[Results of an epidemiologic surgery carried out with men 50-80 years of age to study urinary disorders, quality of life and sexual function]. / Résultats d'une enquête épidémiologique menée chez des hommes âgés de 50 à 80 ans étudiant troubles mictionnels, qualité de vie et fonction sexuelle.

OBJECTIVE: The prevalence of urinary symptoms, their impact on quality of life and sexuality and the man's attitude in relation to these problem were studied by a self-administered questionnaire (including I-PSS, 6 questions of DAN-PSS-1, BPHQL9 and IIEF). MATERIAL AND METHODS: This questionnaire was sent by mail to a national representative sample of 3,500 French men aged 50 to 80 years. Of the 2,372 men who returned an interpretable questionnaire, 21%, 33% and 42% belonged to the severe or moderate category for symptoms, tolerance of symptoms, and alteration of quality of life, respectively. RESULTS: 81% of men reported sexual activity during the last 4 weeks. 8.3% of men were treated with "antiprostate" medical treatments, and 8% had been operated (16% of them were treated medically after the operation). Only 29% and 17% of men had talked about their sexual and urinary problems, respectively. CONCLUSION: Alteration of functional and perceived sexuality was correlated with age and the severity of symptoms in non-operated patients, but the poor correlations between scales evaluating sexuality and symptoms indicate that sexuality is a difficult aspect to investigate.

[Piezoelectric ESWL for ureteral calculi. Impact of topography and lithiasis measurements on therapeutic approaches and performance]. / LEC piézoélectrique des calculs de l'uretère. Influence de la topographie et des mensurations lithiasiques sur les modalités et performances thérapeutiques.

OBJECTIVE: To evaluate the influence of the site and dimensions of ureteric stones on the modalities and performances of in situ piezoelectric extracorporeal shockwave lithotripsy (ESWL). MATERIAL AND METHODS: A population of 385 patients with solitary radiopaque ureteric stones was analysed. The long axis of these stones (211 (55%) lumbar, 38 (10%) iliac and 136 (35%) pelvic stones) ranged from 5 to 21 mm (mean = 8.2 mm). The initial shock wave frequency was 4/s. Lumbar stones were treated in the dorsal supine position under diaz-analgesia and pelvic stones were treated in the ventral supine position without systematic sedation. The influence of wave frequency (1 versus 4/s) on the level of sedation and therapeutic performances was studied on 146 patients with lumbar (n = 92) or pelvic stones (n = 54). The results were evaluated after only one ESWL session and were analysed statistically by Student's test and Fisher test. RESULTS: The overall complete success rate was 74%. Iliac stones were characterized by significantly (p < 0.05) lower (61%) performances. The results were inversely proportional to the size of the stones, as the complete success rate was only 25% for stones > 12 mm. For lumbar stones, a lower frequency allowed a very significant reduction (p < 0.0001) of the level of sedation required without affecting the performance. For pelvic stones, a low frequency significantly (p < 0.05) limited the efficacy of ESWL, especially for stones > 8 mm (27% of complete successes). CONCLUSION: In situ piezoelectric ESWL allows effective management of most ureteric stones with of long axis between 5 and 10 mm. In the context of outpatient treatment, however, this approach requires modulation of the shock wave frequency according to the site of the stone. Another therapeutic approach, particularly endoscopy, should be considered for very large stones.

Analgesia in piezoelectric SWL: comparative study of kidney and upper ureter treatments.

BACKGROUND: The development of newer-generation lithotripters has reduced the pain associated with SWL, but many patients still require some form of sedation. We prospectively compared the analgesic requirements for kidney and upper ureteral treatments. Predictive factors for pain during piezoelectric SWL were also studied. PATIENTS AND METHODS: A total of 102 consecutive patients without any previous experience of SWL were treated for renal (N = 70) or upper ureteral (N = 32) calculi using the EDAP LT02 lithotripter. The stones' largest diameter ranged from 4 to 30 mm (mean 9 mm). Patients were given an oral dose of 60 mg of dextropropoxyphene hydrochloride and 800 mg of paracetamol associated with 100 mg of ketoprofene per rectum 30 minutes before treatment. The SWL session was begun at low intensity and increased to the maximal range of energy as rapidly as could be tolerated by the patient. The amount of pain during treatment was recorded according to a visual analogue scale (VAS). Further analgesia using intravenous alfentanil was given as required by the severity of the pain. Visual analog pain scores, additional sedation requirements, and success rates after one session were analyzed. RESULTS: The VAS scores and intravenous sedation requirements were significantly lower for patients with upper ureteral stones than for those with renal calculi (P < 0.01). The stone-free rates after one session were, respectively, 90% and 73% (P < 0.05). On the other hand, SWL tolerance was significantly lower for women presenting with renal stones (P < 0.05). CONCLUSION: Piezoelectric SWL without intravenous sedation is suitable for the treatment of upper ureteral calculi. However, such an approach is less efficient in the management of kidney stones, especially for female patients.

