[Initial results of a novel technique for sperm retrieval in male infertility due to refractory retrograde ejaculation]. / Résultats préliminaires d'une nouvelle technique de recueil du sperme vésical en présence d'éjaculation rétrograde réfractaire au traitement médical.

AIMS: To describe and evaluate a novel technique of spermatozoa retrieval from patients suffering from infertility secondary to refractory retrograde ejaculation. METHOD: Prospective study to compare mobility and vitality of spermatozoa obtained from urine (U) after oral modification of chemical parameter (PH, Osmolarity) versus from endovesical instillation of sterile spermatozoa culture medium before ejaculation (F). Patients were their own controls. Twelve month prospective follow-up was achieved to document the results of assisted procreation. RESULTS: Eight patients were included and mobility and vitality were improved in all patients after F technique was compared to U technique. With U technique, eight patients on eight had negative defrost test; after F technique, seven patients on eight had a positive defrost test and could therefore have access to assisted reproduction techniques. Four couples had five ICSI and obtained three pregnancies leading to five births. CONCLUSION: Endovesical instillation of sterile spermatozoa culture medium before ejaculation was a safe and effective technique to improve spermatozoa quality in male infertility related to refractory retrograde ejaculation.

[The spinal cord injured patient: semen quality and management by Assisted Reproductive Technology]. / Le blessé médullaire: quel sperme et quelle prise en charge en Assistance médicale à la procréation?

Men with spinal cord injury present a unique infertile population. Only 10 % of them can father children without medical assistance, owing to potential impairments in erection, ejaculation and semen quality. The algorithm typically followed is to retrieve semen by Penile Vibratory Stimulation, in case of failure by Electro Ejaculation. Most of these patients have normal sperm concentrations but abnormally low sperm motility and vitality in the ejaculate. The reasons for poor semen quality in spinal cord injured men are reviewed. If semen cannot be obtained by Electro Ejaculation, or if the ejaculate from Penile Vibratory Stimulation or Electro Ejaculation contains an insufficient quantity or quality of sperm for in vitro fertilization with intracytoplasmic sperm injection, then retrieval of sperm from reproductive tissues is attempted. Despite abnormal semen quality, successful pregnancies with sperm from spinal cord injured male partners have occurred by intravaginal insemination, intrauterine insemination, and in vitro fertilization with intracytoplasmic sperm injection. The prevailing pregnancy and fecundity rates in couples with a spinal cord injured male partner are reviewed.

[Urinary incontinence following open prostatectomy or laparoscopy for local prostate cancer. A review of relevant literature]. / Incontinence urinaire après prostatectomie ouverte ou laparoscopique pour cancer prostatique localisé. Une revue de la littérature.

AIM: Evaluate urinary continence after radical prostatectomy. MATERIALS AND METHOD: Recent series about urinary continence were studied. RESULTS: In seven articles analyzed, continence fluctuated between 63.6 and 91.9%. Evaluation benchmarks were depending on study. Unlike self-questionnaires, objective criteria (pad test) should be more reliable. Carcinologic prognostic factors were not implicated directly. The most frequently preoperative risk factors of incontinence were: age, BMI. Peroperative parameters, attesting of surgical difficulties could have a functional impact. Bladder neck preservation could affect the recovery velocity but not functional results. Length of catheterization and lack of urinary rehabilitation could be influent. The mean of continence evaluation after radical prostatectomy was different for each study. CONCLUSION: Comparability was difficult because operative technique, group's features and mean of functional evaluation were different from study to study. Several risk factors were found but without consensus. It would be necessary to separate carcinologic and functional risk factors.

[Two-years follow-up of radiofrequency thermotherapy for urination disorders due to benign prostatic hyperplasia]. / Résultat à deux ans de la thermothérapie prostatique par radiofréquence pour troubles mictionnels liés à l'HBP.

