Testicular Metastasis of a Upper Urinary Tract High-grade Papillary Urothelial Carcinoma, 2 Years After Nephroureterectomy.

Urothelial carcinomas are the fourth most common tumors in men. Upper tract urinary carcinomas (UTUCs) are uncommon and represent only 5-10% of urothelial carcinomas.(1) Metastatic testicular cancers are rare and primary tumor sources are the prostate, lung, and gastrointestinal tract. We report the first case of testicular metastasis 2 years after initial curative surgery for a high-grade UTUC, all other reported cases weren't proceed by curative surgery.(3).

Prospective evaluation of early postoperative male and female sexual function after radical prostatectomy with erectile nerves preservation.

Prostate cancer screening has led to the diagnosis of localized prostate cancer in increasingly young and sexually active men. Accordingly, the impact of cancer treatment on sexual function is gaining more attention. To prospectively evaluate the impact of radical prostatectomy (RP) on male, female and conjugal sexual function. Patients were prospectively assessed by an urologist and a sexologist before and 6 months after robot-assisted laparoscopic RP (RALP). RALP was performed with uni- or bilateral neurovascular bundle preservation by a single surgeon. Postoperatively, all patients were prescribed tadalafil 20 mg, 3 times a week during 6 months. Male and female sexual functions were evaluated by using the International Index of Erectile Function (IIEF-5), the Female Sexual Function Index (FSFI) and the Lock-Wallace Marital Adjustment Test (MAT). Continuous variables were analyzed with rank-sum and t-tests, as needed, and categorical variables with chi-squared tests. All tests were two-sided, with a P-value ⩽ 0.05 considered significant. Twenty-one couples were included. Mean patient male and female age was 62.4 and 60.7 years, respectively. Bilateral nerve sparing was performed in 12/21 (57%) patients. Median preoperative IIEF-5 was 20/25, corresponding to mild erectile dysfunction (ED). Median preoperative FSFI and MAT were both within normal range (28/36 and 114/158, respectively). Six months following surgery, both IIEF-5 (11/25) and FSFI (25/36) had significantly dropped (P=0.007 and 0.003, respectively). Postoperative decreases in IIEF-5 and FSFI scores were associated within couples. MAT scores (115/158), however, remained unaffected by RALP, showing an unmodified relationship satisfaction postoperatively. Finally, bilateral nerve sparing surgery preserved not only male but also female sexual function. This study shows that the expected short-term post-RALP ED is associated with a worsening of female sexual function, whereas nerve sparing surgery has a protective effect on both the patient's and his partner's sexual function with a significant effect of bilateral over unilateral neurovascular bundle preservation. Furthermore, we found that conjugal complicity remains stable throughout the first semestrial postoperative period despite the decrease in sexual function.

Can Dopamine Depletion at DAT Scan in a Non Parkinson Patient be the Cause a Refractory Overactive Bladder?

We report here the first case of treatment of idiopathic refractory overactive bladder with dopamine. A female patient consulted for urge incontinence. Management included all recommended treatments without success. DAT scan was finally performed showing clear reduction in dopamine secretion without diagnosis of any neurological condition. Patient started dopamine treatment. At 1 month, patient described persistence of mild urgency and frequency but complete resolution of urge incontinence. At 3 months patient was completely dry with only persistence of mild frequency. Functional imaging and central nervous system target might represent new ways of managing idiopathic overactive bladder.

[Should we prescribe phosphodiesterase inhibitors for the treatment of symptomatic benign prostatic hyperplasia]. / Est-il opportun de prescrire des inhibiteurs de la phosphodiestérase pour traiter le prostatisme?

This October, the FDA has approved the use of phosphodiesterase inhibitors for the treatment of micurition symptoms due to benign prostatic hyperplasia, so as for erectile dysfunction. This decision is essentially based on the results of 2 studies that we discuss in this article. Although methodologically well designed, these works show that phosphodiesterase inhibitors decrease only weakly, but statistically sigificatively the micturition score of patients suffering from prostatism. Besides that, only one of these papers show a limited effect on a single objective micturitionnal parameter. According to the present knowledge, it appears judicious to prescribe tadalafil to treat benign prostatic hyperplasia symptoms of patients suffering simultaneously of a significant erectile dysfunction.

