Systematic biopsies accurately predict extracapsular extension of prostate cancer and persistent/recurrent detectable PSA after radical prostatectomy.

OBJECTIVES: To determine if methodic analysis of systematic echo-guided biopsies associated with prostatic-specific antigen (PSA) and PSA density can accurately predict the actual pathologic stage of prostate cancer (Ca P). METHODS: One hundred patients with clinically localized (T1, T2) Ca P who underwent radical prostatectomy (RP) were preoperatively staged by digital rectal examination (DRE), measurement of serum PSA (Yang Pros-check) and PSA density (PSAD), and transrectal echo-guided systematic biopsies (three in each lobe aiming to sample prostatic capsule) to evaluate T stage, Gleason grade, number of positive biopsies, and presence of cancer in the periprostatic tissues. Radical prostatectomy specimens were processed following the McNeal method. The PSA levels were measured every month for 2 years. RESULTS: Extracapsular disease was detected on the specimen in 45% of the patients, persistent/recurrent detectable PSA in 47% (mean follow-up 18 months). Clinical stage T2 B, presence of Gleason grade 4, PSA > 25 ng/mL, PSAD > 0.6, number of positive biopsies > 66% of the total number of cores taken had a positive predictive value (PPV), respectively, of 72%, 66%, 80%, and 87%. Periprostatic tissue was evaluable on the core biopsies in 77% of the cases. Presence of cancer in the periprostatic fat on the core biopsies had a PPV of 94% for extracapsular disease/biological recurrence. CONCLUSIONS: The presence of extracapsular cancerous tissue on prostatic core biopsies accurately predicts extracapsular extension of Ca P. Therefore, care should be taken when performing prostate biopsies to sample the prostate capsule and surrounding tissues to obtain a more accurate staging of the disease. The second best predictor of extracapsular disease is the percentage of positive biopsies.

Early detection of prostate cancer in men with prostatism and intermediate prostate-specific antigen levels.

OBJECTIVES: To determine the prevalence of prostate cancer and the diagnostic ability of prostate-specific antigen density (PSAD) in men with lower urinary tract symptoms and intermediate prostate-specific antigen (PSA) levels of 4 to 10 ng/mL (Hybritech assay) and to assess the clinical significance of prostate cancers in men who subsequently underwent radical prostatectomy. METHODS: Six systematic transrectal ultrasonography (TRUS)-guided biopsies were performed in 153 symptomatic men (mean age, 66 years) with PSA levels between 4 and 10 ng/mL, irrespective of digital rectal examination (DRE) findings. Prostate volume was also determined by TRUS and PSAD was calculated (serum PSA divided by volume of entire prostate). The rate of positive biopsies was compared with PSAD (more than 0.2 versus less than 0.2), DRE (positive versus negative), and patient's age (more than 70 years versus 61 to 70 versus 60 or less). Eligible patients with cancer underwent radical prostatectomy, and specimens were analyzed with regard to clinical significance of tumors. RESULTS: The overall cancer detection rate was 29.4%. PSAD and DRE, but not age, were both statistically significant in differentiating negative from positive biopsies. Independent of DRE findings, mean PSAD was significantly lower in biopsy-negative cases (0.29 +/- 0.17 and 0.25 +/- 0.16) than it was in positive cases (0.34 +/- 0.17 and 0.35 +/- 0.15). Half of the patients who underwent radical prostatectomy had pathologically nonorgan-confined disease (more than pT3), 34% had positive margins, and 47% had a Gleason score of 8 to 10. PSAD, DRE, and age could not predict outcome, probably owing to the small number of patients. However, the number of positive biopsies (1 or 2 versus 3 to 6) was able to predict pathologic stage. CONCLUSIONS: In men with lower urinary tract symptoms and intermediate PSA levels of 4 to 10 ng/mL, PSAD may be useful in the selection of patients for prostate biopsy. Carcinomas found using these criteria are of clinical importance.

