal dose was 8 % lower with MRI, compared to delineation using TDM. CONCLUSION: Superimposition TDM/MRI improves accuracy, decreases delineation variability, and allows to spare anterior part of the rectum from irradiation. It remains unknown whether this strategy translates into clinical benefit.

[Study of urinary continence after radical prostatectomy. Comparison between laparoscopic and retropubic prostatectomy based on a series of 251 cases]. / Etude de la continence urinaire après prostatectomie radicale. Comparaison entre prostatectomie rétropubienne et coelioscopique à propos de 251 cas.

INTRODUCTION: The objective of this study was to compare the results in terms of continence and quality of life between retropubic radical prostatectomy and laparoscopic radical prostatectomy, performed according to the same principle of retrograde dissection from the apex. MATERIAL AND METHOD: The series was composed of 120 patients undergoing retropubic radical prostatectomy and 131 patients undergoing laparoscopic radical prostatectomy performed in the Limoges hospital, urology and andrology department, between January 2002 and September 2005. Continence was evaluated by anonymous self-administered questionnaire sent to the patient's home. Pain was evaluated by visual analogue scale and narcotic consumption. Predictive factors of continence were analysed. RESULTS: The two groups were comparable in terms of pathological stage, Gleason score and age. The laparoscopy group comprised more patients with a history of transurethral resection of the prostate and more obese patients. No significant difference was observed between laparoscopy and laparotomy for degree of continence (71% versus 76%; p>0.05), time to return of continence (13 weeks versus nine weeks; p>0.05) and rate of mild (14% versus 13%), moderate (7% versus 6%) and severe (7% versus 5%) urinary incontinence. The anastomosis secondary stenosis rate was also identical in the two groups. Age was found to be a predictive factor for continence, especially for the mean time to return periods of continence. The patient's weight, prostate weight and TNM stage were not predictive factors for incontinence. The incontinence rate was 40% for salvage prostatectomies after radiotherapy. The mean duration of bladder catheterization was 6.9 days in the laparoscopy group and 7.2 days in the laparotomy group. Narcotic consumption was significantly lower in the laparoscopy group (21 mg versus 36 mg; p<0.05). CONCLUSION: Laparoscopic radical prostatectomy appears to give the same results in terms of continence as retropubic radical prostatectomy. However, these procedures were the first laparoscopic prostatectomies performed in the department, suggesting that, with greater experience, the results of laparoscopy could become superior to those of laparotomy. The laparoscopic technique also appeared to provide better patient comfort by decreasing postoperative pain.

Efficacy and tolerability of radiotherapy as treatment for bicalutamide-induced gynaecomastia and breast pain in prostate cancer.

OBJECTIVE: To assess the efficacy and tolerability of localised radiotherapy for the treatment of bicalutamide ('Casodex''Casodex' is a trademark of the AstraZeneca group of companies.)-induced gynaecomastia and/or breast pain. METHODS: This open-label, non-comparative, multicentre study included 51 patients receiving bicalutamide 150 mg for the treatment of non-metastatic prostate cancer (T1b-T4, Nx, M0). Patients who developed symptomatic gynaecomastia and/or breast pain received two 6-Gy fractions of external-beam radiation to the breasts and were then assessed at two 3-monthly follow-up visits. RESULTS: 37/51 (72.5%) patients experienced gynaecomastia and 41/51 (80.4%) experienced breast pain, typically within the first 6 months. Twenty seven and 38 patients, respectively, went on to receive breast irradiation. Following radiotherapy, gynaecomastia improved or resolved in 7/27 (25.9%) and 2/27 (7.4%) cases, respectively, and breast pain improved or resolved in 12/38 (31.6%) and 3/38 (7.9%) cases, respectively. No change was observed in 7 patients (25.9%) with gynaecomastia and 12 patients (31.6%) with breast pain, while 9 patients (33.3%) and 8 patients (21.1%), respectively, worsened. Radiotherapy-related adverse events, reported by 18/41 (43.9%) patients, were generally mild and short lived (median duration approximately 5 weeks). CONCLUSIONS: Therapeutic radiotherapy, using two fractions of 6 Gy external-beam radiation to the male breast, improves the intensity of bicalutamide-induced gynaecomastia and/or breast pain in approximately one-third of patients. Adverse events were often mild and short lived.