[Testicular torsion: a tricky diagnosis]. / Torsion testiculaire: une urgence piège.

In common urological practice, testicular torsion is one of the most serious emergencies. Consequences can be devastating for the patient, both physically and psychologically. The primary care physician should be able to quickly identify the pathology and refer immediately the patient to a center with surgical facilities. Rapid diagnosis provides the best chances to save the patient's testicle, which may suffer irreversible damage as soon as 6 hours after the onset of the symptoms. History and clinical examination remain the cornerstones of the diagnosis, and are often sufficient to select patients who need surgical exploration. If time allows it, Doppler Ultrasound can often help distinguish torsion from other scrotal conditions, but cannot be considered as a 100% diagnostic tool.

[Robotic partial nephrectomy: development and advantages]. / Développement de la néphrectomie partielle robotisée: avantages.

Surgery is the first line of treatment of renal cell carcinoma. For small tumours confined to the kidney (< or = 4 cm), partial tumour resection has logically become the standard treatment. When technically feasible, partial nephrectomy may be applied to treat tumors less than 7 cm, according to 2010 recommendations of the European Association of Urology. In addition, nephron-sparing surgery has proven to positively impact on quality of life. Robotic-assisted laparoscopy partial kidney resection has recently emerged. Its indications are as yet undergoing validation, while open surgery still remains the gold standard. For the patients, the consequences of this minimally invasive evolution are evident: The comfort and postoperative recovery are respectively greater and faster compared to conventional open surgery.

Female hydrocele: the cyst of Nuck.

The canal of Nuck is the portion of the processus vaginalis within the inguinal canal in women. A hydrocele of the canal of Nuck is equivalent to an encysted hydrocele of the cord in men. The literature reveals very little about this rare condition in the adult female patient. In this paper, we report a case of hydrocele of the canal of Nuck in a young female. The diagnosis was made with ultrasound and magnetic resonance imaging and then confirmed preoperatively and by histopathology. Although rare, a hydrocele of the canal of Nuck has to be included in the differential diagnosis of a groin lump in female patients.

[Robot-assisted surgery in urology]. / Roboterassistierte Operationen in der Urologie.

Since 1990, laparoscopic surgery has undergone a tremendous evolution. As patients and surgeons alike push toward minimally invasive surgery, more and more complex operations have been performed by laparoscopy. However, highly complex and technically demanding procedures--such as radical prostatectomy--have revealed the limits of classical laparoscopic surgery. The introduction of the Da Vinci robot has changed the face of modern laparoscopy because it provides the surgeon with three-dimensional vision, more instrumental degrees of freedom, and greater ergonomics. Thus, laparoscopy has been able to strengthen its role in urology and is increasingly being used for radical prostatectomies, pyeloplasties, and ureteral operations such as ureterovesical reimplantations. For most types of operations, functional and early oncological outcomes appear similar to those of conventional laparoscopy or open surgery. The main drawbacks of robotic surgery are the costs of the disposable instruments and maintenance, which overshadow the initial purchase price. The near future will show how European health systems will react to this new financial burden. Our institution, within a university hospital with moderate patient recruitment, was equipped with a four-arm Da Vinci robot in February 2006. As of April 2008, 120 urological operations had been performed. Because robotic surgery is associated with a specific learning curve, divisions with limited case numbers may refrain from doing this type of surgery. The aim of this article is to evaluate the feasibility and efficiency of the initial period of a robotic program in a midsize division.

[Treatment of localized prostate cancer: the role of robotic radical prostatectomy]. / Traitement du cancer localisé de la prostate: quelle est la place de la prostatectomie radicale robotisée?

