[Management of male urinary incontinence after radical prostatectomy (CTMH AFU 2006 - 4/5): place of intraurethral macroplastique injection, artificial urinary sphincter and cell therapy]. / Prise en charge d'une incontinence urinaire masculine après prostatectomie radicale (CTMH AFU 2006 - 4/5): place de l'injection intra-urétrale de macroplastique, du sphincter urinaire artificiel et des thérapies cellulaires.

The management of moderate urinary incontinence after radical prostatectomy may require the use of an artificial sphincter, which remains the reference technique although it requires implantation of material, sometimes involving redo operations. Submucosal macroplastique injections have been proposed, but the results do not appear to be maintained over time. Cell therapy, consisting of the injection of stem cells into or close to the sphincter, probably represents the approach of the future, but in 2006, studies were still only at the evaluation phase.

[Management of male urinary incontinence after radical prostatectomy (CTMH AFU 2006 - 5/5). Prevention of incontinence and CTMH guidelines]. / Prise en charge d'une incontinence urinaire masculine après prostatectomie radicale (CTMH AFU 2006 - 5/5) Prévention de l'incontinence et recommandations du CTMH.

Preservation of continence essentially depends on the operator and the quality of the operative procedure. The number of publications on this subject reflects the desire of urologists to provide their patients not only with control of the cancer but also preservation of their sexual and urinary functions. Ideally, surgery should preserve the striated sphincter and levator muscles, the neurovascular pedicles when oncologically acceptable, and the bladder neck and a leak-proof anastomosis must be ensured. The surgeon must satisfy two imperatives to achieve these objectives: a good knowledge of anatomy and meticulous preservation of this anatomy from the beginning to the end of the operation by highly selective dissection in selected patients. Finally, the Comité des Troubles Mictionnels de l'Homme (Male Voiding Disorders Committee) proposes guidelines for the diagnosis and treatment of urinary incontinence after radical prostatectomy.

[Management of male urinary incontinence after radical prostatectomy (CTMH AFU 2006-1/5): incidence and role of urodynamic assessment and electromyography]. / Prise en charge d'une incontinence urinaire masculine après prostatectomie radicale (CTMH AFU 2006-1/5): incidence et rôle du bilan urodynamique et de l'électromyogramme.

The incidence of postprostatectomy urinary incontinence varies according to the technique used, over time and according to the type of management, with an incidence at one year ranging from just a few percent to more than 60%. Assessment is required in the case of persistent disabling urinary incontinence despite well conducted perineal rehabilitation one year after surgery or earlier in the case of severe incontinence. Urodynamic assessment is the essential examination to quantify urethral closure pressure. A review of the literature of urodynamic assessment and electromyography is presented.

[Management of male urinary incontinence after radical prostatectomy (CTMH AFU 2006-2/5): place of perineal rehabilitation and medical treatment]. / Prise en charge d'une incontinence urinaire masculine après prostatectomie radicale (CTMH AFU 2006-2/5): place de la rééducation périnéale et du traitement médical.

The treatment of incontinence is changing, but perineal rehabilitation still plays an essential role and is usually able to rapidly and effectively improve urinary incontinence. Medical treatment modalities are fairly limited: anticholinergic drugs have a limited efficacy except in the case of unstable bladder demonstrated by urodynamic assessment and, despite encouraging preliminary results, duloxetine has not obtained scientific recognition or marketing authorization.

[Management of male urinary incontinence after radical prostatectomy (CTMH AFU 2006-3/5): place of periurethral balloon and suburethral tape]. / Prise en charge d'une incontinence urinaire masculine après prostatectomie radicale (CTMH AFU 2006-3/5): place des ballons périurétraux et des bandelettes sous uréthrales.

The treatment of incontinence is changing. Perineal rehabilitation still plays an essential role, but new modalities are now available with promising results, particularly periurethral balloon and suburethral tape, which may be indicated after failure of well-conducted perineal rehabilitation and before artificial sphincter. Periurethral balloons consist of two silicone balloons filled with a mixture of saline and radiopaque agent inserted transperineally on either side of the urethra as close as possible to the bladder neck. Titanium ports connected to each balloon allow adjustment of the volume contained in the balloon at any time after surgery. This technique appears to be promising but further studies are required to clearly define many unresolved issues, including results based on longer follow-up and patient selection according to the severity of incontinence or their treatment history (radiotherapy). Suburethral tape is used to exert permanent static compression of the urethra and was still under development in 2006. Fairly heterogeneous materials are used and no consensus on this issue has yet been reached. Follow-up is still relatively short and few studies have addressed the problem of patient selection. Some authors consider that the best indication is mild-to-moderate incontinence, which has not yet been clearly defined.