Le sphincter artificiel urinaire chez l'homme à propos de 23 cas

Objectif Evaluer notre experience dans la mise en place des sphincters artificiels urinaires (SAU). Discuter; apres une revue de la litterature; les indications; les examens complementaires et le pronostic. Patients et methodes Il s'agit d'une etude retrospective; a partir de 23 cas de sphincters artificiels type AMS 800; poses a des patients de sexe masculin; dans le service d'urologie au Centre Hospitalo-Universitaire Dupuytren de Limoges; et colliges sur une periode de 10 ans; entre avril 1996 et avril 2005. L'age moyen de nos patients etait de 70.3 ans; avec des extremes de 47 et 77 ans. Huit de nos malades ont recu un traitement par radiotherapie pelvienne d'un cancer de la prostate. Les causes d'insuf-fisance sphincterienne etaient: une prostatectomie radicale dans 10 cas; une resection endoscopique d'un adenome de la prostate dans 5 cas; une adenomectomie transvesicale dans 4 cas; une sphincterotomie endoscopique avec un agrandissement vesical dans 2 cas; une radiotherapie externe curative pour adenocarcinome localise de la prostate stade T2a dans un cas; et une cysto-prostatectomie avec enterocystoplastie type Camey II dans un cas. Les examens complementaires demandes etaient une analyse des urines; un bilan biologique inflammatoire et infectieux; une uretro-cystoscopie et un bilan urodynamique. Une reeducation perineale a ete pratiquee dans tous les cas; tandisqu'une injection du materiel macroplastique n'a ete faite que dans 15 cas. Enfin un sphincter artificiel a ete mis en position periuretrale dans tous les cas. Resultats L'appreciation du resultat fonctionnel du sphincter artificiel est basee sur la clinique et la satisfaction du patient. On a evalue ces resultats 6 mois apres l'activa-tion du sphincter. Sur nos 23 patients; 18 se disent entierement satisfaits et les 5 autres signalent des fuites qui sont minimes et positionnelles ou liees a des efforts; dont un avec une diminution du jet. Les complications sont apparues plus tard; en effet sur nos 23 SAU; 9 ont ete greves de complications dont 3 cas ont ete facilement corriges. Il s'agit: d'une complication d'ordre technique avec une hyperpression dans le ballon; une fistule vesico-parietale a minima et une migration de la pompe ayant necessite de la repositionner. Dans les autres 6 cas; la complication etait une erosion de l'uretre par la manchette; survenue en moyenne dans un delai de 5 ans apres la mise en place. Conclusion L'efficacite du sphincter artificiel AMS 800 pour la prise en charge de l'incontinence urinaire par insuffisance sphincterienne chez l'homme est indiscutable comme en temoigne le taux de satisfaction des patients qui en sont porteurs. Neanmoins; il persiste encore un taux d'echec non negligeable ayant souvent des consequences graves puisqu'il se solde en general par l'ablation du materiel surtout s'il s'agissait d'une erosion uretrale. Pour ceci; un respect des indications; une selection stricte des candidats; et un bon suivi des patients est necessaire dans l'espoir de diminuer l'emergence de complications

Anterior urethral valves and diverticula.

Obstructive lesions of the anterior urethra (valves, diverticula) are rare and can be difficult to diagnose. One recent case led us to review existing international reports; there are case histories for 260 patients over a 20-year period. The anatomical interpretation of these lesions is far from being unequivocal but many authors clearly distinguish between valves and diverticula, the basic difference being in the contiguity between the anomaly and the corpus spongiosum. Where the clinical presentation depends on age, the diagnosis depends essentially on voiding cysto-urethrography, which must image the whole urethra. Generally, the treatment for valves is simple, consisting of endoscopic resection. For diverticula it is not always necessary or desirable to remove the diverticulum; if there is a well-formed distal obstructing lip, removing it may be enough to cure the obstruction.

[Splenic lobulation and pseudo-cancer of the left kidney]. / Lobulation splénique et pseudo-cancer du rein gauche.

Discovery of a mass in the spleno-reno-pancreatic region requires complementary investigations to exclude a false diagnosis of renal tumour. While resembling a renal tumour, such masses can actually correspond to splenic lobulation, a cyst of the tail of the pancreas or a splenic entity (accessory spleen or splenosis).

Adenocarcinoma in the exstrophic bladder.

We report 2 cases of cancerous transformation in an exstrophic bladder. The histology of these tumors, methods of surveillance, and treatment are discussed in conjunction with a review of published reports. These rare tumors are almost entirely adenocarcinomas. Their treatment is surgical (radical cystectomy) with or without associated radiation therapy. Surveillance for patients with bladder exstrophy, whether surgically corrected or not, is indispensable and rests on cystoscopy and urine cytology.

Renal lesions in Von Hippel-Lindau disease: the benign, the malignant, the unknown.

OBJECTIVES: To describe the features and treatment of renal lesions in von Hippel-Lindau disease (VHL) from a series of patients, to highlight important issues in the management of these lesions. MATERIALS AND METHODS: We performed a retrospective study in 7 patients with VHL who underwent surgery for renal lesions between January 1990 and July 1996. The initial evaluation consisted of an abdominal CT scan and renal arteriography. RESULTS: The mean age of patients at the time of discovery was 38 (+/- 12.01 years). All cases were of type 1. Radiology assessment underestimated the gravity of the lesions in 5 patients. In all patients, unilateral surgery was performed with the kidney being conserved in 4 cases. Of the 44 lesions removed, 23 had signs of progressiveness (atypical or malignant cyst, renal cell carcinoma), most of the cancers were of low grade. 84% of the lesions did not exceed 3 cm and 48% were

[Benign prostatic hypertrophy: mini-invasive treatments (interstitial laser-transurethral needle ablation-thermotherapy)]. / Hypertrophie bénigne de la prostate: traitements mini-invasifs (laser interstitiel-TUNA-thermothérapie).