Robotic prostatectomy has progressively emerged as an oncologic and functional equivalent to the gold standard of open surgery, with minimally invasive advantages such as a short hospital stay, less blood loss and early return to complete activity. However, mastering the technique remains delicate and requires regular and sufficient practice to reach the aforementionned advantages. Because of the marketing pressure, there is now a plethora of robots available in some areas. This will lead to the multiplication of occasional operators, whose negative impact on the efficiency of the procedure is demonstrated. The solution may be that of aviation: improve skills on a simulator in order to correctly perform clinically. It is now necessary to stimulate the elaboration of such a simulator.

Urothelium dependent inhibition of rat ureter contractile activity.

PURPOSE: We investigated whether urothelium modulates isolated rat ureter contractions. MATERIALS AND METHODS: Segments of intact and urothelium-free ureters were placed in organ baths at 37C. The contractile effects of KCl and endogenous ureteral contractile agents were recorded in the absence and presence of the cyclooxygenase inhibitors indomethacin (1 microM) or ketoprofen (10 microM). The effect of the prostacyclin analogue iloprost was tested on the KCl and agonist induced responses obtained in the presence of ketoprofen. RESULTS: Without stimulation ureters were quiescent but spontaneous contractions often developed in urothelium-free ureters. Sensitivity to KCl was greater in the absence of urothelium. In intact ureters neurokinin A and vasopressin induced rhythmic contractions, whereas carbachol, norepinephrine, bradykinin and angiotensin II were inactive. In urothelium-free ureters the response to neurokinin A and vasopressin was enhanced and the other agonists, except norepinephrine, promoted contractions. In the presence of cyclooxygenase inhibitors intact ureters responded to carbachol, bradykinin and angiotensin II, and the response to neurokinin A, vasopressin and KCl increased. Responses obtained in urothelium-free ureters were not affected by the presence of cyclooxygenase inhibitors. In the presence of ketoprofen iloprost antagonized the KCl and agonist induced contractile effects in intact but not in urothelium-free ureters. CONCLUSIONS: Data suggest that the urothelium prevents spontaneous contractile activity and decreases the potential excitatory effects of endogenous contractile agents on ureteral motility. The mechanism underlying this inhibitory effect appears to involve the participation of a urothelial cyclooxygenase product such as prostacyclin, which could activate the release of urothelium derived relaxing factor(s) that are as yet unknown.

Efavirenz-induced urolithiasis.

We describe the first case of efavirenz-induced urolithiasis in a 47-year-old HIV-positive patient. Urinary obstruction led to pyelonephritis and septic shock, requiring emergency ureteral catheterisation. The subsequent clinical course was favourable, allowing the patient's discharge on day 5. A 7 mm, radio-translucent, non-crystalline, beige stone was extracted during catheterisation. Stone analysis by Fourier transform infrared spectrometry, liquid chromatography and mass spectrometry revealed a stone composed of efavirenz (EFV) metabolites M4, M5, M8 (as described by Mutlib et al. in 1999) and approximately 50% of unspecified proteins. EFV is a non-nucleoside reverse transcriptase inhibitor introduced to European markets in 1999. It is principally metabolised by cytochrome P450 3A4 and 2B6. Of the dose, 14-34% is excreted in the urine, 1% as unchanged drug. The patient had been taking 600 mg EFV per day for 3 years. As EFV-induced urolithiasis has not been reported so far, we would like to draw the attention of the medical community to this potentially severe complication.

Nitric oxide production within rat urothelial cells.

