The role of endourology in ureteropelvic junction obstruction.

Endopyelotomy has benefited from abundant confirmatory investigations, and significant progress in different technical modalities has occurred. Retrograde techniques, including the Acucise (Applied Medical, Laguna Hills, CA) cutting balloon and the ureteroscopic Holmium laser incision, are becoming preferred approaches while the other modalities retain their specific indications. Long-term results and potential complications have been carefully studied and reported. Better identification of risk factors has prompted precise preoperative investigations and allowed for careful patient selection, leading to improved results. These results approach those of open pyeloplasty, but with minimal morbidity.

Testicular torsion after previous orchidopexy for undescended testis.

We report one case of acute testicular torsion following orchidopexy for an undescended testis. A review of the literature reveals only ten similar cases. History of a previous testicular surgery should not preclude the possibility of a torsion in that testicle. We conclude that at orchidopexy for an undescended testis, eversion of the tunica vaginalis is an essential step to avoid any future torsion.

Endopyelotomy. Prognostic factors and patient selection.

Although clearly a valid alternative to dismembered pyeloplasty for ureteropelvic junction obstruction in adults, endo(uretero)pyelotomy has not been universally accepted in the general urologic community because of the 10% to 30% inferior success rate and the concern regarding hemorrhagic complications. Identification of prognostic factors for success and complications are therefore of primary importance. The length of stricture, the grade of hydronephrosis, and the level of renal function are well recognized prognostic factors. Crossing vessels also play a role, and in association with the grade of hydronephrosis, they seem to be a major prognosticator of outcome. With attention to such prognostic factors, and appropriate patient selection, results can now approach the gold standard of dismembered pyeloplasty.

[Severe and unexpected occurrence of water-electrolyte disorders in the postoperative period]. / Désordres hydro-électrolytiques sévères et inattendus survenus en période post-opératoire.

Unexpected severe electrolyte imbalance in the postoperative period. Report two cases. Two cases of inappropriate secretion of antidiuretic hormone are reported. In each patient, the physiopathology is reviewed. Differential diagnosis and treatment of hyponatremia is discussed.

Efficacy of laser prostatectomy at 2-years' follow-up.

A total of 32 patients with symptomatic benign prostatic hyperplasia were treated with the right-angle firing neodymium:YAG laser fiber at a 60 W power setting. All these patients represented a high operative risk (ASA score > or = 3) and were excluded by the anesthesiologist for classic surgical treatment. Twenty-six patients were followed at least 24 months; the six remaining patients died of intercurrent disease. Efficacy of treatment was assessed at 3, 6, 12, 18, and 24 months postoperatively by International Prostatic Symptom Scores, peak urinary flow rates, prostatic volume, and radiographic or endoscopic imaging of the prostatic urethra. The mean preoperative symptom score was 25, the mean peak urinary flow rate 7.6 mL/sec, and mean prostatic volume 31 cc. At 2 years postoperatively, the mean symptom score was 5, the mean peak urinary flow rate was 19.3 mL/sec, and the mean prostatic volume was 18 cc. In two elderly patients, in spite of a significant improvement of symptomatology and peak flow rate, a surprisingly obstructed prostatic urethra was found endoscopically.

Vessels around the ureteropelvic junction: significance and imaging by conventional radiology.

We studied the influence of vessels crossing the ureteropelvic junction and of the grade of hydronephrosis in 86 patients who underwent endoureteropyelotomy. With a follow-up ranging from 1 to 12 years, the presence of crossing vessels had a significant negative influence on the outcome and recurrence rate of the procedure. The success rate was 82% when no vessels were present but only 33% when crossing vessels were documented. In 13 of 15 failures (87%), a crossing vessel was found at open pyeloplasty. The degree of hydronephrosis was a less potent detrimental factor, with an 81% success rate in low-grade and 54% in high-grade hydronephrosis. The best results (90% success) were obtained in patients with no crossing vessels and low-grade hydronephrosis and the worst (30% success) in those with high-grade hydronephrosis in the presence of crossing vessels. Selection of patients according to those prognostic factors is recommended. Conventional intravenous urographic imaging techniques proved insufficient, and only angiography provided diagnostic accuracy; less-invasive methods are desirable.

[Percutaneous treatment of tumors of the upper urinary tract]. / Traitement percutané des tumeurs du haut appareil urinaire.

In our Institution, 23 patients were selected for percutaneous resection of tumors of the upper urinary tract. Two patients underwent a second procedure: the first for ipsilateral recur and the second for an heterolateral tumor. Among these 23 patients, 11 presented a benign tumor, 9 were treated for a transitional carcinoma of whom 2 invasive state. Both underwent a nephro-ureterectomy. For the 7 superficial transitional carcinomas, the mean follow-up period is 30.4 months. The ipsilateral local recurrencee is 14.3% (1/7), and concern a poorly differentiated tumor (G III). The advantage of the endoscopic techniques to explore and treat the upper urinary tract tumors is double. With these techniques, we can diagnose and treat adequately benign tumors which don't justify radical surgery. In the case of transitional tumors, the percutaneous way is an acceptable method of management when it appears better to avoid a radical treatment (solitary kidney, bilateral synchronous tumors, impairment of total renal function, general injuries). However, it must be performed only in selected cases, and patients should be carefully selected.

[Paratesticular rhabdomyosarcoma]. / Rhabdomyosarcome paratesticulaire: à propos d'un cas.

The observation presented is based on one patient 18 years old who presents a paratesticular rhabdomyosarcoma stage I. A radical orchidectomy through on inguinal incision with high ligation of the spermatic cord was performed. We have omitted retroperitoneal lymph node dissection. The patient was treated by postoperative chemotherapy with V.A.C. during five weeks. Our patient remains disease free one year post-surgery, but after that, he presents suddenly a symptomatic bone metastasis of the thigh-bone and a massive metastatic pulmonary spreading, without retroperitoneal lymph nodes on the CT-scan. A multidisciplinary approach has considerably improved the prognosis of this tumor. Some reports suggest that routine retroperitoneal lymphadenectomy may be unnecessary for patients with no evidence of nodal involvement on CT-scan. The recent literature insists on problems cause by retroperitoneal lymph node involvement, but our clinical caused must induce us not to underestimate the potential of hematogenous spreading of this tumor.

[Hypospadias: surgical aspects and personal experience]. / Hypospadias: aspects chirurgicaux et expérience personnelle.

In the last eight year period, a series of 102 hypospadias reconstruction performed in our institution were reviewed. 50% presented with marked degree of chordee. Four types of repair where used: MAGPI (n degree 18), Mathieu (n degree 41), Duckett (n degree 28), two stage repair (Duplay) (n degree 12), other procedures (n degree 3). Overall complication rate was 18% and was related to major procedure and difficult technical situations. It never compromised the final outcome of the procedure. The relatively high complication rate mentioned in the literature and in our series emphasizes that hypospadias surgery has to be done by well trained surgeons in this field.