Prognostic significance of PI-RADS 5 lesions in patients treated by radical prostatectomy.

PURPOSE: To analyse the pathological features and survival of patients with a PI-RADS 5 lesion on pre-biopsy MRI. METHODS: We extracted from a European multicentre prospectively gathered database the data of patients with a PI-RADS 5 lesion on pre-biopsy MRI, diagnosed using both systematic and targeted biopsies and subsequently treated by radical prostatectomy. The Kaplan-Meier model was used to assess the biochemical-free survival of the whole cohort and univariable and multivariable Cox models were set up to study factors associated with survival. RESULTS: Between 2013 and 2019, 539 consecutive patients with a PI-RADS 5 lesion on pre-biopsy MRI were treated by radical prostatectomy and included in the analysis. Follow-up data were available for 448 patients. Radical prostatectomy and lymph node dissection specimens showed non-organ confined disease in 297/539 (55%), (including 2 patients with a locally staged pT2 lesion and lymph node involvement (LNI)). With a median follow-up of 25 months (12-39), the median biochemical recurrence-free survival was 54% at 2 years (95% CI 45-61) and 28% at 5 years (95% CI 18-39). Among the factors studied, MRI T stage [T3a vs T2 HR 3.57 (95%CI 1.78-7.16); T3b vs T2 HR 6.17 (95% CI 2.99-12.72)] and PSA density (HR 4.47 95% CI 1.55-12.89) were significantly associated with a higher risk of biochemical recurrence in multivariable analysis. CONCLUSION: Patients with a PI-RADS 5 lesion on pre-biopsy MRI have a high risk of early biochemical recurrence after radical prostatectomy. MRI T stage and PSA density can be used to improve patient selection and counselling.

[Multiple bladder diverticula caused by occipital horn syndrome]. / Diverticulose vésicale liée à un syndrome de la corne occipitale.

We report on the case of a child who presented with recurrent, multiple, and voluminous bladder diverticula. Bladder diverticula are defined as a herniation of the mucosa through the bladder muscle or the detrusor. Causes are numerous and diverticula can be classified into primary congenital diverticula (para-ureteral - or Hutch diverticula - and posterolateral diverticula); secondary diverticula (resulting from chronic mechanical obstruction or from neurological disease; and diverticula secondary to connective tissue or muscle fragility. The latter is seen in disease entities such as prune belly syndrome, Ehlers-Danlos syndrome, cutis laxa syndrome, OHS (occipital horn syndrome), Menkes disease, and Williams-Beuren syndrome. In this patient, the cause of these diverticula was OHS, a genetic, recessive X-chromosome-linked syndrome, responsible for abnormal tissue caused by a disorder in copper metabolism. This case reminds us of the importance of pushing the diagnostic workup when presented with multiple and/or large bladder diverticula, and in particular to search for rare malformation syndromes after exclusion of an obstacle.

Long-Term Functional, Cosmetic and Sexual Outcomes of Hypospadias Correction Performed in Childhood.

OBJECTIVE: Hypospadias surgery, especially when performed early in life, may have a significant impact on the urinary and sexual functions in an adult. Because the literature is still limited, this paper assesses long-term functional, cosmetic and sexual results of hypospadias repair performed in childhood. PATIENTS AND METHODS: The study includes 275 patients older than 12 years treated for a hypospadias by an Onlay, Mathieu, Duplay, or Duckett's technique between January 1990 and December 2000. Flowmetry results were retrospectively obtained from patients' charts. The Paediatric Penile Perception Score (PPPS), the Hypospadias Objective Scoring Evaluation (HOSE) and the IIEF-5 score (when older than 16 years old) questionnaires were used to assess cosmetic and sexual results. The PPPS is designed to assess both penile self-perception with regard to meatus, glans, skin and general appearance. The HOSE is a five-point scoring system designed to allow an objective appraisal of the outcome of hypospadias repair, based on evaluating meatal location, meatal shape, urinary stream, straightness of erection, and the presence and complexity of any complicating urethral fistula. RESULTS: Qmax were within age-adjusted references, independent of the surgical technique, with median (range) Qmax of 18.8 ml/s (range 3-45, n = 136). Patients expressed a high satisfaction for every single item of the penile perception scale (PPPS), with mean values between 2 (satisfied) and 3 (very satisfied). Eighty-two percent were satisfied or very satisfied of the overall evaluation of penile appearance. Eighty-one percent of patients had a normal erectile function (IIEF-5 >22; n = 35/43). CONCLUSIONS: Taking into account the limitation of a small number of patients resulting from a low 21% questionnaire's response rate, the results of this study align with previous reports from the literature and confirms that hypospadias repair using standard techniques results in acceptable functional, cosmetic and sexual outcomes. This study highlights the need of developing a set of standard approved outcomes assessments tools for evaluating the long-term impact of hypospadias repair performed in infancy.

