[Prognostic value of erythrocyte polyamines levels in renal cell carcinoma. Prospective study in 418 cases]. / Valeur pronostique des polyamines érythrocytaires dans le cancer du rein. Etude chez 418 patients.

OBJECTIVES: Polyamines: Spermine (Spm) and Spermidine (Spmd), are essential for cell proliferation and differentiation. A measurement of erythocytes polyamines (EPA) was developed in our institution. Our objective was to evaluate this marker as a new prognostic factor in renal cell carcinoma. PATIENTS AND METHODS: A blood sample was prospectively taken before surgery, among 418 patients who had an enlarged nephrectomy (n=318) or a partial nephrectomy (n=100) to quantify EPA rates by using the HPLC technique. The qualitative and quantitative variables have been compared using chi(2) and Student statistical analyses. The survivals have been normalized by the Kaplan Meier and Cox methods. RESULTS: The average age of our population was 64 years (21-88). The average decline was 41 months (1-214). The median size of tumors was 6.5cm (1-24). The median rate of Spm and Spmd were respectively 4.7 (1-83) and 9 (2-86)nmol/8.10(9) erythrocytes. Spm and Spmd were linked to the T stage (p=0.001), and the ECOG (p=0.001 and 0,008). Spm was not linked at N and M stages but at the Fuhrman grade (p=0.001). Spmd was linked to the N, M stages (p=0.04). With univariate analysis, the tumor diameter, the TNM stage, the Fuhrman grade as well as Spm and Spmd (p<0.0001) were predictors of specific survival. With multivariate analysis, some prognostic factors remained independent: the TNM stage, the ECOG and Spmd, a continuous variable (p=0.0001), pushing the rank of Fuhrman out of the model. When Spm and Spmd were dichotomized in quantitative variables, they were both independent factors. CONCLUSION: The EPA is a new prognostic tool, before surgery, which will be tested for its integration into prognostic normograms.

Absence of VHL gene alteration and high VEGF expression are associated with tumour aggressiveness and poor survival of renal-cell carcinoma.

BACKGROUND: The von Hippel-Lindau gene (VHL) alteration, a common event in sporadic clear-cell renal-cell carcinoma (CCRCC), leads to highly vascularised tumours. Vascular endothelial growth factor (VEGF) is the major factor involved in angiogenesis, but the prognostic significance of both VHL inactivation and VEGF expression remain controversial. The aims of this study were to analyse the relationship between VHL genetic and epigenetic alterations, VHL expression and VEGF tumour or plasma expression, and to analyse their respective prognostic value in patients with CCRCC. METHODS: A total of 102 patients with CCRCC were prospectively analysed. Alterations in VHL were determined by sequencing, Multiplex Ligation-dependent Probe Amplification (MLPA) and methylation-specific MLPA. Expression of pVHL and VEGF was determined by immunohistochemistry. Plasma VEGF was measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: VHL mutation, deletion and promoter methylation were identified in 70, 76 and 14 cases, respectively. Overall, at least one VHL-gene alteration occurred in 91 cases (89.2%). Both VEGF tumour and plasma expression appeared to be decreased in case of VHL alteration. Median progression-free survival and CCRCC-specific survival were significantly reduced in patients with wild-type VHL or altered VHL and high VEGF expression, which, therefore, represent two markers of tumour aggressiveness in CCRCC. CONCLUSION: Stratifying CCRCCs according to VHL and VEGF status may help tailor therapeutic strategy.

The postoperative bacteriuria score: a new way to predict nosocomial infection after prostate surgery.

OBJECTIVE: Urinary tract infections are the leading nosocomial urologic infections and may be a cause of added morbidity and costs, and sometimes sepsis. The aim of this study was to design a predictive score for these complications after prostate surgery. DESIGN: Multicenter prospective survey. SETTING: Eleven French urology centers. PATIENTS: All patients undergoing transurethral resection of prostate (TURP) during a 3-month period. RESULTS: The overall incidence of postoperative bacteriuria was 25.0% (95% confidence interval, 17.7%-29.5%). Almost all patients (95.7%) received antibiotic prophylaxis. A predictive postoperative bacteriuria score (POBS), with a 6-point scale of 0 to 5, was constructed on the basis of independent risk factors identified in multivariate analysis of a test sample of patients (n=135) and tested in a validation sample (n=73). Significantly more infections occurred in patients with a POBS of 2 or higher (87 [8%] vs 48 [50%]; P<.0001). With the test sample, this yielded a sensitivity of 77%, a specificity of 77%, a positive predictive value of 50%, a negative predictive value of 92%, and a global accuracy of 77%. CONCLUSIONS: POBS could be used to distinguish patients at risk of developing infection after TURP. This information might be useful for implementing selective prevention measures or for adjustment for differences in nosocomial infection rates when comparing data between urology centers.