AIM: To describe medium-term functional results of Transurethral Needle Ablation (TUNA) to treat symptomatic benign prostatic hyperplasia (BPH) refractory to medical treatment. MATERIALS AND METHOD: Patients who completed at least 2 years follow-up after TUNA were systematically offered a reevaluation including: Flowmetry, PSA, symptom score (IPSS), satisfaction index visual analogic scale (VAS) and a treatment impact evaluation with a Likert scale (ranging from much worse to much improved). RESULTS: From December 2002 to January 2007, 45 patients were treated with TUNA under local regional anaesthesia (prostatic block). Twenty-seven of them were followed-up longer than 24 months (median follow-up 44 months [26-52]). Changes in the selected outcomes were: increase in Qmax from 9.5 mL/s preoperatively to 9 mL/s at 6 month and 11.5 mL/s after 2 years; increase in IPSS from 19.3 before TUNA to 16.3 at 6 month and 16.5 after 2 years. About subjective evaluation, 58% of patient gave a satisfaction VAS>or=6, and the improvement index was greater or equal to +1 in 67% of case. CONCLUSION: In this initial monocentric experiment, despite a modest improvement of objective parameters and a 20% of retreatment rate, TUNA give contentment and improvement sensation for 60% of patients who were treated for non-efficiency of medical treatment for benign prostatic hyperplasia.

[Techniques, indications and results of permanent prostate brachytherapy for localized prostate cancer]. / Techniques, indications et résultats de la curiethérapie interstitielle par implants permanents dans le cancer localisé de la prostate.

Permanent seed brachytherapy as a monotherapy is an appropriate treatment in patients with low risk localized prostate cancer such as intraprostatic cancer, T1-2 stage, PSA less than 10 ng/mL, low tumour volume, well differentiated cancer (Gleason score less than 7), gland size less than 50 mL, no micturition symptoms that could decompensate after implantation. A brachytherapy program needs a specialized multidisciplinary team with the collaboration of urologists, radiotherapists (authorized person to manipulate radioactive elements), and physicists. The 10-year oncologic and morbidity results have been published in the literature and are comparable to those of other standard treatments of localized prostate cancer such as radical prostatectomy and external beam radiation therapy.

European collaborative group on prostate brachytherapy: preliminary report in 1175 patients.

OBJECTIVE: To establish a multi-centre database of a large number of patients treated with brachytherapy across Europe. METHODS: A total of 1175 patient files were registered in the database and the completeness of the data on these patients resulted in the majority being included in the analysis. RESULTS: The database of patients treated with brachytherapy across Europe indicates that optimal patient selection for this procedure has been made, both in terms of outcome and side-effects, which will be subject of future analyses. This should enable refinement of the treatment choice and administration as well as provide useful guidance to other centres that want to establish this procedure for their patients. It will also set the ground for prospective studies. CONCLUSIONS: The established database indicates that brachytherapy as a treatment option for prostate cancer is well established in many centres.

[Botulism toxin in practice]. / Toxines botuliques: utilisation pratique.

Botulinum toxins (A and B) are neurotoxins derived from Clostridium botulinum. Clostridium are anaerobic bacteria. C. botulinum produces exotoxins (A to G) with distinct antigenicities. The neurotoxins inhibit the release of the neurotransmitter acetylcholine from the axon terminals of motor neurons. Botulinum toxin is officially used in clinic for the treatment of muscular hyperactivity (strabismus, blepharospam, cervical dystonia). Botulinum toxins are also used in non recognized clinical applications: neurogenic incontinence, palmar and axillary hyperhidrosis, chronic anal fissure. The respective formulations of Botox, Dysport and Neurobloc are described. Special considerations for administration are introduced.

[Correlation between Gleason score of prostatic biopsies and the one of the radical prostatectomy specimen]. / Corrélation entre le score de Gleason des biopsies prostatiques et celui de la pièce de prostatectomie radicale.