[Pneumonia in elder institutionalized patients:derivation and/or prognostic classification criterion]. / Neumoní en el anciano institucionalizado: criterios de derivación y/o clasificación pronóstica.

OBJECTIVE: To know the clinical features of nursing home residents with pneumonia comparing with patients with Community-acquired pneumonia and identify the main prognostic index of mortality. MATERIAL AND METHODS: Longitudinal prospective study including all the elderly patients hospitalized in Cantoblanco Hospital of Madrid during the year 2001 for pneumonia and classified according to the Fine prognosis index and the SEPAR criteria. RESULTS: Of the 78 patients with pneumonia, 27 came from Residence, with an average of age of 86.85(+/- 6.43) years old, opposite to 83.11 (+/- 5.87) years in patients with Community acquired pneumonia ( p<0.05). Of all of them, 33,3% belonged to class IV and 66.7% to class V of Fine. Of all the variables studied, only the age (p= 0.03) and the hypoxemia (p= 0.03) were statistical significant. CONCLUSIONS: Nursing home residents with pneumonia are older and have more prevalence of morbi-mortality than those with Community acquired pneumonia. In our study, the age and the hypoxemia were the two independent prognosis factors associate to more mortality.

Neumonía en el anciano institucionalizado: criterios de derivación y/o clasificación pronóstica / Pneumonia in elder institutionalized patients: derivation and/or prognostic classification criterion

Objetivo: Conocer el perfil clínico de los pacientes con neumonía procedentes de Residencia comparándolo con los de neumonía adquirida en la comunidad (NAC) no institucionalizados e identificar los principales índices pronósticos de mortalidad. Material y métodos: Estudio prospectivo longitudinal de todos los ancianos ingresados en el Hospital de Cantoblanco de Madrid durante el año 2001 diagnosticados de neumonía y clasificados según el índice pronóstico de Fine y los criterios de la SEPAR. Resultados: De los 78 pacientes con neumonía, 27 procedían de Residencia, con una edad media de 86,85 (ñ 6,43) años, frente a 83,11 (ñ 5,87) años en los procedentes de domicilio (p<0,05). De ellos, el 33,3 por ciento pertenecían a la clase IV y el 66,7 por ciento a la clase V de Fine. De todas las variables estudiadas, sólo la edad (p= 0,03) y la hipoxemia (p= 0,01) fueron estadísticamente significativas. Conclusiones: Los pacientes con neumonía procedentes de Residencia tienen mayor edad y mayor prevalencia de morbi-mortalidad que los procedentes de su domicilio. En nuestro estudio, la edad y la hipoxemia son los dos factores pronósticos independientes asociados a mayor mortalidad (AU)

Papel de la infección por Clostridium difficile en la reactivación / Role of Clostridium difficile infection in the relapse of ulcerative colitis

Aportamos el caso de una mujer de edad avanzada con historia antigua de despeños diarreicos ocasionales no estudiada, que presentó un episodio de diarrea nosocomial secundaria a infección por Clostridium difficile. Se realizó una colonoscopia y biopsia ante la respuesta incompleta al tratamiento con vancomicina, siendo diagnosticada de colitis ulcerosa activa subyacente. La incidencia con la que el C.difficile se ha relacionado como desencadenate de un brote de colitis ulcerosa, se sitúa en torno al 10 per cent. Entre los pacientes con colitis ulcerosa es infrecuente encontrar los factores desencadenates clásicos de la infección por C. dif ficile: hospitalización reciente y/o uso previo de antibióticos; así como, tambien es inhabitual la visualización macroscópica de pseudomembranas. Parece existir una correlación directamente positiva entre el índice de actividad de la colitis ulcerosa y la frecuencia de la infección por C.difficile en estos pacientes. El tratamiento específico de la colitis pseudomembranosa, en la mayoría de los casos, es suficiente para controlar el brote de colitis ulcerosa, sin precisar potenciar el tratamiento de base (AU)

[Role of Clostridium difficile infection in the relapse of ulcerative colitis]. / Papel de la infección por Clostridium difficile en la reactivación de la colitis ulcerosa.

A case of nosocomial diarrhea by Clostridium difficile in an older woman with an old history of increasing stool frequency, is reported. Colonoscopy and biopsy was performed due to an incomplete response to vancomicyn, and the diagnosis of underlying ulcerative colitis was made. The incidence of Clostridium difficile infection associated with the relapse of ulcerative colitis is nearly 10%. In patients with ulcerative colitis, macroscopic pseudomembranes and the usual predisposing factors for Clostridium difficile infection, usually, are not present. It seems to exist a significant correlation between the severity of the relapse and Clostridium difficile. The specific treatment of the pseudomembranous colitis, in the majority of the cases, is sufficient for a correct control of relapse of ulcerative colitis.