[Acute and chronic prostatitis, how will we manage it ten years from now?]. / La prostatite aiguë et chronique, quette prise en charge? Perspectives pour tes dix prochaines années.

Pelvic pain syndrom arises in an increasing number of men during their life. The present classification of prostatitis in four categories facilitates a comprehensive review of its diagnosis and treatment. The development of techniques related to molecular biology will favour a deeper knowledge in the future.

[Treatment of heterotopic ossification by extracorporeal shock wave: 26 patients]. / Traitement des paraostéoarthropathies par ondes de choc. Etude sur 26 patients.

OBJECTIVES: To evaluate the effects of extracorporeal shockwave therapy (ESWT) on heterotopic ossification leading to functional limitations in the short and medium term. METHODS: Twenty-six patients with heterotopic ossification received sessions of ESTW (4000 shocks, 3/s), with an energy ranging from 0.54 to 1.06 mJ/mm2, once a week for 4 consecutive weeks. Intermediary assessments performed 1 month after the last session related to pain (on a visual analog scale [VAS]), range of motion, functional independence (FIM), walking distance (whenever possible), radiology, and blood calcium and alkaline phosphatase levels. Eighteen patients with total hip arthroplasty (THA) were followed up by quiz, at 11 months, on average. RESULTS: Heterotopic ossification was neurogenic in 5 patients and nonneurogenic in 21. The length of evolution of ossification was 32+/-21 months. The measurements showing significant improvement in the short term were pain, with a mean decrease of 4.32 to 1.14 on a VAS; joint flexion, with an mean increase of 8.18+/-11.9 degrees; and walking distance, with a mean increase from 1126 to 2776 m. The treatment was tolerated for the most part. THA cases showed a decline in factors initially shown to be improved. However, the long-term results were superior to clinical status before treatment. CONCLUSION: ESWT might be an interesting treatment for heterotopic ossification and can be a complement to usual medical treatment, physiotherapy, and before surgery.

Screening for prostate cancer--how to manage in 2006?

National Societies usually recommend screening for Prostate Cancer (PC) with Serum Prostate Specific Antigen (PSA) and digital rectal examination annually beginning at age 50. In high risk population including men with a family history of PC or African population screening should start at age of 45 years. PSA has been widely used to detect PC despite the fact that PSA is not specific for PC. Over the years serum PSA level of greater than 4.0 ng/ml was considered the treshold to perform prostate biopsy, searching for PC. In 2005 the Prostate Cancer Prevention Trial (PCPT) demonstrated that the cut-off of 4.0 ng/ml for PSA is not anymore adapted due to the fact that this survey found in 15% of men with PSA < or = 4.0 ng/ml a prostate cancer on sextant biopsies. Today the value of PSA and the cut-off for Prostate biopsy is questionned suggesting that PSA level higher than 2.6 ng/ml must be the case to propose Prostate Biopsy. Catalona confirms that approximately 25% to 30% of men with PSA 2.6 to 4.0 ng/ml have prostate cancer. Schröder and Gosselaar assert that screening for PC at low PSA levels (< 4.0 ng/ml) risks to detect clinically insignificant cancers which are no threat to man. So far in the year 2006 screening for PC demonstrates accumulating evidences of efficacy but persistent uncertainty. The major question for an urologist at work when facing a young men searching early diagnosis of PC is: at which level of PSA do we have to perform rectal biopsy?

EAU guidelines on diagnosis and treatment of upper urinary tract transitional cell carcinoma.

OBJECTIVES: On behalf of the European Association of Urology (EAU) guidelines for diagnosis, therapy and follow-up of upper urinary tract transitional cell carcinoma (UUTT) patients were established. Criteria for recommendations are based of level 2 only, as large randomised clinical trials have not been performed in this type of disease. METHOD: A systematic literature research using Medline Services was conducted. References were weighted by a panel of experts. RESULTS: TNM classification 2002 is recommended. Recommendations are developed for diagnosis, radical and conservative treatment and for local chemo-immunotherapy. Prognostic factors are defined. Recommendations for follow-up after different types of treatment are given.