Long-term results of bladder neck reconstruction for incontinence in children with classical bladder exstrophy or incontinent epispadias.

OBJECTIVE: To review the long-term results of bladder neck reconstruction (BNR) in patients with classical bladder exstrophy or epispadias, and to review the concept of continence surgery in these two groups, stressing the difficulty in finding an adequate balance between urine storage (which implies high outlet resistance and low storage pressure) and complete bladder emptying (which implies low outlet resistance and a transient increase in bladder pressure); surgery cannot achieve 'continence' (which implies active mechanisms) but only 'dryness' (which implies passive mechanisms). PATIENTS AND METHODS: Eighty patients with classical bladder exstrophy (52 male, 28 female) and 25 with incontinent epispadias (17 male, 18 female) had their bladder neck reconstructed after a Young-Dees-Leadbetter procedure, subsequently modified by Mollard. The treatment is detailed and results reviewed after a mean follow-up of 11 years. All patients were treated and followed in the same institution. RESULTS: In the exstrophy group, 36 (45%) patients presented with a dry interval of > 3 h, with urethral emptying after one BNR; 52 (65%) presented with recurrent urinary tract infections, 19 (24%) with urinary stones, 21 (26%) with dilated upper urinary tracts, 13 (16%) with bladder perforations and one with an adenocarcinoma of the bladder. Thirty-eight patients (48%) required further surgery; 51% of all patients required an endoscopic procedure within 3 months after the BNR and 26% had endoscopic procedures for late (> 3 months) urine retention. In the epispadias group, 13 (52%) patients presented with a dry interval of > 3 h with urethral emptying after one BNR; 12 (48%) had recurrent urinary tract infections, five (20%) upper tract dilatation, two (8%) bladder stones, one (4%) bladder perforation and one an adenocarcinoma of the bowels after a ureterosigmoidostomy. Ten (40%) children required further surgery. CONCLUSION: We compared the present results for continence with those in other published series; most complications encountered were related to the obstructive pattern of bladder emptying and the abnormal bladder urodynamic behaviour caused by BNR. We consider that BNR is unpredictable and the roles of the other factors in urinary continence are discussed. Alternative procedures are detailed. The concept of continence surgery in exstrophy and incontinent epispadias is reviewed, stressing the importance of favouring bladder development and limiting obstructive patterns of bladder emptying that cause severe and recurrent complications.

Does site-specific labelling and individual processing of sextant biopsies improve the accuracy of prostate biopsy in predicting pathological stage in patients with T1c prostate cancer?

