[Renocutaneous fistula: report of a chronic inguinal fistula]. / Fistules rénocutanées: à propos d'un cas de fistule chronique inguinale.

The authors report a new case of isolated spontaneous nephrocutaneous fistula revealed by a persisting draining sinus in the left groin. Their present causative factors are identified. The computed tomography and magnetic resonance imaging actually may resolve the diagnostic dilemma and are helpful in the surgical treatment.

[Benign neurogenic tumors of the lumbar plexus. Role of the enucleation procedure]. / Tumeurs nerveuses bénignes du plexus lombaire. Intérêt du procédé d'évidement.

Benign neurogenic tumours originating from lumbar plexus or roots are rare. Two cases are reported. Resection, often possible with another localisation, may result in neurological deficit in these cases. Enucleation, the best choice, is not always feasible. Hollowing-out is therefore a procedure worth understanding.

Influence of free-to-total prostate specific antigen variability on the early diagnosis of prostate cancer: a comparative study of three immunoassays.

OBJECTIVE: To compare three immunoassays for total prostate specific antigen (tPSA), free PSA (fPSA), free-to-total PSA ratio (f/tPSA), and the f/tPSA thresholds for optimal differentiation between benign prostatic hypertrophy (BPH) and prostate cancer in 141 consecutive patients referred for prostatic disease. PATIENTS AND METHODS: The study included 43 patients with prostate cancer and 98 with BPH, all confirmed histologically. PSA levels were assessed using the following assay kits just before histological analysis of the prostate; Hybritech (Tandem-R PSA, normal values, NV, < 4 ng/mL, and Tandem-R free PSA), Cis Bio (PSA-RIACT, NV < 2.5 ng/mL and fPSA-RIACT) and Immunocorp (PSA-IRMA, NV < 4 ng/mL and Free PSA-IRMA). The results were assessed to determine the sensitivity, specificity and threshold values of the different assays to differentiate patients with BPH and cancer. RESULTS: The mean tPSA and f/tPSA ratio were statistically different in assays with different NVs. The mean fPSA values differed significantly between the Hybritech and Cis Bio, between the Hybritech and Immunocorp but not between the Cis Bio and Immunocorp assays. With receiver operator curve analysis, there were no statistically significant differences among the three immunoassays in f/tPSA (0.72 for Hybritech, 0.73 for Cis Bio and 0.64 for Immunocorp) or between the tPSA and fPSA curves for each manufacturer. With the sensitivity fixed at 90%, different f/tPSA thresholds were defined (0.22, 0.34 and 0.25 for Hybritech, Cis Bio and Immunocorp, respectively). The specificities (i.e. the percentage of unnecessary biopsies spared) were 22%, 21% and 31%, respectively (not significantly different). CONCLUSION: Each immunoassay could be used to distinguish prostate cancer and BPH at different f/tPSA thresholds, with 21-30% of unnecessary biopsies spared. There was no difference in overall performance among the different assays. Further studies are needed to better define the exact use of the f/tPSA ratio in the routine diagnosis of prostate cancer.

[The dynamics of projectile wounding. Concepts in ballistic injuries]. / La dialectique du projectile. Notions de balistique terminale.

Analysis of the structure and terminal ballistic behavior of bullets provides a better understanding of their wounding power. The studies of ballistics specialists serve as a base. The concept of "scientific shot" remains an intellectual approach to a random phenomenon. Wound ballistic studies examine the behavior of projectiles in vivo or in a simulation medium. War events, in which projectiles do not meet requirements of international conventions, sport or hunting accidents, urban violence may confront the surgeon with various types of ballistic pathologies. The appropriate saying of Lindsey that the surgeons has to treat a wound and not a weapon should not justify etiologic ignorance.

[Solitary fibrous tumor of the seminal vesicles: apropos of a case]. / Tumeur fibreuse solitaire des vésicules séminales: à propos d'un cas.

Solitary fibrous tumours constitute a rare disease, which has never previously been described in the seminal vesicles. We report a case of solitary fibrous tumour of the right seminal vesicle in a 53-year-old man. The diagnosis of seminal vesicle tumour was based on transrectal ultrasonography and MRI. The histological diagnosis was established after surgical resection of this tumour. The small biopsy samples and the heterogeneous appearance of these lesions make it difficult to establish the diagnosis on biopsies alone. The surgical attitude to solitary fibrous tumour of the seminal vesicle depends on the clinical features and the course of the lesion.

