[The prevention of the recurrence of stage pTa bladder tumors using intravesical instillation of BCG]. / Prévention des récidives des tumeurs de vessie de stade pTa par instillation endovésicale de BCG.

45 patients were included in a retrospective study designed to assess the long-term efficacy and tolerance of immunotherapy by intravesical BCG instillation in the treatment of stage pTa bladder tumours (mean follow-up 52.7 months, range: 12-87 months). 41 patients (91% responded to immunotherapy: 24 (53%) did not develop anu recurrences with a mean follow-up of 49.4 months (range: 19-87 months) and 17 (37.7%) were improved by treatment as the interval between recurrences was significantly increased. 4 patients (8.8%) failed to respond to BCG therapy with progression to stage pTa G3 vesical papillomatosis in one patient. The local tolerance was poor for twelve patients (26.6%), requiring discontinuation or spacing of the instillations. Other complications such as prostatitis and intense fever were observed. Three patients had persistent disturbances of micturition following treatment in the form of urinary frequency due to the decreased bladder volume. Neither the grade, nor the frequency of recurrences prior to treatment, nor the solitary or multifocal nature, nor the site of the initial tumour appeared to influence the response to BCG therapy and did not constitute independent individual prognostic indicators.

[Autosomal dominant polycystic kidney disease: urologic complications and results of kidney transplantation: 217 patients]. / La maladie polykystique rénale autosomique dominante: complications urologiques et résultats de la transplantation rénale: 217 patients.

The authors report a retrospective series of 217 cases of autosomal dominant renal polycystic disease collected over a period of 30 years in the urology and nephrology departments of Nantes university hospital. They study the incidence of urological complications, observed in 87 patients (40%), consisting of calculi (15%), infection (22%, with 4 deaths), intracystic haemorrhages (3.5%) and urinary tract compression (2%). The diagnostic and therapeutic methods are presented and discussed. The results of renal transplantation are also analysed: 39 patients were transplanted, 72% retained a functioning kidney with a mean follow-up of 44.9 months (range: 12-108 months) and three patients died as a result of infectious complications. The 1-year and 3-year actuarial transplant survival rate of 92% was similar to that of renal transplantations performed for another form of renal disease. Preparation for renal transplantation remains an essential problem: the two major indications for pre-transplantation nephrectomy were the size of the kidneys and the presence of infection.

[Acquired phimosis, or preputial sclero-atrophic lichen in children]. / Le phimosis acquis, ou lichen scléro-atrophique préputial de l'enfant.

From 1979 to 1988, 8 cases of balanitis xerotica obliterans were histologically demonstrated in children at Nantes University Hospital. In 6 of these 8 patients, whose average age at the time of consultation was 9.4 years, the phimosis was obviously acquired or recurrent, and the prepuce was sclerous, thick, and produced a tight distal phimosis. One child coming to consultation for relapsing urinary infections at once presented with a long, tight stenosis of the anterior ureter, associated with a dilatation of the upstream ureter and a filiform stream of urine. All the children were circumcised, and the histological study of the specimen demonstrated characteristic lesions in the superficial derma. During the same operation, meatostomy was performed in two children presenting with meatal stenosis. Six of 8 children were followed up with an average time lapse of 6 months: one of them presented with an involvement of the glans penis and a moderate meatal stenosis, which disappeared spontaneously. No improvement occurred for the child presenting with an extensive stenosis of the anterior ureter, in spite of the local instillation of androgens then of corticoids, but his left kidney was dilated on sonograms. Balanitis xerotica obliterans in children is often not recognized and regarded as a common phimosis; it can be suspected because of the clinical features of the phimosis. The condition must be confirmed by the histological study of a circumcision specimen, then followed up regularly to prevent any risk of involvement of the glans, of the ureteral meatus or of the anterior ureter.

[Prevention of complications in inguinal lymphadenectomy]. / Prévention des complications de la lymphadénectomie inguinale.