UNLABELLED: The Gleason score obtained on prostatic biopsies is an essential element in the treatment decision for localized prostate cancer. The objective of this study was to evaluate the correlation between the biopsy Gleason score and the definitive Gleason score and to propose a classification into 3 groups in order to improve this correlation. MATERIAL AND METHODS: One hundred radical prostatectomies were performed between 1995 and 1998. Eighty four of these patients underwent 6 biopsies. The Gleason score of the biopsies and operative specimens were compared. The concordance between the biopsy Gleason score and the operative specimen Gleason score was initially analysed score by score. The concordance was then established according to three groups, well differentiated tumours (score 2-4), moderately differentiated tumours (score 5-7), poorly differentiated tumours (score 8-10). RESULTS: The concordance between the biopsy Gleason score and the operative specimen Gleason score was perfect in only 37% of cases. A 1-point difference of the score was observed in 35.7% of cases and a 2-point or greater difference was observed in 27.3% of cases. By classifying patients into 3 groups, the concordance increased from 37% to 72.6%. CONCLUSION: The classification of patients into three distinct groups (well, moderately and poorly differentiated tumours) increases the concordance between the biopsy Gleason score and the definitive Gleason score. However, the limitations of the biopsy Gleason score must be kept in mind, particularly in the case of low-grade tumours.

[Patterns of use of terazosine in current medical practice in ambulatory patients with obstructive and irritative obstructive disorders of urination]. / Modalités d'utilisation de la térazosine en pratique médicale courante chez des patients ambulatoires présentant des troubles mictionnels obstructifs et irritatifs.

OBJECTIVES: To evaluate the efficacy and to describe the modalities of use of terazosin hydrochloride dihydrate, prescribed under conditions of routine clinical practice to a vast population of patients with benign prostatic hyperplasia (BPH). MATERIAL AND METHODS: 1,624 patients suffering from BPH and requiring medical treatment were included in this multicentre open clinical trial performed by 983 general practitioners. After a one-week titration phase, terazosin was administered for 4 weeks at the dosage of 5 mg per day as a single dose in the evening at bedtime. The efficacy of treatment was assessed by the variation of the IPSS score between inclusion and the end of treatment, the treatment response rate (at least 3 point reduction of the IPSS score) and the course of the quality of life score. The safety of treatment was evaluated by clinical interview and physical examination at each visit and by analysis of all adverse events occurring during the trial. RESULTS: A mean 45.8% improvement of the IPSS score (corresponding to a mean decrease of 8.81 points) was demonstrated between D0 and D35 (p < 0.001). The treatment response rate was 91.8%. A mean improvement of 2.11 points (p < 0.001) of the quality of life score was obtained. Complementary subgroup analysis (moderate dysuria n = 775 and severe BPH n = 702) showed that the efficacy of treatment was independent of the initial severity of the voiding disorders. The clinical safety of treatment was considered to be good in 92.5% of cases by the investigators. The incidence of adverse events attributable to treatment and related to a fall in blood pressure was 2.6%. Less than half (20/43, i.e. 1.25% of the population) of the patients experiencing this type of adverse event had to discontinue treatment. The ease of use of treatment was considered to be good in 85.2% of cases. CONCLUSION: Terazosin constitutes an effective symptomatic treatment for BPH when surgery is not indicated, whether the initial disorders are moderate or severe. The safety of treatment appears to be perfectly satisfactory, in a patient series representative of the general practice outpatient population concerned by BPH (age, state of health, concomitant treatments). The one-week progressive dose regimen allows cautious introduction of treatment and generally does not raise any problems of acceptability.

[What is the role of the correspondence of free PSA/total PSA in the staging of local prostate cancer? Series of 50 radical prostatectomy cases]. / Le rapport PSA libre/PSA total a-t-il sa place dans la stadification du cancer localisé de la prostate? A propos d'une série de 50 prostatectomies radicales.