[Peroperative ultrasound scanning of the pancreas]. / Echotomographie per-opératoire du pancréas.

Intraoperative realtime high resolution ultrasound scanning of the pancreas seems to be a new and promising procedure. We have performed it in 28 patients: the normal ultrasound picture of pancreatic ducts and parenchyma was defined in 9 patients without pancreatic disease; in 19 patients with pancreatic disease, intraoperative ultrasound was compared with preoperative ultrasound examination. Seven of 8 patients with pancreatic carcinoma and 4 of 6 with calcifying chronic pancreatitis had positive findings, respectively. In 3 cancer patients, intraoperative ultrasound investigation avoided a long and unavailing dissection of the tumor by revealing extensive spread. In selected cases, intraoperative sonography allowed to characterize and to localize pancreatic carcinoma: portal vein invasion, relationship of the tumor to the duct of Wirsung and small hepatic metastases. In chronic pancreatitis, intraoperative ultrasound information concerning the dimensions of the pancreatic duct, the structure and the localization of pseudocysts was comparable to that obtained by radiological opacification. Furthermore, intraoperative ultrasound exploration guided proper incision and evacuation of pancreatic pseudocysts in two patients. Operative ultrasound seems to us to be mandatory during pancreatic surgery. Further experience with this technique is needed in a larger number of patients. However, we believe that it could replace intraoperative cholangiography and pancreaticography in the assessment of extension and complications of pancreatic disease.

[Treatment of inguinal hernia with unsplit mersylene prosthesis. Significance of the parietalization of the spermatic cord and the ligation of epigastric vessels]. / Cure des hernies de l'aine par prothèse de mersylène "non fendue". Intérêt de la pariétalisation du cordon et de la ligature des vaisseaux épigastriques.

The authors describe their technique of "thorough" dissection of the spermatic cord by the inguinal route. After parietalization of the cord and ligature of the epigastric vessels, a wide prosthesis of unsplit mersylene can be inserted through the groin behind the muscular layer brought down to Cooper's ligament. From their experience of 120 patients operated upon and without relapse at follow-up, they feel able to recommend this method in cases of recurrent hernias with weak walls and large sac and of hernias occurring in elderly of obese subjects.

[Mucosecreting tumors of the appendix. 3 cases]. / Les tumeurs mucosécrétantes de l'appendice. Trois observations.

The three cases reported here illustrate the diagnostic, therapeutic and prognostic problems raised by these tumours. These are rare lesions with little suggestive symptoms, which explains why they are exceptionally diagnosed before surgery. Mucosal hyperplasias and cystadenomas are benign formations with a 90-100% survival rate 5 years after appendicectomy, even when non-cellular mucoid effusion is present. Cystadenocarcinomas are malignant tumours with mucoid secretion containing epithelial cells; they have a tendency to recur despite repeated evacuations, and their 5-year survival rate is approximately 25%; death results from intestinal obstruction or compression of intra-abdominal viscera by the mucoid substance.

[Benign ureteral stenoses. Dilatation with an angioplasty balloon]. / Sténoses urétérales bénignes. Dilatation au ballon d'angioplastie.

An angioplasty balloon was used to dilate 23 benign ureteral stenoses in 21 patients. The anterograde approach through percutaneous puncture of the kidney was used in 19 cases. Following dilatation, an 8 F to 24 F catheter was left in the ureter. Dilatation was successful in 13 out of 23 cases (56%) followed up for 1 month to 2 years. It failed in 8 cases, and 2 patients are undergoing ureteral remodelling. Thus, dilatation of benign ureteral stenoses after percutaneous renal puncture was effective in about 60% of the cases. The follow-up period is still too short for us to determine the indications of this technique according to the cause and duration of the stenosis.

[Conservative surgical treatment of acute pancreatitis. Strategy and technic]. / Traitement chirurgical conservateur des pancréatites aiguës. Stratégie et technique.