Endoscopic resection is the "gold standard" to treat benign prostatic hyperplasia refractory to medical treatments, because it is effective and only relatively aggressive. In young patients or debilitated elderly patients, there is a place for so-called minimally invasive surgical treatments, consisting of three possibilities: interstitial laser, TUNA (transurethral needle ablation), and thermotherapy. The results of these last two techniques are very similar o those obtained by endoscopic resection, with virtually no complications. These treatments are performed on an outpatient basis and have no consequences for sexuality. Thermotherapy has also been approved by the FDA in the USA. In France, these treatments can only be used in the context of a clinical trial.

[The Indiana pouch: a technic for simple continent urinary diversion]. / La poche d'Indiana: une technique de dérivation urinaire continente simple.

OBJECTIVE: Description of the Indiana pouch, a continent urinary diversion after cystectomy for urogenital tumours, and for the sequelae of neurogenic and traumatic bladders. MATERIAL AND METHOD: This was a retrospective study of 16 patients undergoing, between June 1991 and March 1995, cutaneous urinary diversion by ileocaecal graft, detubularized in the colonic segment, with continence ensured by the ileocaecal valve. The postoperative follow-up (4 to 36 months) was performed at 3, 6 and 12 months (abdominal ultrasonography alternating with abdominopelvic CT scan), then annually (CT scan). Finally, a urodynamic assessment was performed in 7 patients. RESULTS: No early complications related to the reservoir were observed. Late complications of the diversion were related to the uretero-colonic anastomosis with 3 dilated renal subunits. Continence was achieved in 12 out of 15 patients, while one patient finally refused self-catheterization. In the patients in whom a urodynamic assessment was performed, the mean capacity of the reservoir was 671.4 +/- 273.9 mL for a filling pressure of between 3.7 +/- 1.6 and 11 +/- 2.5 cm H2O and an ileocaecal valve closure pressure of 97.9 +/- 117.1 cm H2O (full reservoir). CONCLUSION: The Indiana pouch is a useful urinary diversion as it is simple to perform and is associated with a low revision rate, while ensuring low-pressure continence.

[Urinary infections in pregnant women]. / L'infection urinaire chez la femme enceinte.

Urinary tract infection is frequent during pregnancy with a high potential risk for mother and child. Based on a review of the literature and a retrospective survey conducted in 20 representative French university hospitals during 1993, the authors propose a practical review designed to standardize the therapeutic approach to this disease. They define a high-risk group which requires systematic screening and close surveillance during pregnancy. They evaluate the need for complementary investigations in relation to the 3 clinical presentations encountered (asymptomatic bacteriuria, cystitis and acute pyelonephritis) taking into account their respective adverse effects. The therapeutic modalities of the three clinical forms are then described, including drainage of the urinary tract.

[Diagnostic and therapeutic approach in organic impotence]. / Approche diagnostique et thérapeutique des impuissances organiques.

The incidence of impotence increases with age. Its etiology is always complex and often multifactorial. The hidden organic causes of impotence are as follows in decreasing order of frequency: arterial, venous, neurological and endocrine. Paraclinical investigation of erection dysfunction plays an important role: hormone levels, arterial Doppler, digitalised rigidimetry, the intracavernous test, cavernometry-cavernography and internal iliac angiography, are used to define the diagnosis and determine appropriate management. It is stressed that supportive sex therapy is often indispensable and that penile prostheses are the final recourse, when treatment based upon etiology has failed.

[The role of ultrasound-guided trans-rectal puncture in the treatment of prostatic abscess]. / Place de la ponction transrectale écho-guidée dans le traitement des abcès prostatiques.

Prostatic abscess is a rare complication of urinary tract infection, whose symptoms and signs are not often specific. Prostatic abscess can now be easily diagnosed by transrectal ultrasonography. The authors report six cases of prostatic abscess diagnosed by ultrasonography. These abscess were successfully drained by ultrasound-guided transrectal aspiration, which may constitute a useful solution, as the classical treatments to date consist of transurethral resection or rectotomy.

[Perineal rehabilitation of female urinary incontinence. Long term results]. / Rééducation périnéale au cours de l'incontinence urinaire féminine. Résultats à distance.

The results of perineal rehabilitation in 101 women with urinary incontinence are evaluated with a follow-up of 18 months (9-37 months). The authors try to precise the clinicals and urodynamicals initials factors of a bad pronostic.