[Value of detection of carcinoma in situ in conservative surgery of germ cell tumors of the testis]. / Intérêt de la recherche du carcinome in situ dans la chirurgie conservatrice des tumeurs germinales du testicule.

OBJECTIVE: It is currently proposed to perform tumour enucleation in mono-orchid patients presenting with a small germ cell tumour, in order to preserve physiological endocrine function. However, this conservative surgery must be accompanied by treatment of any carcinoma in situ lesions present in the remaining testicular parenchyma. MATERIAL AND METHODS: The presence of carcinoma in situ was investigated in 35 patients with germ cell tumour of the testis on samples obtained from the presumably healthy pulp of the orchidectomy specimen, adjacent to and away from the tumour. Samples away from the tumour were performed according to principle of surgical testicular biopsy. Histological examination also concerned the tissue situated in contact with the tumour. RESULTS: 25 patients (74.22%) presented intratubular germ cell dysplasia in the testicular parenchyma presumed to be healthy. These lesions were always concomitantly observed on samples performed adjacent to and away from the tumour. It was observed more frequently in seminomas, but was also observed in other histological forms. CONCLUSION: Because of the diffuse nature of carcinoma in situ in germ cell tumours of the testis, pulp samples adjacent to the tumour are sufficient to ensure the diagnosis during conservative surgery. Carcinoma in situ is currently treated by local radiotherapy.

[The incidence of the variability of the free PSA/total PSA ratio on the early diagnosis of prostate cancer]. / Incidence de la variabilité du rapport PSA libre/PSA total sur le diagnostic précoce du cancer de prostate.

INTRODUCTION: In patients with moderate elevation of total PSA, the use of the Free PSA/Total PSa ratio (F+T PSA) has been shown to be useful in the diagnosis of impalpable prostatic cancer. However, the cut-off values proposed in the literature vary from study to study and according to the immunoassay kit used. Our prospective study was designed to compare 3 different kits (Tandem, Cis Bio and Immunocorp) on the same series of patients in order to determine on the basis of these results and a review of the literature, the optimal ratio for which prostatic biopsies should be indicated in the presence of an isolated elevation of Total PSA. MATERIAL AND METHODS: Serum samples from 141 patients (43 cancers and 98 cases of histologically confirmed BPH) were included. Assays were performed concomitantly with histological examination of the prostate, using Tandem, Cis Bio and Immunocorp kits. RESULTS: In the overall patient population, Total PSA and Free PSA assays were statistically different for the 3 kits (p < 0.001). The F/T PSA ratio was always statistically different between the cancer and benign prostatic hyperplasia groups (p < 0.002). The cut-off values defined by a sensitivity of 90% were of 0.22 for Tandem (specificity: 27.5%), 0.34 for Cis Bio (specificity: 19.4%) and 0.26 for Immunocorp (specificity: 26.5%). When the total PSA level was between 4.0 and 10.0 ng/ml, these cut-off values also differed: 0.23 for Tandem (specificity: 26.6%), 0.35 for Cis Bio (specificity: 17.2%) and 0.25 for Immunocorp (specificity: 29.7%). In patients with a non-suspicious digital rectal examination and a F/T PSA ratio less than 0.10, the cancer detection rate (number of biopsies required to diagnose 1 cancer) was 1.66 for Tandem, 1 for Cis Bio and 1.87 for Immunocorp versus 7.7 while, when the F/T PSA ratio was greater than 0.22, the cancer detection rate was infinity (no cancer beyond this limit), 12.5 and 23, respectively. CONCLUSION: The F/T PSA ratio increases the specificity of prostatic cancer detection in patients with a total PSA between 4 and 10.0 ng/ml with a non-suspicious digital rectal examination, therefore resulting in a reduction of the useless biopsy rate and defining more relevant indications for biopsies in the case of periodic follow-up. The systematic indication of this ratio in the screening context cannot be recommended, but it can be useful to demonstrate stage TIC tumours in order to avoid numerous useless biopsies.

[Role of testicular biopsy in the investigation of a carcinoma in situ]. / Place de la biopsie testiculaire dans la recherche d'un carcinome in situ.

Carcinoma in situ (CIS) of the testis is recognized to be a precursor of cancer. Radiological examinations are not sufficient to improve the diagnosis. So the diagnosis is made by testicular biopsy. The indications are controlateral testis biopsy in man with testicular cancer and risk factors (cryptorchidism, dysgenetic gonads...) and extragonadic germ cell tumors. The authors review the risk factors. Chemotherapy is not sufficient to eradicate the CIS. A dose of 16 Gy of localized radiation is curative, excludes bilateral orchidectomy and preserves androgen function and azoospermic patient.