OBJECTIVE: To evaluate whether individual labelling and processing of the sextant of origin improves the accuracy of prostate biopsy in predicting the final pathological stage after radical prostatectomy in patients with T1c prostate cancer. PATIENTS AND METHODS: The charts of 386 patients treated for prostate cancer by radical prostatectomy between January 1996 and June 1999 were reviewed. In all, 124 patients fulfilled the following inclusion criteria: no abnormality on digital rectal examination (DRE) or transrectal ultrasonography, a prostate specific antigen (PSA) level before biopsy of < or = 20 ng/mL, and prostate cancer diagnosed after one set of random sextant biopsies, with the cores being submitted in six separate containers individually labelled for the sextant of origin. RESULTS: Within this series of patients with a low tumour burden, the preoperative PSA, biopsy Gleason score and unilateral vs bilateral involvement were not significant predictors of disease extension. The percentage of positive cores and the number and topography of positive sextants were both statistically significant predictors of organ-confined disease. Although these two variables appeared to be statistically equivalent on a first analysis in the overall series, a subgroup of patients was identified who benefited from the complete topographical information, i.e. those 52 (42%) patients with a Gleason score of < 7, 25-75% positive biopsies and < or =3 positive sextants. CONCLUSION: These results support the individual labelling of biopsy cores in selected patients with a normal DRE and a moderately elevated PSA, as it helps to better predict the final pathological stage. This substantial benefit outweighs the additional effort by the pathologist.

Umbilical reconstruction in patients with exstrophy: the kangaroo pouch technique.

PURPOSE: Before the current attitude of umbilical preservation and transposition at bladder closure in patients with exstrophy the navel was systematically removed. Many patients without an umbilicus complain about this deformity. We report a simple technique of umbilical reconstruction using a rectangular skin flap fashioned as a kangaroo pouch. MATERIALS AND METHODS: Four patients 10 to 20 years old with exstrophy underwent this procedure. A small cutaneous pouch was fashioned by folding a vertical rectangular skin flap and the pouch was anchored deeply to the rectus fascia. A compressive dressing was packed into the new umbilicus and left in place for several days. RESULTS: The 4 patients have an excellent cosmetic result with adequate location, good morphology and sufficient depth at a mean followup of 8 months (range 6 to 11). CONCLUSIONS: Our technique of umbilical reconstruction is easy to perform and provides good mid-term cosmetic results. This technique is particularly adapted for patients with exstrophy who often require external genital reconstruction at the same time.

Laparoscopic ureterolithotomy for ureteral calculi.

BACKGROUND AND PURPOSE: Most patients with ureteral calculi that do not pass spontaneously can be treated by either extracorporeal shockwave lithotripsy (SWL) or ureteroscopy. In rare cases of large, hard and chronically impacted stones, or after failure of first-line treatments, surgical ureterolithotomy is still indicated. Laparoscopy allows performing this procedure in a minimally invasive manner. PATIENTS AND METHODS: Twenty-four patients (22 men and 2 women) underwent laparoscopic ureterolithotomy between 1994 and 1999. The procedure was indicated in 10 cases as a salvage treatment after failure of SWL (5 patients), ureteroscopy (2 patients), both (1 patient), laparoscopic ureterolithotomy (1 patient), or even open ureterolithotomy (1 patient), and in 14 patients as a primary treatment for large stones (median size 11.5, range 8-33 mm). The first 3 procedures were carried out via the retroperitoneal route and the following 21 via the transperitoneal approach. RESULTS: All but 1 stone were successfully removed in a mean operating time of 111 (range 45- 180) min. Postoperative pain was managed with first-line analgesics. Hospital stay ranged from 2 to 10 (mean 3.8) days. The 2 postoperative complications encountered were prolonged ileus (1 patient) and venous thrombosis (1 patient). CONCLUSIONS: Laparoscopic ureterolithotomy is a safe and effective procedure that enables the urologist to maintain a minimally invasive strategy when first-line treatment have failed or are unlikely to be effective.

[Current approach to hypospadias in children]. / Approche actuelle de l'hypospade chez l'enfant.

Hypospadias surgery has dramatically changed over the last 15 years with a new anatomical approach of the ventral penile anomalies and new techniques of repair. The description of the hypoplasia of the tissues forming the ventral aspect of the penis (ventral radius of the penis) beyond the division of the corpus spongiosum, and the concept of urethral plate are the two key-elements to select the most appropriate technique of reconstruction. These modern concepts and the various surgical techniques used are reported here with their results.

[Treatment of neurogenic urinary incontinence in children]. / Traitement de l'incontinence urinaire neurogénique de l'enfant.