Piezoelectric lithotripsy of ureteral stones: influence of shockwave frequency on sedation and therapeutic efficiency.

OBJECTIVE: The aim of this randomized study was to assess the relation between shockwave frequency, sedation, and efficiency in piezoelectric extracorporeal shockwave lithotripsy (SWL) for ureteral calculi. METHODS: A random sample of 114 patients aged between 15 and 74 (mean 45) years were treated at the shockwave frequencies of 1 (N = 57) or 4 (N = 57) per second using the EDAP LT 02 lithotripter at maximum energy. The stones' largest diameter ranged from 5 to 18 mm (mean 7.6 mm). Lower ureteral stones were treated with the patient in the prone position and upper ureteral stones in supine position. The duration of SWL sessions and stone measurements were statistically similar for patients treated at low and high frequencies. The levels of required sedation (none, intramuscular analgesia, intravenous sedation-analgesia) and stone-free rates after one session were analyzed by Student's t-test or Fisher's exact test. RESULTS: Sedation did not differ statistically with SWL frequency for mid and lower ureteral calculi. However, the use of intravenous sedation-analgesia was less common for patients with upper ureteral stones treated at low rather than high frequency (19% and 100%, respectively; P < 0.0001). The success rate was significantly lower (P = 0.04) for lower ureteral calculi treated at low v high frequency (65 % and 89%, respectively) but was not statistically affected by frequency for upper ureteral stones. CONCLUSION: We recommend high frequency for piezoelectric SWL of lower ureteral calculi, especially for stones with a maximum diameter > or =8 mm. On the other hand, low-frequency SWL appears to be suitable for the treatment of upper ureteral stones.

Direct percutaneous approach to the upper pole of the kidney: MRI anatomy with assessment of the visceral risk.

PURPOSE: In an attempt to determine the visceral risk secondary to a direct percutaneous puncture of the upper renal calix, the anatomic relations of the upper pole of the kidney were studied by magnetic resonance imaging. METHODS: Examination was performed on 25 normal volunteers placed successively in the right and left prone oblique position. The kidney axis and minimal distances from the cutaneous plane at the level of the upper and lower poles were measured. Axial and tangential simulated percutaneous approaches to the upper renal calix were compared in term of risk of damage to the pulmonary, splenic, and hepatic parenchyma. RESULTS: The transversal anteversion angle was statistically comparable for right and left kidneys, but the sagittal anteversion angle was significantly higher for right kidneys (p = 0.05). The minimal distance from the cutaneous plane was statistically comparable for the upper and lower poles. The lower pole was significantly deeper for left than right kidneys (p = 0.01). The visceral risk was statistically comparable for left and right kidneys and was significantly higher in case of an approach in the axis of the upper renal calix or through the 10th intercostal space compared to a puncture via the l1th space (p = 0.0001). CONCLUSION: A percutaneous puncture of the upper pole of the kidney above the 11th rib increases the risk of visceral damage. Preoperative evaluation, with the aid of CT scan or MRI, of the risk of pulmonary, splenic, or hepatic injury could be carried out in these cases.

Piezoelectric shockwave lithotripsy of urinary calculi: comparative study of stone depth in kidney and ureter treatments.