Not all patients with acute pancreatitis can be cured by medical treatment alone; surgery is mandatory when signs of aggravation or complications are present. The authors propose a new strategy involving bilateral subcostal laparotomy, wide approach to the pancreas, evaluation of the lesions and therapeutic decision: either abstention or excision which may be performed according to rules or adapted to each case. The abdominal wall is then closed, often around a pre- and peripancreatic Mikulicz's drain. This method has substantial advantages: the dangers of hasty and inappropriate surgical procedures on ill-defined lesions are avoided, necrotic areas can be removed, drainage is facilitated and possible reoperations are restricted to the supramesocolic cavity.

[Familial pheochromocytoma and Van Hippel-Lindau disease]. / Phéochromocytome familial et maladie de Von Hippel-Lindau.

The authors report the case of a 41-year old man who presented simultaneously with phaeochromocytoma, paraganglioma and renal carcinoma. The postoperative finding of metaiodobenzylguanidine uptake foci showed that the phaeochromocytoma was malignant. The patient's son had a phaeochromocytoma and a pancreatic cyst. The phaeochromocytoma had no clinical manifestations and had been discovered by systematic assays of urinary catecholamines and their derivatives. These abnormalities are those of Von Hippel-Lindau disease.

[Detection of prostatic cancer in symptomatic patients with serum levels of prostate-specific antigen between 4 and 10 ng/ml]. / Détection du cancer prostatique chez les patients symptomatiques ayant des taux d'antigène prostatique spécifique sérique entre 4 et 10 ng/ml.

OBJECTIVES: Determine the incidence of prostate cancer in patients consulting for common miction disorders and serum prostatic specific antigen (PSA) between 4 and 10 ng/ml. METHODS: A total of 153 patients consulted for miction disorders. In 107 of them, the digital examination was abnormal and PSA was between 4 and 10 ng/ml. Transrectal sonography and prostatic biopsies were performed in these 107 patients. We determined the number of cancers detected and assessed the contribution of PSA density (PSAD) to diagnosis. In patients undergoing radical prostatectomy, invasion of the capsule (C+) and positive exeresis section (M+) were recorded. RESULTS: Cancer of the prostate was diagnosed in 29.4% of the patients on the basis of at least 1 of the 6 biopsies. This rate was 47.8% in patients with an abnormal and 21.5% with a normal digital examination. Radical prostatectomy was performed in 32 patients: 50% of them were C+ and 33% M+. CONCLUSION: Biopsy of the prostate is indicated in patients with an abnormal prostate at digital examination when PSA is between 4 and 10 ng/ml. When the prostate appears to be normal, PSAD may be helpful in determining when to perform a biopsy. Intermediary serum PSA levels do not guarantee favorable pathological characteristics.

[Percutaneous treatment of fistulas and stenoses after anastomosis of the uretero-digestive tract]. / Traitement par voie percutanée des fistules et des sténoses aprés anastomose urétéro-digestive.

14 ureteral stenoses and 5 fistulae following an uro-intestinal anastomosis (UIA) were managed by a transrenal percutaneous approach. The stenoses (12 uretero-ileal and 1 uretero-colic anastomoses) were dilated with an angioplasty balloon and stented for several weeks. After withdrawal of the stent, performed on 12 out of 14 patients, the dilatation was successful in 8/12 cases (66%), with a follow up of 3 to 36 months. All the fistulae were dried. In 2 cases, complete recovery was achieved after placement of a bilateral nephrostomy tube. In 2 other cases, the ureter was stented at the site of the fistula which dried without sequelae after withdrawal of the stent. In the last case (uretero-colic diversion) surgery was performed after the fistula dried for the cure of a complete stenosis associated with the fistulae. The use of percutaneous nephrostomy is highly recommended for the management of post-operative stenoses and fistulae before considering surgical correction.

[Pyelo-duodenal fistula complicating pyelonephritis]. / Fistule pyélo-duodénale compliquant une pyélonéphrite.