[Recent traumatic injuries of the urethra]. / Traumatismes récents de l'urètre masculin.

Traumatic injuries of the urethra are uncommon. Most Lesions of the anterior (bulbar urethra) are straddle injuries and are initially dealt with by a suprapubic catheter with delayed treatment when urethral stenosis does ensue. Traumatic disruption of the posterior urethra is in most cases related to a pelvic fracture and is often associated with multiple life-threatening injuries, which receive priority treatment. Management of posterior urethral disruption remains a highly controversial issue: alternative treatments include early endoscopic realignment, early open surgical repair and suprapubic catheter and delayed open surgical repair. Management of urethral injuries is described and the different operative techniques are detailed.

Spinal cord compression in metastatic prostate cancer.

INTRODUCTION: Spinal cord compression (SCC) in metastatic prostate cancer is not rare occurring in 1 to 12% of patients. We have analysed patients treated for this condition in our institution assessing outcome and prognostic factors. MATERIAL AND METHODS: Retrospective analysis of the notes of 24 patients hospitalised with SCC due to metastatic prostate cancer from 1987 to 2001. RESULTS: At presentation 3 patients were ambulant with mild neurological deficit, 12 patients were paraparetic and 9 patients were paraplegic. Diagnosis was established by emergency myelogram, CT-scan or MRI of the spine. 8 patients had received no hormone treatment prior to diagnosis of SCC. 19 patients presented dorsal or lumbar pain requiring opioid treatment on average 60 days before onset of neurological symptoms (range 10-840). All patients underwent steroid treatment; the 8 patients without prior hormone therapy were treated with bilateral orchidectomy, 1 out of these 8 patients had castration without other treatments; 12 patients underwent radiotherapy alone and 9 radiotherapy and laminectomy; 2 patients were in terminal conditions and receive only steroid treatment. Overall 15/24 patients were ambulant after treatment. 8 out of 9 patients treated by laminectomy and radiotherapy were ambulant after treatment versus 7 out of 12 patients treated by radiotherapy alone.17 patients died during follow-up with a median survival of 4 months (2 weeks to 49 months). 7 patients were alive at the last control with a mean follow-up of 10 months (range 4-40). CONCLUSION: Outlook in patients with spinal cord compression from metastatic prostate cancer is poor. Efforts must be concentrated on prevention of spinal cord compression. Patients with hormone resistant prostate cancer who develop persistent back pain should undergo imaging studies (bone scan, spine CT-scan or MNR) and prophylactic local radiotherapy to the spine if bony metastases are identified.

Short term therapy for uncomplicated urinary tract infection today. Clinical outcome upholds the theories.

The clinical and bacteriological activity of fosfomycin trometamol (FT) has been compared with several other antibiotics in the treatment of uncomplicated urinary tract infections. A single dose of FT had activity comparable with a 5-day course of trimethoprim in a trial where the causative organism and its sensitivity were unknown. In another trial FT showed better long term eradication compared with a 5-day course of cephalexin and other studies suggested a single dose of FT was comparable with a 7-day course of nitrofurantoin or norfloxacin. There were few important side effects with fosfomycin therapy and it was considered a safe and effective first line treatment in uncomplicated urinary tract infection.

[Renal cell carcinoma in adults less than 40 years of age: a particular cancer? Incidence, outcome and review of the literature]. / Le cancer du rein de l'adulte de moins de 40 ans: un cancer particulier? Incidence, évolution et revue de la littérature.

OBJECTIVE: To study the incidence, clinical presentation, pathological prognostic factors and disease outcome of RCC in young adults less than 40-years-old. MATERIAL AND METHODS: The notes of 400 patients treated by radical nephrectomy for RCC suspicion, between January 1984 and december 1999 were reviewed. Twenty-nine patients (7.25%) were under 40. RESULTS: The most common histological cell type was clear cell carcinoma, found in 20 patients (69%). At a median follow-up of 80 months, 20 patients (69%) were disease free and 9 (31%) died of the disease. When comparing patients less than 40 years vs older than 40 years, we found significant differences in histology type (clear cell carcinoma 69% vs 91%; P = 0.0001), and tumor stage at presentation (pT2 = 34.5% vs 17.3%; P = 0.04) (pT3 = 20.7% vs. 42%; P = 0.03). Disease free survival was not significantly different between the 2 groups (69% vs 65.7%; Log rank test P = 0.4). CONCLUSION: Although rare, RCC in young adults seems to follow a course similar to the disease seen in older patients. Stage at presentation was different between the 2 populations however survival was not affected by age.