PURPOSE: The aim of this prospective study was to assess the relation between stone depth and the efficiency of piezoelectric extracorporeal shockwave lithotripsy (SWL). PATIENTS AND METHODS: A total of 150 patients presenting with 25 pelvic, 75 caliceal, and 25 upper and 25 lower ureteral calculi were treated using the EDAP LT02 lithotripter. All of the stones were easy to localize with sonographic and radiographic systems, and their largest diameter ranged from 4 to 25 mm (mean 8.5 mm). Renal and upper ureteral calculi were treated with the patient in the supine position and lower ureteral stones in prone position. On the basis of a meticulous stone localization and focusing, depth measurements were carried out under real-time ultrasonic guidance, the minimal distance between the cutaneous plane and the focal point being recorded only for definitely localized calculi. RESULTS: Ureteral calculi were significantly deeper than renal stones (p < 0.0001), but the distance from the cutaneous plane was statistically similar for upper and lower ureteral calculi. Stone depth was statistically affected by body mass index (BMI), patients with a BMI >25 having significantly deeper renal and ureteral calculi than subjects with a BMI < or =25 (p < 0.00001 and 0.01, respectively). Renal stones resisting SWL were significantly deeper than successfully treated calculi (p < 0.03). At the level of the ureter, the success rate after one SWL session was 85% for stones with a depth < or =110 mm and 57% for deeper stones, the difference being significant (p < 0.05). CONCLUSION: Stone depth has a significant influence on treatment outcome after piezoelectric SWL for both renal and ureteral calculi. We recommend particular attention be given to corpulent patients presenting with ureteral stones.

[Urologic management of cystine lithiasis in the upper urinary tract. Modalities and indications]. / Prise en charge urologique de la lithiase cystinique du haut appareil urinaire. Modalités et indications.

Cystine urinary stones is a relatively rare hereditary disorder of dibasic amino acid transport characterized by frequent recurrences. The management of these stones remains problematical despite the remarkable progress in the urological treatment of upper urinary tract stones. Cystine stones are particularly refractory to extracorporeal shock waves and relatively inaccessible to dye pulsed laser (504 nm). Apart from this exception, endourological techniques often represent the most appropriate therapeutic solution, but they are associated with significant morbidity. The physicochemical characteristics of these stones also allow dissolution by urinary alkalinization or the formation of disulfide compounds. In parallel with oral treatments, which constitute the basis of prevention of recurrence, dissolution can be obtained by direct perfusion of the urinary tract. This approach often requires irrigation for several weeks with a risk of the specific complications of catheterization, especially percutaneous catheterization. Prophylaxis, essentially consisting of dilution and dissolution of urinary cystine, raises the problem of the potential adverse effects of drug treatment. Cystinuria is easily detectable and can be investigated either systematically or only in the families concerned. However, the incidence as well as the frequently benign nature of cystinuria tend to limit its value and its indications.

[Prognosis in pT3b infiltrating tumors of the bladder treated by adjuvant chemotherapy]. / Pronostic des tumeurs infiltrantes de vessie de stade pT3b traitées par chimiothérapie adjuvante.

OBJECTIVE: To evaluate the prognosis of stage pT3bM0 invasive urothelial bladder tumours treated by cystectomy alone or combined with adjuvant chemotherapy according to the MVAC protocol (methotrexate, vinblastine, adriamycin and cisplatin). MATERIAL AND METHODS: From 1987 to 1996, 90 patients with stage pT3M0 urothelial bladder tumours were treated with isolated cystectomy (n = 69) or followed by MVAC chemotherapy (n = 21). Lymph node stage was N0 (n = 55), N+ (n = 29) or Nx (n = 6). Essentially selected because of their good general status, patients treated with chemotherapy had a lymph node stage N0 (n = 7) or N+ (n = 14). Chemotherapy had to be suspended in 2 cases and with a fatal outcome during treatment in 4 cases, due to tumour progression, surgical complication or bone marrow aplasia. RESULTS: 65 deaths have occurred with a follow-up of 2 to 120 months (m = 15), including 2 postoperative deaths, 39 cancer deaths and 14 intercurrent deaths. The 1-year, 2-year and 5-year actuarial survival rates were 70%, 48% and 19% for stage N0 and 54%, 25% and 3% for stage N+, respectively, with corresponding median survivals of 20 and 12 months (p < 0.005). The recurrence rate increased from 40% at stage N0 to 62% at stage N+ (p = 0.05), and the corresponding recurrence-free survivals were 16 months and 7 months (p < 0.02). The median survival without chemotherapy ranged from 11 months at stage N+ to 20 months at stage N0 and, with chemotherapy, from 19 months at stage N+ to 67 months at stage N0. The median recurrence-free survival with and without chemotherapy, was 43 months and 17 months at stage N0 and 12 months and 7 months at stage N+. CONCLUSION: The prognosis after cystectomy for stage pT3b bladder cancer is severe, especially in the presence of lymph node involvement. Adjuvant chemotherapy according to the MVAC protocol tends to improve survival, especially recurrence-free survival, and appears beneficial at stage N0. However, the value of this adjuvant treatment, which is associated with a high specific morbidity appears to be more relative at stage N+.