[Value of free/total prostate specific antigen in the early diagnosis of prostate cancer (study of 105 patients)]. / Intérêt du rapport PSA libre/PSA total dans le diagnostic précoce du cancer de la prostate (etude de 105 patients).

INTRODUCTION: Prostate Specific Antigen (PSA) exists in the serum in several molecular forms which can be measured by immunoradiodetectable assays: free PSA and total PSA (which represent the sum of the free PSA and complexed PSA to alpha 1 antichymotrypsin). Recently, the proportion of free to total PSA could enhance the ability to distinguish benign histologic conditions from cancer. MATERIAL AND METHODS: Serum samples of 105 patients (31 histologically confirmed prostate cancers and 74 histologically confirmed untreated benign prostatic diseases) were included in this study. The total and free PSA levels were determined using the PSA immunoradioassay of Tandem-R PSA and Tandem - R free PSA. RESULTS: When all subjects were included, both total PSA and the proportion of free to total PSA significantly differentiated between patients with prostate cancer and patients with benign histologic conditions (p < 0.01 and p < 0.005). However, in men with total PSA values between 4.0 to 10.0 ng/ml, the proportion of free to total PSA significantly differentiated between the patients with benign and malignant histological conditions (p < 0.04). The most interesting was the ability of the proportion of free to total PSA to distinguish patients with total PSA value between 4.0 and 10.0 ng/ml and normal digital examination (p < 0.001). With these values of PSA-T, a free PSA cutoff of 0.23 detected at least 90.4% of cancers and would eliminate 19.4% of negative biopsies. CONCLUSION: Measurement of the free to total PSA level improves specificity of prostate cancer screening in selected men with elevated total serum PSA levels between 4.0 to 10.0 ng/ml and normal digital examination, and can reduce unnecessary prostate biopsies with minimal effects on the cancer detection rate.

[Current aspects of war surgery. From the trauma center to precarious medical care]. / Aspects actuels de la chirurgie de guerre. Du trauma center à la précarité.

War, said Carl von Clausewitz, is a cameleon. In this century, each armed conflict has proved to be unique, particularly in its medical aspects, with its own features and teaching its won lessons. As recent events show, no conflict is a fact of the past. Medical care delivered to war casualties depend on the circumstances of the war, on the medical resources available, but also on the price that cultures or circumstances place on it. Everything separates these two paradigms; on the one hand the "precious" casualty of western armies whose medical support is organized in a concept (forward medical and surgical care, ultra-rapid medical evacuation) tailored to each case, and as close as possible to the medical care of a civilian trauma patient whose models remains the North-American ballistic wound managed in trauma centers; on the other hand, civilian victims, in large numbers, in poor and disorganized countries, often abandoned to their own fate or sorted by "epidemiological" triage, which guarantees a distribution, as efficient as possible, of limited medical care. In war, advanced medical care and precarious medicine may work side by side according to two logics which do not exclude one another and constantly improve.

[Adrenal cystic tumors. Apropos of 8 cases]. / Tumeurs kystiques surrénaliennes. A propos de 8 observations.

We report eight cases of cystic lesions of the adrenal glands. Benign cysts or pseudocysts are the predominant tumors of the adrenal glands. However, neither tumor size, gross aspect, presence of calcified walls, color, cyst contents nor routine laboratory tests can exclude a malignant or hormone secreting lesion. We discuss the role of therapeutics, transparietal puncture and simple radiographic surveillance in the management of patients with cystic tumors of the adrenal glands. Surgery is often indicated or recommended.

[Late diagnosis of the avulsion of the pyelo-ureteral junction treated by ureterocalicostomy]. / Diagnostic tardif d'avulsion de la jonction pyélo-urétérale traitée par urétérocalicostomie.

The authors report an exceptional case of delayed diagnosis of avulsion of the ureteropelvic junction in a 27-year-old man. Organization of the urohaematoma prevented ureteropelvic anastomosis and the kidney could only be preserved by performing ureterocalicostomy. This technique, generally used for tuberculous retracted renal pelvis, or failure of pyelotomy or ureteropelvic junction repair in horseshoe kidneys or kidneys with retracted renal pelvis, allowed renal preservation in this case.

[Subperitoneal rupture of the bladder due to pelvic fractures. Apropos of 3 cases]. / Les ruptures sous-péritonéales de vessie sur fracas du bassin. A propos de trois observations.