Chronic prostatitis: what we know, what we do not know, and what we should do!

Chronic prostatitis is a major health problem in men. This review details the various types of prostatitis, discusses the possible aetiologies and potential pathogens. In addition, the symptoms and therapies are outlined. Those individuals affected by prostatitis suffer from a markedly reduced quality of life with, in many cases, only a limited benefit from treatment. Many questions remain unanswered, and more research is required in this significant disease.

[Carcinomatous degeneration on augmentation ileocystoplasty for tuberculous bladder]. / Dégénérescence carcinomateuse sur iléocystoplastie d'agrandissement pour vessie tuberculeuse.

The development of cancer on the ileal graft after augmentation ileocystoplasty for benign bladder disease is a little known complication. The authors report a case of squamous cell carcinoma in the ileal bladder occurring 37 years after augmentation ileocystoplasty for tuberculous bladder, in a 68-year old patient. Carcinomatous degeneration is usually occurs more than ten years after cystoplasty. Patients treated by this operation must be submitted to annual cystoscopy combined with guided biopsies at the slightest doubt. This surveillance should be started between the 5th and the 10th postoperative year.

Factors influencing adrenal metastasis in renal cell carcinoma.

OBJECTIVES: We determine the incidence and characteristics of adrenal involvement in localized and advanced renal cell carcinoma, and evaluate the role of adrenalectomy as part of radical nephrectomy. MATERIAL AND METHODS: From 1993 to 1999, 210 patients with renal cell carcinoma (RCC), (139 men and 71 women, mean age 60.8 years, range 12-96) underwent radical nephrectomy with associated adrenalectomy. Patients were divided into two subgroups of 106 with localized (stage T1-2 tumor, groupl) and 104 with advanced (stage T3-4N01M01, group2) renal cell carcinoma. A retrospective review of preoperative computerized tomography (CT) of the abdomen was performed. Radiographic findings were subsequently compared to postoperative histopathological results to assess the predictive value of tumor characteristics and imaging in determining adrenal metastasis. RESULTS: Of the 210 patients, 15 (7.1%) had adrenal involvement. Tumor stage correlated with probability of adrenal spread, with T3-4 and T1-2 accounting for 13.4% and 0.9% of cases, respectively (p < 0.001). Upper pole intrarenal RCC most likely to spread was local extension to the adrenal gland, representing 53.3% of adrenal involvement. In contrast, multifocal, lower pole and mid region RCC tumors metastasized hematogenously, representing 21.4%, 7%, and 14% of adrenal metastasis, respectively. The relationship between intrarenal tumor size (mean 7.8 cm, range 4 to 21) and adrenal involvement was not statistically significant. Preoperative CT demonstrated 97.7% specificity, 98.4% negative predictive value, 87% sensitivity and 80% positive value for adrenal involvement by RCC. CONCLUSIONS: Ipsilateral adrenalectomy should only be performed if a lesion is seen preoperatively on CT scan or if gross disease is seen at the time of nephrectomy. The prognosis is poor for RCC with ipsilateral involvement even with complete removal. Because of this poor prognosis we believe that adrenal involvement should constitute a separate stage category.

[Nosocomial infections in urology]. / Infection nosocomiale en urologie.

Hospital acquired infections represent a medical priority for surgeons as well as anesthetists and nursing staff. ANAES charged with national hospital accreditation program establishes protocols and objectives to be attained in terms of quality of care and patient satisfaction. According to available pilot studies, prevention of hospital acquired infections relies on surgical environment, preoperative patient preparation, sterilisation techniques, antibiotic prophylaxis and catheter care. Great improvements are under way in this domain and in management of multiresistant bacterial infections with a decrease in multiresistant kelbsiella infections. Our optimism is however tempered by the increase in methicillino-resistant Staphylococcus aureus (MRSA) infections. Many questions on nosocomial infections are still unanswered due to insufficient scientific evidence and difficulty in organising rigorous studies. Further progress will require a full involvement of hospital administrations and funding health organisations to provide the financial support required to implement preventive procedures and related architectural modifications.