The authors report a case of a pyeloduodenal fistula secondary to a gravidic pyelonephritis. The diagnosis was based on intravenous urography. The etiology was probably an unnoticed dysectasia of the pyelo-ureteral junction. The patient recovered following nephrectomy and duodenal suture. The authors conclude with a discussion of the diagnostic and prognostic interest of percutaneous nephrostomy in the management of this rare complaint.

[Treatment using an endo-urologic approach of stenoses following uretero-intestinal anastomosis]. / Traitement par voie endo-urologique des sténoses aprés anastomose urétéro-intestinale.

Twenty-one strictures following uretero-digestive anastomoses were treated by percutaneous transrenal dilatation. In 20 cases, an Olbert type angioplasty balloon on a guidewire was used. Rigid coaxial dilators were used in one patient after failure of the preceding technique and an electroincision was performed prior to dilatation in the remaining case. Overall, percutaneous transrenal dilatation was successful in nine patients, whereas ten dilatations failed and two patients are undergoing continued modeling with a mean follow-up of 16 months (range 1-42 months). Success rates by type of anastomosis were as follows: Bricker 5/12; Coffey 1/4; enterocystoplasty 2/4 and ureteroileovesical anastomosis 1/1. The date of development of the stricture, duration of modeling, and caliber of the indwelling catheter were apparently without influence on results. Because morbidity is low with percutaneous transrenal dilatation, this technique is advocated as first-line treatment, with surgery being reserved to failures.

[Early endoscopic treatment of a complete traumatic rupture of the membranous urethra]. / Traitement précoce par voie endoscopique d'une rupture traumatique complète de l'urètre membraneux.

A man presenting complete traumatic disruption of the membranous urethra, with a 1 cm gap between the proximal and distal urethra, underwent successful endoscopic reconstruction ten days after the injury. When the urethral catheter was removed after fifteen days, peak flow rate was 25 cc per second. One internal urethrotomy was necessary 8 months later. Twenty months after the injury, cystography and retrograde urethrography revealed satisfactory restoration of urethral continuity. We suggest that this treatment be considered in complete traumatic disruption without hematoma and with less than a 1 cm gap between the proximal and distal urethra.

[Treatment of urethral stenosis using Olbert's balloon dilatation angioplasty. Re-evaluation of the results]. / Traitement des sténoses urétrales par dilatation au ballon d'angioplastie d'Olbert. Réévaluation des résultats.

Twenty-eight patients with an urethral stricture underwent Olbert's angioplasty balloon dilatation under local anaesthesia and fluoroscopic control. Four dilatations failed. Six were performed palliatively after failure of classical urethral catheterisation. Sixteen dilatations were performed curatively: thirteen patients developed a recurrent stricture after periods of between 3 days and 12 months. Three patients were cured. Our results suggest that angioplasty balloon dilatation is ineffective as a curative procedure and should be reserved for inoperable patients requiring and indwelling catheter, in whom classical catheterisation has failed.

[A pharmacokinetic study of diffusion in adenomatous prostatic tissue of an intravenous bolus of cefamandole]. / Etude pharmacocinétique de la diffusion dans le tissu prostatique adénomateux d'un bolus intra-veineux de céfamandole.

Twenty-three patients undergoing transurethral resection of the prostate for benign prostatic hypertrophy received antibiotic prophylaxis with a second generation cephalosporin, cefamandole, administered by a single IV bolus of 2.5 g. A pharmacokinetic study was performed on blood and resection chips collected at regular intervals. Cefamandole penetrates rapidly into the prostate without any saturation threshold. It diffuses less extensively and persists for a shorter period in elderly subjects, but penetrates to an identical degree regardless of the volume of the adenoma. The prostatic concentration was always higher than the minimal inhibitory concentration for the bacteria generally encountered, except for pseudomonas. The pharmacokinetic study of cefamandole therefore demonstrated that an IV bolus of 2.5 g is perfectly suitable for antibiotic prophylaxis prior to prostatic resection.