The current management of neurogenic urinary incontinence is exclusively urological and therefore palliative. However, urological techniques have considerably advanced over the last 20 years and now allow continence with protection of the upper urinary tract in the very great majority of cases. The authors review the various techniques proposed in achieve acceptable continence and define the indications based on published results and their personal experience.

[Complete radical prostatectomy and positive lymph nodes (stages pT1 to 4, N1 to 3, M0, D1)]. / Prostatectomie radicale totale et ganglions positifs (stades pT1 à 4, N1 à 3, M0, D1).

Lymph node metastases are rarely detected during radical prostatectomy (55/647 patients in our series or 8.5%) and several authors consider that lymphadenectomy is unnecessary in most cases. Criteria based on clinical stage, PSA and tumor grade have been elaborated in order to avoid pelvic lymph node dissection in a low risk population. It is commonly admitted that patients with clinically localized prostate cancer, a PSA level < 10 ng/ml, and a Gleason score < 7 could be spared a pelvic lymphadenectomy. In our series, these patients account for 12% of positive nodes. The best treatment for prostate cancer patients with a nodal disease is controversial. We compare the evolution of two groups of patients: radical prostatectomy alone or combined with an immediate adjuvant hormonal treatment. We observe a difference between the two groups for biological progression (PSA failure) but not yet for clinical progression nor for survival as our mean follow-up in only 6 years.

Is adrenalectomy part of radical nephrectomy?

Standard radical nephrectomy entails en bloc removal of the kidney together with Gerota's fascia and the ipsilateral adrenal. Thanks to the refinement of imaging techniques (ultrasound, CT and MRI), smaller tumors are being diagnosed. In addition, direct extension to the adrenal gland or adrenal metastasis can be detected in most cases. This is why several authors reserve adrenalectomy for large and/or upper pole tumors or abnormal appearing glands on preoperative CT-scan. However, preoperative diagnosis is not always accurate. Furthermore, micrometastatic adrenal invasion at the time of nephrectomy and late recurrences in the persistent adrenal have been documented, so that partisans of adrenalectomy only spare the adrenal in exceptional cases. The authors have reviewed several series in the litterature as well as there own, and conclude that ipsilateral adrenalectomy can be omitted for small middle- or lower pole tumors when the adrenal appears normal on CT and during the surgical intervention.

Megaureter in childhood: conservative or surgical management?

Antenatal and incidentally diagnosed megaureters can be safely treated conservatively after careful work up by combined imaging technics. Serial and repeated imaging are non the less usually necessary to confirm the diagnosis. This aspect could be fastidious and expensive. In case of symptoms, breakthrough infections or loss of kidney function, surgical treatment should be considered and good results can be expected. Refluxing megaureter has to be considered as high grade reflux and surgical approach is more often suggested. The authors have reviewed the experience of 139 patients with megaureters treated in the last decade to illustrate those facts.

[Recurrence following radical surgery for prostatic cancer. Analysis of clinical, biological and anatomo-pathological prognostic factors]. / Récidive après chirurgie radicale pour cancer prostatique. Analyse des facteurs pronostiques cliniques, biologiques, et anatomopathologiques.