OBJECTIVE: To refine the pretreatment staging of localized prostate cancers. MATERIAL AND METHOD: Prospective study on 50 total prostatectomy specimens from men with apparently prostate-confined adenocarcinoma. Preoperative assay of the free PSA/total PSA ratio and analysis of this ratio according to the presence of capsular effraction, capsular invasion and positive margins. RESULTS: Significant difference of this ratio according to the presence or absence of capsular effraction (13.2% versus 18.9%), capsular invasion (12.4% versus 17.5%) and positive margins (11.6% versus 16.3%). CONCLUSION: The free PSA/total PSA ratio can be useful for staging of prostate cancer, but this needs to be confirmed by a large-scale prospective study.

[In vitro and in vivo models developed from human prostatic cancer]. / Modèles in vitro et in vivo développés à partir de cancers prostatiques humains.

The possibility of maintaining and studying human prostatic cancers in an in vitro and in vivo environment has allowed the development of rare but essential tools to study many aspects of the biology of these cancers. Although none of the available models is perfect, the sum of the studies conducted with these models over more than 20 years constitutes the basis for major progress in our understanding of this disease. The most widely used cell lines (cultured in vitro) are PC-3, DU-145 and LNCaP. They are limited by the fact that they are essentially androgen-independent cell lines, derived from metastatic sites. Due to the slow growth of prostatic cancers, it is very difficult to obtain cancer cell lines which can be transplanted in immunodeficient animals (such as athymic mice) and only a few xenografts are currently available, some of which, like PCV-82, LuCaP 23, CWR-22, are androgen-dependent or sensitive. These models can be used to study host-tumour interactions as well as endocrinological interactions, stroma-tumour cell interactions, and to analyse molecular phenomena related to stages of hormone dependence and hormone resistance. In vitro and in vivo models of metastatic prostatic cancer have also been developed and appear to have a crucial impact on the understanding of metastatic mechanisms and new therapeutic approaches. This paper describes the main experimental models developed from human prostatic cancers, their main characteristics, their value compared to clinical cancers and some of the major studies conducted with these models. Due to the exponential progress in molecular biology techniques and oncogenetics, it appears essential to increase the number and diversity of experimental models of prostatic cancer in order to advance research concerning the crucial phenomena occurring during the course of this disease, from oncogenesis to currently incurable metastatic stages.

Clinical experience with 80 inflatable penile prostheses.

OBJECTIVES: Prosthetic surgery for impotence has been transformed by the use of inflatable prostheses, superseding the old semi-rigid designs. Our objective is to report the functional results and the complications of this type of surgery. METHODS: 80 inflatable prostheses were implanted between October 1987 and October 1994. The mean follow-up was 3 years and assessment of the objective (mechanical functioning of the prosthesis and complications) and subjective results (sexuality of the patients) was made in 68 patients. RESULTS: There were: 54.5% functional disturbances, 7% infections, and 27.5% prosthesis removals. Most of the patients were satisfied, although only 65% returned to regular sexual activity. CONCLUSIONS: The choice between an inflatable and a semi-rigid prosthesis should be carefully discussed because of the frequent mechanical complications that have been reported for the sophisticated designs. Inflatable penile prostheses nevertheless remain the design of choice. Their reliability has been increasing since the manufacture of monobloc designs. Such a device is costly, and should be compared with that of intracavernous injections.

Impact of recombinant human granulocyte colony stimulating factor on dose intensity and toxicity of three cycles of methotrexate, vinblastine, doxorubicin and cisplatin in patients with previously untreated urothelial bladder carcinoma.