Inguinal lymphadenectomy, as indicated in the treatment of metastases of carcinoma of the penis and of malignant melanoma in the inguinal lymph nodes, involves considerable mortality and morbidity. From February, 1988, to January, 1990, we performed 15 inguinal lymphadenectomies in 10 patients with an average age 51.9 +/- 5.3 years. The technique used combined a transverse incision parallel to the inguinal fold, complete inguinal lymphadenectomy, transposition of the sartorius muscle and vaporization of a film of fibrin glue. The last 2 operations, besides the effectives protection of the femoral pedicle, aim at suppressing dead spaces that may produce hematomas, subcutaneous infection or lymphoceles, and at avoiding the insertion of an aspiration drain, which causes persistent lymphorrhea. Out of the 15 cases of lymphadenectomy, 5 presented with a small- (48 ml in average) or medium-volume (200 ml) lymphocele, which was treated by a simple evacuating puncture. No necrosis of the skin edges, subcutaneous infection or lymphorrhea were observed. These results are encouraging, since our patients can rapidly resume their social life and have an acceptable quality of survival.

[Post-traumatic stenosis of the membranous urethra]. / Sténoses post-traumatiques de l'urètre membraneux.

Secondary urethral stricture is the most serious complication of traumatic rupture of the membranous urethra, directly related to the treatment of the rupture. In a series of 45 patients treated for urethral rupture with a minimal follow-up of 5 years, 30 developed stricture (66%). An urethral guide, inserted in 31 cases, was responsible for the stricture in 26 of these cases (84%). This stricture developed rapidly (average of 7.4 months), whether the initial rupture was complete or incomplete and was longer (average of 35 mm) in the case of complete rupture. End-to-end urethrorraphy performed between the 15th and 35th day in 14 patients was complicated by 4 secondary strictures (28%). The treatment of the stricture depended on the initial treatment of the rupture and the radiological length of the stricture. In the case of stricture secondary to an urethral guide, end-to-end urethrorraphy for a stricture less than or equal to 40 mm (12 cases) and 2 stage urethroplasty for a stricture greater than 40 mm (4 cases) achieved a good result in 68.8% of cases. The strictures secondary to end-to-end urethrorraphy (4 cases) were treated by direct vision urethrotomy (3 cases) with 100% of immediate good results and by urethral telescoping (1 case) complicated stress urinary incontinence.

[Electrocoagulation of the paraurethral glands (Reiser's operation) in women with urethro-cystalgia]. / L'électrocoagulation des glandes para-urétrales (opération de Rieser) dans les uréthro-cystalgies de la femme.

One hundred nineteen cases of women with chronic urethrocystalgia were reviewed. The symptoms were dominated by urethral burning (83%) and pollakiuria (75%). Electrosection of the paraurethral glands according to Rieser's technique and resection of the urethral floor (100% of cases) were combined with hymeneoplasty in 9% of cases. The results concern 67 women with a mean follow-up of 6 years: cure: 36%; marked improvement: 34%; no change: 30%. The authors discuss the presence of paraurethral glands, their role in the urethrocystalgia syndrome and the place of Rieser's operation in their treatment.

Clinical experience with leuprorelin acetate before radiotherapy for prostatic cancer.

A total of 40 patients with stages A2 to C prostatic cancer were treated with leuprorelin acetate depot once a month for 2 months before being treated by pelvic irradiation or radical prostatectomy. In the 32 patients who were evaluable, seven (22%) were classified as minor responders after leuprorelin treatment and 23 (72%) as major responders when assessed by rectal examination. Prostate-specific antigens also returned to normal concentrations (5 ng/ml) in 26/31 (84%) patients. Leuprorelin acetate depot suppressed plasma testosterone concentrations to castration values during treatment, but concentrations returned to normal 2 months after completion of treatment. Following radical treatment, there were three deaths--one postoperative and two due to recurrent disease--but there was no isolated local relapse. It is concluded that the protocol was locally well tolerated and was effective in the treatment of stages B2 and C prostatic cancer patients.

[Varicocele in children and adolescents. Is surgery justified?]. / Varicocèle de l'enfant et de l'adolescent. Le traitement chirurgical est-il justifié?

Varicocele, a disease essentially observed in adults, is under-estimated in children and adolescents, in whom, for the majority of authors, the therapeutic management is surgical although the benefits in terms of fertility are unknown. Forty-eight children and adolescents, seen between 1978 and 1983, were followed by clinical examination and subsequent sperm count with a mean follow-up of 5.20 years. The presence at the first examination of the subsequent development of testicular atrophy is a pejorative element in the disease: 12% of children managed expectantly developed left testicular atrophy at puberty associated with severe anomalies of the sperm count. Persistent testicular atrophy after surgery was synonymous with anomalies of the sperm count in all of these children. Regression of moderate atrophy was observed in three children after surgical cure, but the pre and post-treatment sperm counts were normal.