[Transrenal percutaneous treatment of urinary fistula. Apropos of 19 cases]. / Traitement par voie percutanée transrénale des fistules urinaires. A propos de dix-neuf cas.

Percutaneous nephrostomy (PCN) was used to treat 16 ureteral fistulas, two ileal fistulas following ileo-cystoplasty, and one pelvic fistula. Discharge resolved in all cases. PCN alone achieved complete recovery of the ileal and pelvic fistulas. Insertion of a wire-guide through the fistula into the bladder and stenting of the ureter for 5 to 20 days with a 8 to 10 F multi-side-hole catheter was possible in 12 of the ureteral fistulas and ensured complete recovery in every case. Because of complete stenosis, this procedure failed in the four other cases of ureteral fistula, and surgery was therefore required. Transrenal percutaneous treatment of urinary fistulas is a simple, effective procedure requiring only local anesthesia, and can be recommended in recently operated patients, and when retrograde catheterization is inadvisable (ileo-cystoplasty).

[Real-time echography in the evaluation of the venous extension of cancer of the kidney. Prospective study of 50 cases]. / L'échographie temps réel dans le bilan d'extension veineuse des cancers du rein. Etude prospective sur cinquante cas.

Fifty patients with renal carcinoma were evaluated with real time ultrasonography: 15 tumors involved the renal vein (group Ia), 12 of them presented with caval tumor extension (group Ib); 35 tumors did not involve the renal veins (group II). In 3 cases, the renal vein could not be visualized. If the renal veins could be adequately delineated, evaluation of venous extension could be achieved in 100% cases (groups Ia and II). Nevertheless, caval tumor extension could be detected in only 70% cases (group Ib). This prospective study suggests that in the case of renal vein free of thrombus on ultrasonography, further investigations are not necessary to evaluate the venous extension of renal carcinoma. In case of inadequate delineation, or tumor involvement of the renal vein on ultrasonography, evaluation of inferior vena cava is mandatory, either by computed tomography, or inferior cavography.

[Leiomyoma of the urinary excretory tract]. / Les léiomyomes de la voie excrétrice urinaire.

Four cases of leiomyoma of the urinary tract are presented: 3 locations in the bladder and one location in the ureter. Leiomyomas of the urinary tract are rare. These benign mesothelial tumors require conservative resection. Small lesions can be managed with endoscopic techniques.

[Endoscopically "impassable" urethral stenosis. Catheterization under fluoroscopic guidance. Apropos of 11 cases]. / Sténoses de l'urètre "infranchissables" par voie endoscopique. Cathétérisme sous guidage radioscopique. A propos de onze cas.

In eleven patients with impassable urethral stenoses, we attempted retrograde catheterisation with an angiographic guide under fluoroscopic control. The stenosis was able to be negotiated with the guide in 10 cases (91% success). After dilatation by dilators (coaxial or rigid) or by Olbert's angioplasty balloon, we were able to introduce a Foley catheter into the bladder. The only failure was caused by a very marked separation of the two ends of the urethra due to trauma. This simple and effective method constitutes an alternative to immediate surgical treatment of endoscopically impassable urethral stenoses.

[Technical problems raised by renal puncture in the percutaneous extraction of coralliform calculi]. / Problèmes techniques posés par la ponction du rein dans l'extraction percutanée des calculs coralliformes.

Initial puncture and dilation of nephrostomy track(s) remain difficult procedures in percutaneous extraction of staghorn calculi. Technical s adjuvants are necessary and are exposed in detail. The choice of the needle, of the wires and of the catheters for initial puncture and ureteral catheterization is explained. Techniques of "Y" tract and double puncture are exposed. Severe complications (3 cases) are reported. Extraction of up to 90% of the stone can be expected if these technical adjuvants are optimally used.