This single arm, open labeled, non randomized study was aimed to evaluate the toxicity of 3 cycles of MVAC (methotrexate, vinblastine, doxorubicin and cisplatin) with rhG-CSF (5 micrograms/kg/day from day 3 to day 14), on 14 patients with previously untreated infiltrating bladder carcinoma, 42 cycles were administered. Chemotherapy toxicity was very low, with 7% of neutropenia grade 3 or 4.4% of thrombocytopenia grade 2, no mucositis above grade 2 and no nadir sepsis. Bone pain related to rhG-CSF occurred in 14% of cycles. 88% of the cycles were given at full dose without any delay and mean relative dose intensity was 96.4% (RDI was 100% for 9 patients). One patient achieved a complete pathological response (cystectomy: 1) and 6 clinical responses with negative transurethral resection. Addition of rhG-CSF to MVAC chemotherapy allows a high dose intensity of MVAC with very low toxicity over 3 cycles. This association should be compared to standard MVAC or intensified regimens to evaluate efficacy, toxicity, and cost effectiveness.

[The Miami pouch: a reliable continent urinary diversion after pelvic exenteration]. / La poche de Miami: une dérivation urinaire continente fiable après exentération pelvienne.

OBJECTIVES: To describe the technique and present the results obtained with the Miami reservoir, a continent urinary diversion, after pelvic exenteration for advanced gynaecological tumours. METHODS: A Miami reservoir was performed in 12 patients between January 1993 and January 1995. A detubed right colonic reservoir was created using automatic resorbable staples. The ureters were reimplanted into the reservoir using an anti-reflux system and continence was ensured by forming a tube with the terminal loop of ileum and by using a Bauhin valve, which can be reinforced when it is incompetent. Regular postoperative follow-up was conducted (6 to 26 months) with monitoring of laboratory parameters, intravenous urography, opacification of the reservoir, urodynamic assessment of the continent diversion. RESULTS: There were no surgical complications related to the urinary diversion. Urinary continence was obtained in every case and after medical treatment of residual peristaltic contractions of the detubed colonic reservoir in 2 patients. Protection of the upper urinary tract was satisfactory after 2 years of follow-up, without stenosis or reflux of the uretero-colonic anastomoses. The mean capacity of the colonic reservoir was 465.5 +/- 101 ml at 6 months, with filling pressures lower than 20 cm H2O. CONCLUSION: The Miami reservoir is a continent urinary diversion which is relatively easy to perform and reliable in terms of continence and protection of upper tract. However, a longer postoperative follow-up is required. The quality of life of young patients after pelvic exenteration is improved due to this type of contingent diversion which avoids the need for an abdominal urine collector, although it requires intermittent self-catheterization.

Construction of a urinary sphincter by means of an electrically stimulated striated muscle: experimental procedure and urodynamic results on canine model.

A canine model of urinary neosphincter using electrically stimulated autologous striated muscle is described. The superior belly of canine sartorius was activated by a pacemaker with an intermittent low frequency stimulation (0.5-1 pulse per sec) during 7 weeks. Then, the muscle graft was passed around the urethra and sutured back on to itself to form a neosphincter. The surgical procedure was easy to perform and with no complication. Urethral pressure profile was performed initially (T0), and when the muscle was in peri-urethral position, before (T1) and during electrical stimulation (T2). The continence parameter readings (maximal urethral closure pressure MUP, functional length FL, continence zone CZ, and continence area CA) increased from T0 to T1, and from T1 to T2. We noted: 1) 28%, 38%, 52%, and 86% increases for the MUP, FL, CZ, and CA respectively from T0 to T1, 2) 10%, 41%, 30%, and 43% increases for MUP, FL, CZ, and CA respectively from T1 to T2. Chronic low frequency stimulation could transform a skeletal fast-twitch type 2 muscle into a slow-twitch fatigue-resistant type 1 muscle. In this study, morphological changes of the stimulated muscle were noted, whereas phenotype was unchanged. This dynamic autologous neosphincter may be a new alternative to the artificial urinary sphincter prosthesis with fewer complications. Further studies are ongoing to evaluate the efficacy of such a neosphincter as continent system for bladder substitution after pelvic exenteration for pelvic cancers.