[Varicocele in children and adolescents. Is surgical treatment justified?]. / Varicocèle de l'enfant et de l'adolescent. Le traitement chirurgical est-il justifié?

Varicocele , a disease essentially observed in adults, is underestimated der-estimated in children and adolescents, in whom, for the majority of authors, , the therapeutic management is surgical although the benefits in terms of fertility are unknown. Forty-eight children and adolescents, seen between 1978 and 1983, were followed by clinical examination and subsequent sperm count with a mean follow-up of 5.20 years. The presence at the first examination of the subsequent development of testicular atrophy is a pejorative element in the disease: 12% of children simply followed developed left testicular atrophy at puberty associated with severe anomalies of the sperm count. Persistent testicular atrophy after surgery was synonymous with anomalies of the sperm count in all of these children. Regression of moderate atrophy was observed in three children after surgical cure, but the pre- and post-treatment sperm counts were normal.

[Injuries of the posterior urethra. Apropos of 57 patients excluding iatrogenic injuries]. / Les traumatismes de l'urètre postérieur. A propos de cinquante-sept patients à l'exclusion des traumatismes iatrogènes.

Between 1973 and 1986, 57 patients presented with a fracture of the pelvis with rupture of the posterior urethra. All of these patients were treated as an emergency and were then followed periodically with a minimal follow-up of 2 years. There were 4 cases of rupture of the prostatic urethra and 53 cases of rupture of the membranous urethra, including 32 complete ruptures and 21 partial ruptures. In the case of rupture of the membranous urethra, initial treatment, in 34 cases, was realignment by guiding catheter either immediately (25 cases) or deferred emergency (9 cases) and, in the other 19 cases, end-to-end urethrorrhaphy or urethroplasty (2 cases) as a deferred emergency (15th to 32nd day). The results were evaluated on the maximal flow/second and the flowmetry curve, intravenous pyelography with micturating and post-micturating films and the need for dilatations or reoperations. In the cases treated by realignment by guiding catheter, 28 of our 34 patients (82%) developed secondary stenosis which is difficult to treat because of the large amount of granulation tissue and fibrosis, although the best results were obtained by end-to-end urethrorrhaphy (75%). In contrast, repeated dilatations and optical urethrotomies were failures. Deferred emergency end-to-end urethorrhaphy, in 17 cases, ensured a good immediate result in 60% of our patients. Secondary stenosis (7 cases) was always short and easily accessible to optical urethrotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Emphysematous pyelonephritis and perinephritis]. / Pyélonéphrite et périnéphrite emphysémateuses.

The authors report an eighth case of emphysematous perinephritis and a new case of emphysematous pyelonephritis. The general features of these two diseases and their similarities are described: middle aged diabetic women, clinical picture of sepsis, gas images projected over the renal area with delayed excretion on intravenous pyelography, computed tomography reveals the exact site of the emphysematous images (perinephritic and or intraparenchymal). Emphysematous perinephritis may be an early form of emphysematous pyelonephritis. Surgical drainage of the renal compartment allows conservative management at this early stage.

Management of regional lymph nodes in carcinoma of the penis.

In the management of carcinoma of the penis, standard treatment of the primary tumor is by radiotherapy for small lesions (Tis, T1, T2 located in the glans) and by amputation in other cases (T2 with invasion of the shaft). The diagnosis and treatment of regional lymph nodes are thus the essential problems with this cancer. In our series of 45 patients with a minimum 5-year follow-up, clinical assessment was incorrect in 22.5% of cases (22% of the patients with negative bilateral biopsy of the superficial inguinal nodes developed metastases), and many of the complications (flap necrosis, lymphedema) occurring after inguinal lymphadenectomy contributed to a poorer quality of patient survival. A therapeutic approach to the management of regional lymph nodes in order to combat the carcinoma more effectively and improve patient survival quality is suggested.

[Sterility and tumors of the testis. Study of late exocrine and endocrine functions in stage I or IIA tumors]. / Stérilité et tumeurs du testicule. Etude des fonctions exocrine et endocrine à distance dans les tumeurs de stade I et IIA.