Delayed closed reduction of rotatory atlantoaxial dislocation in an adult.

We report a case of rotatory atlantoaxial dislocation due to a rugby injury in an adult. The patient presented with torticollis 4 weeks after the injury. The neurological evaluation was normal. Reduction proved difficult to obtain and required 10 days of skull traction followed by gentle manipulation. After reduction, dynamic cervical radiographs showed no instability and magnetic resonance imaging (MRI) confirmed that the transverse ligament was intact. After 6 weeks of immobilization in a Minerva jacket, a dynamic rotatory computed tomography (CT) scan confirmed that the atlantoaxial joint was stable. Such cases of atlantoaxial joint dislocation in adults treated by traction after a considerable delay are rare. In our patient, demonstration by MRI that the transverse ligament was intact led to the decision to use conservative therapy, which proved successful.

[Comminuted fractures in multiple trauma patients: an analysis of 31 cases]. / Fracture comminutive du calcanéum chez le polytraumatisé. Analyse de 31 cas.

PURPOSE OF THE STUDY: We analyzed calcaneum burst fractures in multiple trauma patients and propose a management scheme. MATERIAL AND METHODS: In a retrospective study, we isolated 23 patients with 31 calcaneum burst fractures. All were stage V in the Duparc classification. We call them "pied de mine" fractures as they resembled those described in military reports. Half of them (16 cases; 54%) were open fractures. All patients suffered multiple injuries and 12 had a psychiatric history. These fractures were associated with spinal fracture in 17 cases (73%) and half had neurologic deficit, limb fracture in 16 (73%), and pelvic fracture in 12 (52%). The most frequent associated foot injuries were a talus fracture in 9 cases (29%) and Chopart displacement in 10 cases (32%). Clinical evaluation used the Maryland foot score, foot print and radiologic evaluation with lateral retrotibial view. RESULTS: Mean follow-up was 35 months. Mean Maryland foot score was 62.7 and 13 cases were pain free. Pain was due to conflict with the lateral malleolus, bony plantar thorns, medial malleolus and subtalar osteoarthritis. Orthopedic shoes were used 11 times. The other patients used sports shoes. Subtalar mobility was most frequently absent (23/29 cases, 2 amputations). Foot print showed 13/16 flat feet; 6 thorns were indirectly visible. Two patients had retraction toes and were initially treated by external fixation. Radiologic evaluation showed 23/29 complete subtalar arthrodeses, 23/29 migration of the great tuberosity, often(17/23 cases) associated with varus angulation. Eleven patients needed subsequent surgery: 5 for arthrodeses and 6 for resection of bony thorns. Rate of complication was high, especially for open fractures: 2 infections for 15 closed fractures, and 8 infections (50%) for 16 open fractures with 2 cases of chronic osteitis. Secondary amputation was required in 2/31 cases due to sepsis. TREATMENT PROPOSITIONS: For closed calcaneum burst fractures, it is better to wait one week before osteosynthesis. This delay is used to decrease edema with limb elevation and compressive bandaging. Skin tension due to trauma is increased by edema and osteosynthesis gives a high risk of wound disunion. We recommend reduction and Y-plate fixation even for burst fracture. Reduction must lower the tuberosity and correct the varus. After surgery, subtalar spontaneous arthrodesis is usually observed in a good position. Any bony plantar thorn must be resected. For open calcaneum burst fracture, the risk of sepsis is high. First treatment is debridement, stabilization and external fixation with antibiotic therapy. Stabilization should improve vascularization and facilitate internal fixation. The external fixation can be placed on the medial side to free the lateral approach to the calcaneum. Flap repair can be performed after one week when skin tension has subsided and areas of necrosis controlled.

Duplex Doppler sonography of the flaccid penis: potential role in the evaluation of impotence.