To better characterize risk factors of progression (or recurrence) of prostate cancer after radical surgery, we analysed clinical and biological preoperative characteristics and post-operative pathology results in a series of 179 patients who underwent radical prostatectomy between January 1, 1993 and December 31, 1994. The mean follow-up in the series is 36 months (24-36). 39 patients treated before radical prostatectomy by hormonotherapy or surgery (TURP, TULIP) were excluded from analysis. 28 patients treated with immediate adjuvant therapy were also excluded from the study on risk factors of recurrence. Clinical understaging is 37% (50/134 patients with stage T1-T2 have extracapsular extension or invasion of seminal vesicles). Preoperative PSA value is related to the pathologic stage. Extracapsular disease was found in 17% and 46% when PSA was < 4 ng/ml or > 10 ng/ml respectively, thereby confirming the poor staging value of preoperative PSA alone. Analysis of the surgical margins demonstrates a statistically significant difference (p = 0.018) between patients with a preoperative PSA < 10 ng/ml (22% of positive margins) and those with a PSA > 10 ng/ml (42% of positive margins). Predictive factors of recurrence were analyzed in the 112 patients who have not received pre- or postoperative treatment. The respective impact of clinical stage, preoperative PSA value, Gleason score, invasion of prostatic apex, capsular perforation, surgical margins, invasion of seminal vesicles or of pelvic lymph nodes, and invasion of intraprostatic, intracapsular or extraprostatic nerves were evaluated. In T3 cases, we observe 50% recurrence (but only 4 patients fall into this group) versus 14% in clinically localized tumors (T1c-T2c). No recurrence is detected when preoperative PSA is < 4 ng/ml; on the contrary 21% of patients with a PSA > 10 ng/ml recurred. Infiltration of the apex does not influence prognosis. In our experience, capsular perforation is a worse prognostic factor than positive surgical margins, the respective rate of failure being 25% and 17% respectively. Invasion of extraprostatic nerves increases the risk of failure compared to capsular perforation alone (31% vs 18%). Seminal vesicles invasion significantly worsens prognosis (50% vs 13% recurrence respectively; p = 0.024). All patients with positive lymph nodes recurred (p = 0.001).

Prophylactic immunosuppression with anti-interleukin-2 receptor monoclonal antibody LO-Tact-1 versus OKT3 in liver allografting. A two-year follow-up study.

A prospective trial was conducted in 129 recipients of primary liver transplantation, to compare induction immunosuppression using triple drug therapy (cyclosporine, steroids, and azathioprine; group 1, n = 42), versus triple drug therapy with a 10-day course of OKT3 (group 2, n = 44) or of the anti-interleukin-2 receptor monoclonal antibody LO-Tact-1 (group 3, n = 43). Two-year actual patient survival rates were 64%, 79%, and 93% in groups 1, 2, and 3, respectively (1 vs. 2, NS; I vs. III, P = 0.003; 2 vs. 3, NS). Up to 2 years after transplantation, 18%, 44%, and 53% of the grafts in groups 1, 2, and 3, respectively, had not experienced steroid-resistant acute rejection (1 vs. 2, P = 0.002; 1 vs. 3, P = 0.007; 2 vs. 3, NS). The overall incidence of chronic rejection was 4%. OKT3 therapy, but not LO-Tact-1, significantly increased the incidence of cytomegalovirus infections (P = 0.019). In conclusion, immunoprophylaxis with LO-Tact-1 seemed to provide a liver graft acceptance rate at least as satisfactory as that with OKT3, without an increase in the incidence of infections.

The unreliability of the lidocaine/monoethylglycinexylidide test for assessment of liver donors.

The serum monoethylglycinexylidide (MEGX) level 15 min (t15) after i.v. administration of lidocaine (1 mg/kg) in liver donors was retrospectively correlated with graft outcome and early hepatic function. Among the 35 orthotopic liver transplants studied, 4 recipients had to be retransplanted within 10 days post-OLT because of early graft nonfunction or dysfunction, and 3 recipients died, with a median (range) donor MEGX t15 (ng/ml) of 100 (86-119) and 169 (146-182), respectively. The remaining 28 OLT patients living with functioning grafts had a donor MEGX of 87 (18-245). No significant correlations could be found between donor MEGX t15 and recipient mean and peak glutamic-oxaloacetic and -pyruvic transaminases, total serum bilirubin, or mean and minimum prothrombin time values studied from day 1 to day 5 post-OLT. Moreover, categorization of donors using the MEGX t15 cut-off point of 80 ng/ml could not predict liver graft quality, as previously suggested. In summary, MEGX t15 in liver donors correlated neither with graft outcome nor with early functional parameters. Accordingly, the MEGX test should not be used as an isolated discriminatory evaluation for organ utilization.