Spermatogenesis and plasma hormone levels (testosterone, follicle stimulating hormone and 17 beta estradiol) were studied in patients presenting stage I or IIA testicular tumors. Patients with a previous history of cryptorchidism or varicocele, and those who had received combined chemotherapy, were excluded. In 22 patients (10 seminomas and 12 non-seminoma tumors) a spermogram was obtained at the time of orchidectomy, before the procedure in 9 cases and immediately afterwards in 13. Hormone levels, together with tumor marker assay (alpha feto protein and beta HCG) were determined preoperatively. Exocrine and endocrine function were restudied after 3 years of follow up. There was an initial restudied after 3 years of follow up. There was an initial deterioration in spermatogenesis in 17 patients (77.8%) as shown by a sperm count less than 20 million per cm3, an ejaculate volume less than 1.5 cm3 and a motility after one hour of less than 60%. In this group 11 patients had a sperm count of less than 10 million per cm3. Endocrine anomalies discovered included an increase in serum beta HCG levels (7 cases), combined with a decrease in follicle stimulating hormone and an increase in 17 beta estradiol. After 3 years, only 5 of these 17 patients demonstrated fertile sperm (29.4%). The endocrine anomalies tended to regress after orchidectomy. While these endocrine anomalies were always accompanied by hypofertility, their absence was not synonymous with a normal spermogram. Thus the reestablishment of fertile sperm remains unlikely even in early stage testicular tumors.

[Linitis plastica extending through the entire digestive tract. A case report]. / Linite plastique étendue à l'ensemble du tube digestif. Rapport d'un cas.

A 43-year-old man who presented a perplexing diagnostic challenge, had diffuse linitis plastica involving the entire gastrointestinal tract (autopsy). Although the usual primary site is the stomach in case of linitis plastica, invasion of the large and small bowel is rarely seen, but must be searched with proctoscopic exam and barium enema. We review the literature and discuss the pathogeny of this disorder.

[Long-term evaluation of urinary diversion using a rectal bladder]. / Appréciation à long terme de la dérivation urinaire par néovessie rectale.

The long term assessment of urinary diversion by rectal bladder was studied in 18 subjects with a follow-up between 10 and 26 years (mean follow-up: 20 years). The results were evaluated by means of a triple survey: clinical, radiological and laboratory tests. The functional state of the sphincters was assessed, revealing excellent or good results in 13/17 cases for continence of urine during the day, although a lower score was obtained at night, and 14 excellent or good results for continence of faeces. A satisfactory social, professional and sports activity was possible in the majority of cases. An improvement in the results around the age of puberty was observed in 2 cases. The effects on the upper urinary tract was assessed analytically and globally. The global evaluation revealed 32% excellent results, 48% moderate results and 19% poor results. Electrolyte disturbances were only minor and never required treatment. With a follow-up of 20 years, rectal bladder was found to be competitive with other techniques of urinary diversion. It provides satisfactory protection of the kidneys and the generally satisfactory functional results. Furthermore, relatively simple improvements in the operative technique together with the use of sphincter re-education techniques should allow further improvement in the results.

[Congenital superior mesenteric arteriovenous malformations]. / Malformation artério-veineuse mésentérique supérieure congénitale.

An arteriovenous aneurysm in the region supplied by the superior mesenteric artery was detected fortuitously during abdominal arteriography. The absence of a previous history of injury or operation suggested a congenital origin for this infrequently observed lesion. Logical therapy whenever possible is resection of mesentery and the neighbouring intestine.

[Preoperative vascular loading. A guide for the management of volume expansion in the surgery of pheochromocytoma]. / Epreuve de charge vasculaire préopératoire. Guide pour la conduite de l'expansion volémique au cours de la chirurgie du phéochromocytome.

The most acurate fluid replacement is needed for the operative management of patients with pheochromocytoma. Pulmonary capillary wedge pressure monitoring must be incorporated into routine practice for assessing left ventricular filling pressure because discrepancies between central venous pressure and left-sided filling pressure may occur, even in patients apparently free of cardiopulmonary dysfunction. The response to preoperative acute volume loading was used in 11 patients--to detect preoperatively patients in whom fluid infusion was associated with a dangerous increase in pulmonary wedge pressure without improvement in forward flow and--to provide a guide for intraoperative volume replacement. This method confirmed informations suspected from baseline pressure data in one patient: distorsion between right and left ventricular filling pressures. Furthermore it showed an unsuspected ventricular dysfunction in a second patient with normal baseline pulmonary capillary wedge pressure. Both volume and speed of operative fluid challenge were adapted to this preoperative ventricular response.