PURPOSE: Recent studies have suggested that nitric oxide (NO) synthase (NOS) may be localized in the urothelium of the proximal part of the mammalian ureter. We investigated endogenous NO production in the proximal half of the rat ureter, localized its cellular source, characterized the NOS isoforms involved and assessed the impact of NO on ureteral motility. MATERIALS AND METHODS: Direct detection of NO production was performed on primary cultures of living rat ureteral cells with the fluorescent indicator diaminofluorescein. Cultures were incubated with the NO precursor L-arginine or the NOS inhibitors L-NAME (N-nitro-L-arginine-methyl ester) and 1400W. NOS expression was determined by immunofluorescence and Western blot analysis. The functional effects of NO donors were assessed on isolated ureters. RESULTS: Significant basal NO production was demonstrated by the high fluorescence level detected in diaminofluorescein treated cell cultures. NO production was strictly limited to urothelial cells since no fluorescence was seen in smooth muscle cells. Pretreatment with L-NAME or 1400W resulted in a significant decrease in fluorescence. Constitutive and inducible NOS isoforms were detected in urothelial cultured cells and in lysates of the urothelial layer. NO donors inhibited in a concentration dependent manner the agonist induced contractile activity of isolated ureters. CONCLUSIONS: These results suggest that NO production stems from the urothelium and the NO pathway inhibits contractile activity in the proximal half of the rat ureter. Hence, the nitrergic pathway may be an important target for drugs producing relaxation of the mammalian ureter.

Adrenal cortical phaeochromocytoma: a case report of a rare entity.

Adrenal cortical phaeochromocytomas (pseudo-phaeochromocytomas) are a very rare entity and a diagnostic challenge. Of the few cases previously reported, most have incomplete data or lack clinical and biochemical follow-up documenting the cure of the excess secretion of catecholamines after resection of the tumour. We report herein a 62-year-old patient with clinical and biochemical findings diagnostic of a phaeochromocytoma associated with a 2-cm adrenal mass on CT scan. Surgery revealed the presence of an adrenal cortical adenoma with positive staining for the neuroendocrine marker synaptophysin, but negative for chromogranin, as has been previously reported for these rare cortical phaeochromocytomas. After removal of the tumour the clinical symptoms resolved and biochemical markers normalized, demonstrating the causal relationship between the cortical tumour and the excess production of catecholamines.

Mechanical tension controls granulation tissue contractile activity and myofibroblast differentiation.

We have examined the role of mechanical tension in myofibroblast differentiation using two in vivo rat models. In the first model, granulation tissue was subjected to an increase in mechanical tension by splinting a full-thickness wound with a plastic frame. Myofibroblast features, such as stress fiber formation, expression of ED-A fibronectin and alpha-smooth muscle actin (alpha-SMA) appeared earlier in splinted than in unsplinted wounds. Myofibroblast marker expression decreased in control wounds starting at 10 days after wounding as expected, but persisted in splinted wounds. In the second model, granuloma pouches were induced by subcutaneous croton oil injection; pouches were either left intact or released from tension by evacuation of the exudate at 14 days. The expression of myofibroblast markers was reduced after tension release in the following sequence: F-actin (2 days), alpha-SMA (3 days), and ED-A fibronectin (5 days); cell density was not affected. In both models, isometric contraction of tissue strips was measured after stimulation with smooth muscle agonists. Contractility correlated always with the level of alpha-SMA expression, being high when granulation tissue had been subjected to tension and low when it had been relaxed. Our results support the assumption that mechanical tension is crucial for myofibroblast modulation and for the maintenance of their contractile activity.

Hand-assisted laparoscopic bilateral nephrectomy.

Open bilateral nephrectomy in renal transplant patients may be indicated for various reasons and is associated with a significant rate of morbidity and mortality. Laparoscopic bilateral nephrectomy may favorably influence postoperative recovery but is technically difficult. This case report is the first description of hand-assisted laparoscopic bilateral nephrectomy. We believe this technique significantly shortens the operative time, increases the safety of the procedure, and assures the patient the benefits of minimal invasive surgery in terms of postoperative pain and recovery.

Combined antegrade and retrograde endoscopic approach for the management of urinary diversion-associated pathology.