[Management of stage I testicular nonseminomatous germ cell tumors with an embryonic carcinomatous component. 18 cases]. / Prise en charge des tumeurs germinales non séminomateuses du testicule de stade I à composante carcinomateuse embryonnaire. Réflexions à partir de 18 observations.

OBJECTIVE: To evaluate the prognosis and therapeutic modalities of stage I nonseminomatous germ cell tumours of the testis (NSGT) with an embryonic carcinomatous component (EC). MATERIAL AND METHODS: 18 patients with stage I nonseminomatous germ cell tumour of the testis with an embryonic carcinomatous component were treated between 1987 and 1995. EC represented more than 50% of the testicular tumour mass in 15 cases. This tumour contingent constituted the only potential prognostic factor in 4 cases, but vascular or lymphatic emboli (n = 3), tumour stage > pT1 (n = 5) or absence of endodermal sinus component (n = 9) were observed in 14 cases. The first 3 patients underwent retroperitoneal lymph node dissection and the following 15 patients were submitted to surveillance (n = 4) or chemotherapy (n = 11) according to the PVB [Cisplatin, Vinblastine, Bleomycin] (n = 7) or BOE [bleomycin, Etoposide, Cisplatin] (n = 4) protocols. RESULTS: With a follow-up of 10 to 110 months (mean: 46), the survival rate is 100% and the recurrence rate is 22%. None of the patients with a local stage exceeding pT1 relapsed after chemotherapy. 2 patients in whom the EC contingent represented less than 50% of the tumour mass and who were simply watched, did not relapse. 4 relapses, detected 3 to 14 months after orchidectomy (mean: 8.5), during surveillance (n = 2) or after chemotherapy (n = 2), required surgical resection or complementary chemotherapy. They occurred in patients in whom EC represented more than 50% of the testicular lesion. The tumour of initially conservatively managed patients did not contain an endodermal sinus component (n = 2) or presented vascular emboli (n = 1). The subjects treated by chemotherapy were characterized by the presence of emboli (n = 1) or the absence of endodermal sinus component (n = 1). The course after recurrence was favourable in 3 cases and the last patient is currently receiving chemotherapy. CONCLUSION: EC is an independent risk factor whose presence justifies proposal of complementary treatment by retroperitoneal lymph node dissection or chemotherapy, possibly limited to 2 courses of BOE. Surveillance can only be considered in the case of a minority of EC in the tumour, in the absence of any associated risk factors.

[Neuroendocrine tumor of the bladder apropos of a case. Review of the literature]. / Tumeur neuroendocrine de vessie à propos d'un cas. Revue de la littérature.

Neuroendocrine bladder tumours are exceptional, and the positive diagnosis is only established when they are already large and advanced. We report an original case in view of its small dimensions. We discuss the differential diagnosis (mainly bladder metastases from lung cancer) and pathological specificities, particularly the value of epithelial immunolabelling allowing exclusion of lymphoma. Because of the similarities with bronchial neuroendocrine tumours, the potential value of serum NSE assay should be emphasized. Combined surgery-cisplatin-based adjuvant chemotherapy is recommended.

Transrectal ultrasonography in prostatic cancer: interexaminer variability of interpretation.