Three different approaches to the diagnostic and therapeutic management of bladder trauma were adopted in 3 patients. Haematuria was discovered on bladder catheterization. Emergency cystography remains the best diagnostic examination. CT has the same limitations as intravenous urography. There are two schools of thought concerning the treatment of the bladder lesion: surgical repair and healing by simple drainage. The indications depend on the size of the rupture and the severity of haematuria: intravesical clots and the need for continuous irrigation constitute contraindications to simple drainage. Emergency surgery must be combined with treatment of the bone lesions. Apart from external fixation, posterior osteosynthesis, when possible, is also indicated in unstable fractures.

[Value of limited dissection of residual retroperitoneal masses after chemotherapy for malignant non-seminoma tumors of the testis. Apropos of 74 cases]. / Valeur du curage limité des masses résiduelles rétropéritonéales après chimiothérapie des tumeurs malignes non séminomateuses du testicule. A propos de 74 cas.

Since asplatin salts have been used in chemotherapy, the efficiency of this treatment has changed the destiny of advanced forms of testicular cancer. The universally recommended treatment of post-chemotherapy residual retroperitoneal tumor masses is radical retroperitoneal lymph node dissection. Results of our 74 limited expresses of these tumor masses confirm that the chosen treatment was appropriate. It guarantees the future and limits genital sequellae in young patients. It is perfectly consistent with the therapeutic history of this model in cancerology: precisely defined indications for the therapeutic means of a pluridisciplinary pool of resources always increases efficiency, reduces the need for invasive treatment, and limits sequellae.

[Retroperitoneal extragonadal germ cell tumors: apropos of 4 cases. The importance of research of an occult testicular lesion]. / Les tumeurs germinales extragonadiques rétropéritonéales: à propos de 4 observations. Intérêt de la recherche d'une lésion testiculaire occulte.

In the absence of palpable testicular tumor one often retains the primitive character of an extragonadal germ-cell tumor with retroperitoneal localization. This motion must be reconsidered in front of the occasionally late discovery of the scrotal origin of those lesions. The usefulness of testicular sonography in the revelation of infra clinical lesions is now perfectly well admitted. Concurrently, testicular biopsies can provide the notion of carcinoma in situ and its links with the retroperitoneal germ-cell tumor must be indicated precisely. The four related observations allow us to stress on the seriousness of this affection which often remains tardily diagnosed. The specific treatment of the testicular lesion, when it is put into evidence, turns out to be absolutely necessary.

[Parietal problems in thoracic injuries by gunshot]. / Les problèmes pariétaux dans les plaies du thorax par projectiles.

Injury to the thorax is usually studied to determine management strategy, point of thorax drainage, indications for early surgery, and particular visceral injuries. We examine problems related to abdominal wall injuries in projectile trauma of the thorax based on the characteristics of the projectile, and the anatomic, pathologic, clinical and therapeutic features.

[Acute pyelo-ureteral obstruction by an intrasinusal intra- and para-pyelic cyst. Apropos of 3 cases]. / Obstruction pyélo-urétérale aiguë par kyste intra-sinusal intra- et para-pyélique. A propos de 3 cas.

Parapyelic cysts are not uncommon. There is usually no clinical expression of these cysts although development within the sinus can cause obstruction leading to acute nephretic colic. We observed two cases of intrasinus parapyelic cysts and another case of obstructive intrapyelic cyst. At ultrasonography, the only sign was hydronephrosis and a junction syndrome could not be eliminated. Intravenous pyelography demonstrated hydronephrosis and in one case a round intrapyelic mass. Computed tomography was required for diagnosis. Surgical exeresis was required due to the pain and compression damage to the parenchyma. This is a rare indication for surgical treatment of simple cysts of the kidney.

[Diagnostic difficulties and value of partial surgery in multiple tumors of the kidney. Apropos of 4 cases]. / Difficultés diagnostiques et intérêt de la chirurgie partielle dans les tumeurs multiples du rein. A propos de 4 cas.

Multiple renal tumors are rare. Ultrasonic and CT scan examinations will suspect the diagnosis in the majority of cases. With the histological diagnosis and its prognosis, the treatment may be watchful waiting, partial nephrectomy or radical nephrectomy. Partial nephrectomy is indicated in case of multiple tumor in a patient with solitary kidney or for bilateral tumors. Urinary fistulas or renal insufficiency are potential complications, but they are exceptional. Four cases are reported (oncocytoma, angiomyolipoma, papillary tumor and adenocarcinoma) to illustrate the difficulty of diagnosis with imaging and the surgical options.