BACKGROUND: Endourologic management of stones and strictures in patients with a urinary diversion is often cumbersome because of the absence of standard anatomic landmarks. We report on our technique of minimally invasive management of urinary diversion-associated pathology by means of a combined antegrade and retrograde approach. PATIENTS AND METHODS: Five patients with urinary diversion-associated pathology were treated at our institution between May 1997 and October 1998. Their problems were: an obstructing ureteral stone in a man with ureterosigmoidostomy performed for bladder extrophy; two men with a valve stricture in their hemiKock urinary diversions; an anastomotic stricture in a man with an ileal loop diversion; and a long left ureteroenteric stricture in a man with a right colon pouch diversion. After percutaneous placement of an guidewire across the area of interest, the targeted pathology was accessed via a retrograde approach using standard semirigid or flexible fiberoptic endoscopes. Postoperative follow-up with intravenous urography, differential renal scan, or both was performed at 3 to 24 months (mean 12 months). RESULTS: The combined antegrade and retrograde approach allowed successful access to pathologic areas in all patients. Holmium laser/Acucise incision of stenotic segments or ballistic fragmentation of stones was achieved in all cases without perioperative complications. None of the strictures with an initially successful outcome has recurred; however, in one patient, the procedure failed as soon as the internal stent was removed. The patient with the ureteral calculus remains stone free, and his ureterosigmoidostomy is patent without evidence of obstruction on his last imaging study, 24 months postoperatively. CONCLUSIONS: Combined antegrade and retrograde endoscopic access to the area of interest is our preferred method of approaching pathologic problems in patients with a urinary diversion. An antegrade nephrostogram provides better delineation of anatomy, while through-and-through access enables rapid and easier identification of stenotic segments that may be hidden by mucosal folds. Furthermore, this approach allows the use of larger semirigid or flexible endoscopes in conjunction with more efficient fragmentation devices, resulting in enhanced vision from better irrigation. Finally, an initial endoscopic approach may be preferred because its failure does not compromise the success of future open surgery.

Diclofenac and NS-398, a selective cyclooxygenase-2 inhibitor, decrease agonist-induced contractions of the pig isolated ureter.

Non-steroidal anti-inflammatory drugs (NSAIDs) are currently considered a first-line treatment of renal colic. Their action has been ascribed to the inhibition of renal prostaglandin synthesis, which decreases renal blood flow and diuresis, and consequently lowers the pressure in the renal pelvis and ureter. However, the effects of NSAIDs on induced contractions of ureteral smooth muscle have received little attention. Also, there is a lack of clinically relevant spasmolytic drugs for the ureter. Therefore, we studied the influence of the non-selective cyclooxygenase (COX) inhibitor diclofenac, a NSAID drug customarily used in the treatment of renal colic, and of NS-398, a selective COX-2 inhibitor, on induced contractions of the pig ureter. Serotonin (0.1-30 microM), norepinephrine (0.1-30 microM) and neurokinin A (0.03-10 microM) induced reproducible concentration-dependent contractions, which were inhibited by diclofenac and NS-398 (10-300 microM) in a concentration-dependent manner. The sensitivity of neurokinin A-induced contractions to diclofenac was 3-4 times greater than that of the amines. Depending on the concentration, inhibition ranged between 25 and 96% of the initially induced contractile activity. In the presence of inhibitors, supramaximal concentrations of agonists were unable to trigger recuperation of the initially induced contractions. Prostaglandin F2alpha did not reverse the effect of diclofenac on agonist-induced contractions. Removal of diclofenac or NS-398 from the organ baths showed that the inhibition was totally reversible. Thus, the non-selective COX inhibitor diclofenac and the selective COX-2 inhibitor NS-398 are almost equipotent in reducing agonist-induced contractions in the isolated porcine ureter. Although the clinical relevance of this spasmolytic effect remains to be demonstrated, the data suggest that patients suffering from renal colic may benefit not only from the anti-diuretic and analgesic effects of diclofenac, but also from its potential spasmolytic properties. Moreover, selective COX-2 inhibitors may have clinical potential, as they may cause fewer side effects.

The nitric oxide pathway in pig isolated calyceal smooth muscle.