OBJECTIVE: To compare the variability of transrectal ultrasonographic (TRUS) interpretation for the decision of performing biopsies and the lesions to biopsy. METHODS: We extracted at random from our videotape database 16 records of patients who had undergone biopsies, added 2 normal glands and duplicated 2 of these 18 records. Based on the records, 5 well-trained physicians had to describe the images on the tape, and to decide whether or not to biopsy the prostate. A kappa test was computed between each couple of readers, and for the whole group. The kappa test denotes the agreement between examiners. A value of kappa < 0.20 is considered poor to slight agreement, 0.2-0.40 is considered fair agreement. RESULTS: The agreement between the 5 readers was poor for the biopsy decision (kappa < 0.2) and the difficulty to read the records (kappa = 0.05). The results with the global kappa were similar with a highest value < 0.3. Most of the abnormalities were described in the peripheral zone. The global kappa for the seminal vesicles interpretation is poor, but better for the capsular penetration. CONCLUSION: TRUS has a poor informative value between different practitioners. This poor agreement between different practitioners must lead to more objective ultrasonographic methods.

Pharmacokinetics of moxisylyte in healthy volunteers after intravenous infusion and intracavernous administration with and without a penile tourniquet.

The concentration-time profiles of metabolites of moxisylyte (or thymoxamine), an alpha-blocking agent, were investigated in 18 healthy volunteers after intravenous (i.v.) and intracavernous (i.c.) administrations with and without a tourniquet. Four metabolites, unconjugated desacetylmoxisylyte (DAM), DAM glucuronide, and DAM and monodesmethylated DAM (MDAM) sulfates, were found in plasma and urine. For all metabolites, tmax was significantly increased after i.c. administrations and Cmax was significantly decreased. Maximum plasma level of unconjugated DAM was lower after i.c. administration with (1.81-fold) and without (1.26-fold) a tourniquet than after i.v. administration (43.6 +/- 19.6 ng/ml). The elimination half-life of each metabolite showed no change between the three treatments. The difference of 19 min between the mean residence times of unconjugated DAM after i.c. administration with and without a tourniquet may be compared with the difference between the mean duration of the intumescence, that is, 19 min (73 and 54 min with and without a tourniquet, respectively). Total percentages of metabolites recovered in urine were 66.2 +/- 20.9, 61.4 +/- 12.2, and 58.7 +/- 9.1% after i.v. and i.c. administrations with and without a tourniquet, respectively. In conclusion, tourniquet placed before i.c. administration increased the mean residence time of unconjugated DAM of approximately 25% and seemed to increase the efficacy of the drug in healthy volunteers.

[Hot flashes and hormonal treatment of prostate cancer]. / Bouffées de chaleur et traitement hormonal des cancers de la prostate.

Androgen suppression in the context of the treatment of prostatic cancer is responsible for hot flashes in 75% of patients, which alter the quality of life to varying degrees depending on the patient. They constitute a source of major discomfort in 30 to 40% of patients. The pathophysiology of this effect is now known and involves: sex steroids, central opiates and intrahypothalamic catecholamines. The incidence of hot flashes appears to vary according to the type of hormonal treatment administered. The various treatments available are not equally effective. Non-hormonal treatments are of little value. Hormonal treatments: oestrogens and steroidal antiandrogens are the most effective. Progestogens also appear to be just as effective or even more effective than these other agents, with negligible adverse effects at the doses used in this indication.

[Effectiveness of and tolerance to intracavernous injection of moxisylyte in patients with erectile dysfunction: effect/dose relationship versus placebo]. / Efficacité et tolérance du moxisylyte en injection intracaverneuse chez le patient présentant un dysfonctionnement érectile: relation effet/dose versus placebo.

The authors investigated the optima dose (efficacy and safety) of moxisylyte, an alpha-blocking agent, in a double-blind placebo-controlled crossover study in 30 patients. The origin of the erectile dysfunction was predominantly psychological in 14 patients and neurological in 16 patients. Each patient received 4 intracavernous injections in a randomized order (placebo, 10, 20, 30 mg of moxisylyte) at 7-day intervals. Regardless of the dose, moxisylyte induced significantly greater penile responses than placebo on all erection criteria. The frequency of responses allowing sexual intercourse appeared to be dose-dependent in the two aetiological groups. The erectile responses most frequently obtained were complete rigidity in the "neurological" group and tumescence in the "psychological" group. The safety was excellent for 95.6% of injections and no case of priapism was observed. One patient (neurological patient) experienced two prolonged erections after the dose of 20 mg and another patient (psychological patient) reported 2 headaches after the dose of 30 mg. No pain was experienced on injection. Moxisylyte is very well tolerated and is able to induce an erectile response from the dose of 10 mg. This dose appears to be sufficient in patients with central neurological erectile dysfunction; a dose of 20 mg tends to improve the quality of response in patients with a predominantly psychological disorder, although the differences observed between the doses were not statistically significant in this number limited of patients.