Real indications for adrenalectomy in renal cell carcinoma.

OBJECTIVES: We determined the incidence and characteristics of adrenal involvement in localized and advanced renal cell carcinoma, and evaluated the role of adrenalectomy as part of radical nephrectomy. PATIENTS AND METHODS: From 1993 to 1999, 210 patients with renal cell carcinoma (RCC) (139 men and 71 women, mean age 60.8 years, range 12-96 years) underwent radical nephrectomy with associated adrenalectomy. Patients were divided into two subgroups of 106 with localized (stage T1-2 tumor, group 1) and 104 with advanced (stage T3-4N01M01, group 2) renal cell carcinoma. A retrospective review of preoperative computerized tomography (CT) of the abdomen was performed. Radiographic findings were subsequently compared with postoperative histopathological results to assess the predictive value of tumor characteristics and imaging in determining adrenal metastasis. RESULTS: Of the 210 patients, 15 (7.1%) had adrenal involvement. Tumor stage correlated with probability of adrenal spread, with T3-4 and T1-2 accounting for 13.4% and 0.9% of cases, respectively (p < 0.001). Upper pole intrarenal RCC most likely to spread was local extension to the adrenal gland, representing 53.3% of adrenal involvement. In contrast, multifocal, lower pole and mid region RCC tumors metastasized hematogenously, representing 21.4%, 7%, and 14% of adrenal metastasis, respectively. The relationship between intrarenal tumor size (mean 7.8 cm, range 4-21) and adrenal involvement was not statistically significant. Preoperative CT demonstrated 97.7% specificity, 98.4% negative predictive value, 87% sensitivity and 80% positive value for adrenal involvement by RCC. CONCLUSIONS: Ipsilateral adrenalectomy should only be performed if a lesion is seen preoperatively on CT scan or if gross disease is seen at the time of nephrectomy. The prognosis is poor for RCC with ipsilateral involvement even with complete removal. Because of this poor prognosis we believe that adrenal involvement should constitute a separate stage category.

Prognostic significance of the mode of detection in renal tumours.

OBJECTIVE: To evaluate the mode of detection of 400 renal tumours as a prognostic factor compared with the usual clinical and pathological prognostic variables. PATIENTS AND METHODS: The data were reviewed for 400 patients operated for a renal tumour at our institution between 1984 and 1999, analysing the prognostic value of age, sex, tumour size, stage, grade, vein invasion, adrenal gland invasion, lymph node invasion, metastasis, and mode of detection (incidental or not). The survival rates were assessed using the Kaplan-Meier method and log-rank test, and the data evaluated using multivariate analysis with the Cox proportional-hazard model. RESULTS: In all, 151 (38%) renal tumours were discovered incidentally. There was no significant difference in the percentage of renal cell carcinoma found between the groups of patients discovered incidentally or not (94.4% vs 93.9%). Tumours were smaller in the incidental group (5.7 cm vs 8.7 cm, P < 0.001). In the incidental group, 15.2% of the tumours were treated with partial nephrectomy, against 1.2% in the symptomatic group (P < 0.001). The specific survival was significantly better in patients with renal tumours discovered incidentally (log-rank test, P < 0.001). The multivariate analysis showed that the mode of detection, stage, grade, metastasis (all P < 0.001), and lymphatic extension (P = 0.005) were independent prognostic factors. CONCLUSION: The incidental discovery of renal tumours gives a supplementary benefit to patients in terms of survival, and should be considered as a prognostic factor in addition to stage and grade.

Solitary contralateral adrenal metastasis after nephrectomy for renal cell carcinoma.

Malignant involvement of the contralateral adrenal gland in cases of renal cell carcinoma is extremely rare. Solitary metachronous metastatic involvement of the contralateral adrenal gland from renal cell carcinoma is rarely diagnosed during life. In fact, clinical signs and symptoms of adrenal insufficiency are rare in these patients. We report a case of renal cell carcinoma with solitary metachronous contralateral adrenal metastasis occurring 9 years after radical nephrectomy.