In pig and humans, whose kidneys have a multi-calyceal collecting system, the initiation of ureteral peristalsis takes place in the renal calyces. In the pig and human ureter, recent evidence suggests that nitric oxide (NO) is an inhibitory mediator that may be involved in the regulation of peristalsis. This study was designed to assess whether the NO synthase/NO/cyclic GMP pathway modulates the motility of pig isolated calyceal smooth muscle. Immunohistochemistry revealed a moderate overall innervation of the smooth muscle layer, and no neuronal or inducible NO synthase (NOS) immunoreactivities. Endothelial NOS immunoreactivities were observed in the urothelium and vascular endothelium, and numerous cyclic GMP-immunoreactive (-IR) calyceal smooth muscle cells were found. As measured by monitoring the conversion of L-arginine to L-citrulline, Ca(2+)-dependent NOS activity was moderate. Assessment of functional effects was performed in tissue baths and showed that NO and SIN-1 decreased spontaneous and induced contractions of isolated preparations in a concentration-dependent manner. In strips exposed to NO, there was a 10-fold increase of the cyclic GMP levels compared with control preparations (P < 0.01). It is concluded that a non-neuronal NOS/NO/cyclic GMP pathway is present in pig calyces, where it may influence motility. The demonstration of cyclic GMP-IR smooth muscle cells suggests that NO acts directly on these cells. This NOS/NO/cyclic GMP pathway may be a target for drugs inhibiting peristalsis of mammalian upper urinary tract. Neurourol. Urodynam. 18:673-685, 1999.

The significance of the open bladder neck associated with pelvic fracture urethral distraction defects.

PURPOSE: As a result of pelvic fracture urethral distraction defects, urinary continence relies predominantly on intact bladder neck function. Hence, when cystoscopy and/or cystography reveals an open bladder neck before urethroplasty, the probability of postoperative urinary incontinence may be significant. Unresolved issues are the necessity, the timing and the type of bladder neck repair. We report the outcome of various therapeutic options in patients with pelvic fracture urethral distraction defects and open bladder neck. We also attempt to identify prognostic factors of incontinence before urethroplasty. MATERIALS AND METHODS: We retrospectively reviewed the records of 15 patients with a mean age of 30 years in whom an open bladder neck was identified before posterior urethroplasty between January 1981 and October 1997. RESULTS: Of the 15 patients 6 were continent and 8 were incontinent postoperatively. One patient underwent artificial urethral sphincter implantation simultaneously with pelvic fracture urethral distraction defect repair and was dry postoperatively without sphincter activation. Average bladder neck and prostatic urethral opening on the cystourethrogram before urethroplasty was significantly longer in incontinent (1.68 cm.) than in continent (0.9 cm.) patients. Of the 8 patients who were incontinent 6 underwent bladder neck reconstruction, 1 artificial urinary sphincter and 1 periurethral collagen implant. Five patients with bladder neck reconstruction are totally continent and 1 requires 1 pad daily. The patient who underwent collagen implant requires 2 pads daily and the patient who received an artificial urethral sphincter has minor urge leakage. CONCLUSIONS: Open bladder neck before urethroplasty may herald postoperative incontinence which may be predicted by radiographic and cystoscopic features. Evaluation of the risk of postoperative incontinence may be valuable, and eventually guide the necessity and timing of anti-incontinence surgery, although our preference remains to manage the pelvic fracture urethral distraction defects and bladder neck problem sequentially. Bladder neck reconstruction provides good postoperative continence rates and is our technique of choice.

Renal lymphoma in an azotemic patient--usefulness of magnetic resonance imaging.

An azotemic patient benefited from diagnostic magnetic resonance imaging (MRI) in the evaluation of his renal mass. This led to suspicion of lymphoma, and provided guidance for percutaneous biopsy. Chemotherapy was then initiated, and an unnecessary nephrectomy was avoided. After a year of follow-up, evolution was stable and renal function significantly improved.