Comparison between exact and parametric distributions of multiple inter-raters agreement coefficient.

The Global Kappa statistic can be used for measuring the degree of agreement between more than two raters. In this paper, we give simple computation formulas in the case of dichotomic and no missing responses in order to describe the exact distribution of Kappa for various sets defined by the number of raters, of different examinations and of positive responses. By programming those computations with the SAS software package, we were able to compare the exact and parametric distributions of Kappa. Although the correlation between parameters is high, a linear regression analysis shows that a strong imbalance between positive and negative responses can lead to misinterpretation of the results when using the parametric method.

Percentage area density of epithelial and mesenchymal components in benign prostatic hyperplasia: comparison of results between single biopsy, multiple biopsies and multiple tissue specimens.

OBJECTIVE: To determine whether histological analysis of six multiple random biopsies of the gland or analysis of only one biopsy provides a good estimate of the different components of the hyperplastic gland compared with the results obtained from tissue specimens (reference values). MATERIALS AND METHODS: The various components of prostate tissue obtained from 30 men undergoing suprapubic adenomectomy were investigated. The histological analysis was performed on multiple tissue specimens reflecting adenoma (reference values) and on one and six biopsies performed at random on the enucleated material of the hyperplastic gland. Immunohisto chemistry using anti-actin as a label of smooth muscle and specific histological staining coupled with computer-assisted quantitative morphometric analysis was used to ascertain the histological composition of the prostate. RESULTS: The mean ( +/- SD) area densities obtained from tissue specimens were 34.1 +/- 5%, 32.4 +/- 6.9%, 17.6 +/- 4.5% and 15.9 +/- 5.5% of smooth muscular and fibrous tissue, and epithelium and glandular lumen, respectively. The mean ratio of stromal to epithelial hyperplasia averaged 4.05 +/- 1.73. Both one and six biopsies gave a good estimate of fibrous tissue and glandular epithelium, but the percentage of smooth muscles was overestimated and the percentage of glandular lumen was underestimated. There was a significant relation between the prostate area densities of glandular epithelium (r = -0.41, P < 0.05), the percentage area density of prostate smooth muscle (r = 0.43, P < 0.05), and the weight of enucleated adenoma. No correlation was found with prostate-specific antigen (PSA). CONCLUSION: It seems feasible to propose medical treatment of benign prostatic hyperplasia (BPH) based on the histological composition of the prostate gland. One biopsy, reflecting in good proportions the nature of the adenoma, would be used to provide insight into the pathogenesis and therapy of BPH.

[Carboplatin and urothelial tumors: review of the literature]. / Le carboplatine et les tumeurs urothéliales: revue de la littérature.

Polychemotherapy appears to increase survival moderately but at a cost of severe toxicity, mainly due to cisplatin. New platinum salts (chiefly carboplatin) have therefore been developed. This review on the use of carboplatin in advanced-stage urothelial tumours was undertaken to find the actual place of carboplatin in the treatment of these tumours, and to describe its best use in polychemotherapy. In 322 patients, carboplatin alone gave 12.9% objective responses (OR), 2.5% complete responses (CR) and 10.4% partial response (PR). Many polychemotherapy protocols were used, most frequently carboplatin/methotrexate/vinblastin. The results were OR: 63%, CR: 19%, PR: 44% among 146 patients. These results confirm the relative efficiency of carboplatin on urothelial tumours, particularly when used in combination. Because of the lack of prospective studies and the wide disparity in the doses and in the dose adjustment, no comparison can be made with cisplatin. Carboplatin has virtually no renal toxicity at the usual doses, and does not require hyperhydratation. The pharmacokinetic behaviour of the two platinum salts is highly different, as carboplatin does not undergo tubular metabolism. The efficiency and tolerance of carboplatin used to be optimised by adapting the dose to the glomerular filtration rate, as was shown for germ cell tumours. In conclusion, these considerations fully warrant further clinical trials of carboplatin.