PURPOSE: Duplex Doppler sonography of the cavernosal arteries of the penis with intracavernous injection (ICI) of vasoactive agents has been widely used to evaluate arterial insufficiency in impotence. Our goal was to assess the potential value of peak systolic velocity (PSV) measurements on the flaccid penis in the diagnosis of arteriogenic impotence. METHODS: Forty-four men underwent duplex Doppler sonography with PSV measurements before and after ICI of prostaglandin E(1). Three different cutoff values for lowest normal PSV before injection-5 cm/second, 10 cm/second, and 15 cm/second-were tested. RESULTS: Thirteen patients had arteriogenic insufficiency based on post-ICI duplex sonography and clinical response. Results for our different cutoff PSV values of 5 cm/second, 10 cm/second, and 15 cm/second in diagnosing arteriogenic impotence were, respectively: sensitivity 29%, 96%, and 100%; specificity 100%, 92%, and 23%; negative predictive value 80%, 92%, and 100%; positive predictive value 100%, 81%, and 41%; and overall accuracy 79%, 93%, and 44%. In the flaccid state, there was a significant difference in mean PSV between the "normal" group (12.6 +/- 0.9 cm/second) and the arteriogenic impotence group (7.7 +/- 1.1 cm/second). Twenty-nine patients with a bilateral PSV of 10 cm/second or less before ICI had a normal clinical response. CONCLUSIONS: A cutoff PSV value of 10 cm/second in the flaccid state had the best accuracy in predicting arterial insufficiency. Duplex Doppler sonography is proposed as the initial test to evaluate the penile arterial supply and to determine whether patients are good candidates for therapy with ICI.

[Physiopathology and evaluation of urinary incontinence in non-institutionalized aged patients]. / Physiopathologie et évaluation de l'incontinence urinaire de la personne âgée non institutionnalisée.

The prevalence of urinary incontinence increases with age, with a predominance of incontinence due to detrusor instability. The development of incontinence in an elderly person can be explained pathophysiologically by the development of age-related histological and functional alterations of the bladder, by increased nocturnal diuresis at the expense of diurnal diuresis and finally, in women, by a reduction of urethral pressure. The initial assessment is essentially clinical and must comprise evaluation of concomitant diseases and drugs likely to favour the development of incontinence, a voiding diary and assessment of the post-voiding residual volume. Only a test for urinary tract infection by dipsticks or urine culture constitutes an essential first-line complementary investigation, as urodynamic studies can be reserved for more complex situations.

Acute spinal cord compression due to intraspinal bleeding from a vertebral hemangioma: two case-reports.

Vertebral hemangiomas can cause acute spinal cord compression either after a minor trauma or during the last 3 months of pregnancy. Failure to recognize the lesion can lead to potentially serious treatment delays. An emergency MRI scan usually establishes the diagnosis of vertebral hemangioma responsible for spinal cord compression requiring laminectomy. We report two cases showing that posterior fixation should be considered: in our experience it prevents vertebral collapse during the interval preceding secondary vertebroplasty, which, if performed, provides highly significant pain relief.

[Mobility of a polyethylene tibial insert in a mobile total knee prosthesis]. / Etude de la mobilité du plateau tibial d'une prothèse totale de genou à plateau mobile.

PURPOSE: We have studied the mobility of a mobile tibial implant in total knee arthroplasty (TKA) by a radiographical evaluation. MATERIAL AND METHODS: We analyzed mobility of the polyethylene tibial insert of 15 "G2S" TKA implanted for one year or more. We established a dynamic radiographical evaluation. We used 3 weight-bearing radiographs: AP in extension and two lateral (one in extension and one at 90 degrees of flexion), two AP with femoral internal and external rotation, 2 strict lateral X-rays in neutral rotation in antero-posterior replacement with a 25 kilograms strength Telos, and 2 AP in varus and valgus with Telos. Wilcoxon's test and Fisher's exact test were used for statistical evaluation. RESULTS: Our study demonstrated preservation of the polyethylene mobility in tibial TKA implant in all movements: in rotation, in antero-posterior translation with Telos, and even in antero-posterior translation during physiological condition with flexion-extension weight-bearing radiographs. Statistical tests were very significant. We noticed that flexion induced anterior translation of tibial polyethylene when PCL was preserved. CONCLUSION: This study answered to our question whether mobility of TKA tibial implant persists after implantation. This mobility should reduce loosening forces to the tibia and stress in the polyethylene component. Now we have to determine the amplitude of mobility required to reach this objective.

Significance of granulomas in bone marrow: a study of 40 cases.

Granulomas in bone marrow are an infrequent finding related to diverse disease. We reviewed 8057 bone marrow studies made over a period of 10.5 years, confirming the presence of granulomas in 40 patients. Global incidence was 0.50% and annual incidence 3.80 cases/yr. Because of the non-specificity of the morphological data, the diagnostic significance of the finding is limited, but it does serve to narrow the field of etiological possibilities. Associated disease was demonstrated in 82.5%, infectious diseases being the most common (tuberculosis, brucellosis, typhoid fever and kala-azar). Two previously unpublished entities are introduced: refractory anemia with excess blast cells (dysmyelopoietic syndrome) and malignant histiocytosis. 3 patients presented human immunodeficiency virus infection, the etiopathogenic role of this retrovirus in the generation of granulomas being unknown. The efficacy of bone marrow study in demonstrating granulomas increases if both the aspirate clot and bone cylinder are examined.