[Semiology of urination disorders in men]. / Sémiologie des troubles mictionnels chez l'homme.

With the ageing of population, the mictional disorders affect 35 at 47% of men 50 years old in many studies. The origins are numerous but especially dominated by prostate adenoma. For this reason, the semiology of mictional disorders of men is necessary at diagnosis orientation and for specific complementary examination. A meticulous interrogation is necessary because these disorders are ignored by the patients or under-estimated and on specific clinical examination. Here, we look at the functional signs and the clinical of prostatic adenoma, prostatisis, prostate cancer and uretral stenosis. Also practical conducting in urine blockage is reviewed.

[Stage M1b prostatic adenocarcinoma: prognostic factors, value of bone scintigraphy]. / Adénocarcinome prostatique de stade M1b: facteurs de pronostic, intérêt de la scintigraphie osseuse.

Based on a retrospective study of 52 patients with prostatic adenocarcinoma and bone metastases (stage M1b), the authors analysed the following prognostic factors at the time of diagnosis: age, general status, bone pain, haemoglobin, local tumour volume, ureteric repercussions, pre and post-treatment PAP and PSA levels, Gleason score, and metastatic spread on bone scan. This study demonstrated two predominant prognostic factors for the appearance of early or late therapeutic escape: tumour differentiation established by the Gleason score (P = 0.003), stage of the disease, i.e. local tumour volume (p = 0.001) and bone mass invaded on bone scan (p = 0.0002). The other prognostic factors can be deduced from these two parameters. Qualitative analysis of the initial bone scan allowed patients with peripheral bone metastases to be distinguished from those with exclusively axial involvement. The two-year survival was 50% in patients with peripheral metastases versus 93% in patients without peripheral metastases (p < 0.05). Although bone metastasis constitutes a decisive prognostic factor, the detection of peripheral bone metastases appears to be a factor of poor prognosis.

Subcutaneous metastases after coelioscopic lymphadenectomy for vesical urothelial carcinoma.

The authors report an exceptional case of subcutaneous metastatic dissemination, located at the puncture points of a coelioscopic lymphadenectomy for a vesical urothelial carcinoma. Few cases of parietal metastasis have been described after coelioscopic check-up for gynaecological and digestive tumours. The onset of this new type of serious complication suggests a need to reassess the benefits of this technique in tumours with lymphatic invasion.

[The inflatable penile prosthesis. Experiences apropos of 58 implants]. / Les prothèses de verge gonflables. Expérience à propos de 58 implantations.

Prosthetic surgery for impotence has been transformed by the development of inflatable prostheses in the place of older semirigid models. Despite the popularity of this new technique, it raises certain questions concerning the functional results and complications of this surgery, which have only occasionally been studied concomitantly in the literature. The sexuality of patients has generally been evaluated on the basis of answers to a questionnaire sent to the patients. This study reports our experience, compared to the data in the literature, based on 58 insertions of inflatable prosthesis between October 1987 and October 1991. After rigorous patient selection and a mean follow-up of 30 months, the surgeon evaluated the objective results (mechanical functioning of the prosthesis, complications) and subjective results (sexuality) in 51 patients. 69.4% of patients presented an anomaly of prosthesis function, 10.3% developed an infection of the prosthesis, 34.5% required removal of the prosthesis, 59% declared that they were satisfied sexually and sexual activity was restored in 55%. This study therefore appears to contradict the optimistic data reported in the literature.

[Supernumerary urethras in men. Report of supernumerary blind epispadias]. / Les urètres surnuméraires chez l'homme. A propos d'un cas surnuméraire épispade borgne.

Supernumerary urethra, a rare anatomical anomaly, can be explained by various embryological theories, accounting for the multitude of classifications proposed. Its diverse, minor or very severe clinical manifestations suggest the diagnosis, which is confirmed by retrograde and voiding cystourethrography. Treatment is surgical or, more rarely, endoscopic.