[Management of perianastomotic stenoses complicating vascular accesses for haemodialysis]. / Prise en charge des sténoses périanastomotiques compliquant les abords vasculaires pour hémodialyse.

OBJECTIVE: Perianastomotic stenoses (PAS) complicating native arteriovenous fistulas (AVF) of the forearm can be treated by angioplasty or surgery. The objective of this study was to report primary patency (PP) and primary assisted patency (PAP) rates of surgery and angioplasty of these stenoses. The secondary objective was to identify factors influencing the patency rates of these reoperations. MATERIAL AND METHODS: Seventy-three patients with a mean age, 65 years were treated for PAS between January 1999 and December 2005 in two centres (Tours and Le Mans), which were retrospectively included. PAS were treated by surgery (n=21) or angioplasty (n=52). The two groups were comparable. The mean follow-up was 39 months for the angioplasty group and 49 months for the surgery group (p=0.088). RESULTS: The PP rate was 71+/-10% for surgery and 41+/-6% for angioplasty (p<0.0175). The PAP rate was not significantly different (p=0.462) between angioplasty (92+/-4%) and surgery (95+/-4%). In the endovascular group, the site of stenosis on the anastomosis was a risk factor for early recurrence (95% CI between 0.006 and 0.392; p=0.047). CONCLUSION: These results suggest that anastomotic stenoses should be treated surgically rather than by angioplasty. Angioplasty and surgery give identical patency rates in other types of perianastomotic stenoses at the cost of a higher reoperation rate for angioplasty.

Human epididymal secretome and proteome.

The proteins that are neosynthesized and secreted in the different regions of the human epididymis were determined by in vitro biosynthesis of epididymal tubules, and the luminal proteins were collected by microperfusion of each tubule. The preparations were analyzed by two-dimensional gel electrophoresis and the proteins were identified by mass spectrometry. Some of the major proteins identified corresponded to serum compounds such as albumin, transferrin and alpha-1-antitrypsin. The other proteins identified included lactotransferrin, clusterin, PEBP, NCP2/CTP/HE1, HE3, Crisp, actin, calmodulin, E12, PGDS, l-lactate dehydrogenase, malate dehydrogenase, carbonic anhydrase, triose phosphate isomerase, glutamyltransferase, glutathione S-transferase P, thioredoxin peroxidase, superoxide dismutase, cathepsin D and cystatin. Epididymal activity is highly regionalized in most species. However, in this study in humans, there were only minor changes in the major proteins secreted. It is suggested that this specificity might be related to the difference between species in the location of the epididymis where sperm become fertile.

[National-ranking exams (NRE) in 2004. Students, faculties and university hospitals are awaiting the results]. / Les epreuves classantes nationales 2004. Premier classement pour les etudiants, les facultés et les CHU.

The results of the 2004 National-Ranking Exams supply interesting but preliminary information. Its intended goal is to rank the students, but it also provides qualitative and quantitative data about students, the success rates of various university teaching and research units (UFR - unité de formation et de recherche), the ranking for each of the 11 possible specialties, student mobility, and the relative desirability of the University Hospital Centres. In these first ranking exams, the medical and surgical specialties appear to be selected by students with the highest ranks, while less good scores lead to public health, occupational medicine. On an individual level, nonetheless, all combinations are seen.

Endocrine cells in the excurrent duct system of the testis. An immunohistochemical analysis.

A systematic search for endocrine cells in the excurrent duct system of the testis was carried out by means of histochemical and immunohistochemical techniques. A panel of antibodies against amine and polypeptide hormones was used. 80 specimens comprising representative areas of rete testis, ductuli efferentes, ductus epididymis and 30 examples of ductus deferens were investigated. Cells immunoreactive for serotonin were detected in four out of 110 specimens. They were invariably in normal-appearing ductuli efferentes. A salient feature was their rarity and focal distribution. We failed to detect any endocrine cells in other segments of the excurrent duct system and notably not among epididymal epithelium. It seems of interest that serotonin cells are specifically distributed throughout remnants of excretory mesonephric tubules in both males and females.

Papillary tumour of the vagina resembling transitional cell carcinoma.

A case of a peculiar papillary neoplasia of the vagina resembling a urothelial tumour is presented. Four vaginal tumours were excised from a 76-year-old woman. Five years before this patient had undergone a uretero-nephrectomy for a non-invasive papillary transitional cell carcinoma of the renal pelvis. The four vaginal tumours demonstrated gross and microscopic similarities to low-grade papillary transitional cell carcinoma of the urinary tract. This observation indicates that multicentric, non-invasive, papillary tumours may affect the whole uro-genital area. The vaginal wall was not overlaid by a normal squamous epithelium, but by a peculiar "transitional-like" epithelium. Variegated endocrine cells were documented within this lining, using immunohistochemical and ultrastructural techniques. The eventuality of a histogenetic link between the tumour and the adjacent epithelial lining remains unresolved.

Glycoprotein hormone alpha-chain-immunoreactive endocrine cells in prostate and cloacal-derived tissues.

All cloacal-derived tissues contain a similar endocrine cell population. Human chorionic gonadotropin (hCG)-like immunoreactivity has been reported in some prostatic endocrine cells. On the other hand, immunoreactivity to alpha-hCG is well known to occur in a variety of extraprostatic endocrine elements. Most cloacal-derived tissues were tested with a panel of monoclonal antibodies against hCG and subunits. The previously described hCG-like positivity was found to be exclusively related to the free alpha-subunit of hCG. Moreover, alpha-chain immunoreactivity was more broadly distributed in most cloacal-derived tissues, including those from the anal canal. In the anal canal, alpha-chain was an excellent marker of the anal transitional zone. alpha-Chain-immunoreactive endocrine cells were normal and nonneoplastic constituents of these tissues; they corresponded to a subpopulation of serotonin cells. In addition, certain prostatic argyrophil cell carcinomas might be exclusively alpha-subunit producing.

[Renal carcinoma with argyrophil cells]. / Carcinome rénal avec cellules argyrophiles.

A case of an unusual type of renal carcinoma is reported. The tumor had a poorly differentiated appearance with focal endocrine differentiation. Scattered argyrophilic cells were revealed by the Grimelius procedure. The relationship of this tumor to other neoplastic processes displaying endocrine differentiation is considered. The present case must be segregated from the classic carcinoid group. It belongs to the heterogeneous class of carcinoma with argyrophil cells and bears some resemblance to the atypical carcinoid.

[Retroperitoneal malignant fibrous histiocytoma]. / Histiocytome fibreux malin rétropéritonéal.

Malignant fibrous histiocytoma is the commonest soft tissue sarcoma of adults. The soft tissue of the extremities is the commonest primary site of malignant fibrous histiocytoma. It is much less common in the female retroperitoneum, leading to diagnostic errors. The clinical, radiographic and CT signs are non-specific. This tumor can only be diagnosed by histology. An initial complete resection is essential for successful treatment of the primary tumor. Radiation therapy is limited and chemotherapy has only been successful in a limited number of cases. This tumor has a poor prognosis. These lesions are relatively rare and consequently difficult to study. The authors report three cases and review the literature.

[Exstrophy of the bladder and pregnancy]. / Exstrophie vésicale et grossesse.

Two patients with bladder extrophy who had been operated on during infancy (the one by reconstruction of the bladder and the other by Coffey's operation) had delivered by Caesarean section, in the one patient of one child and in the other of two normal children. They formed the basis of this study. Vesical extrophy or ectopia vesicae is a rare malformation (in 1/40 000 to 1/50 000 births). It occurs most often in male children. It can be associated with genital, urological and orthopaedic malformations. The principal complications that can occur in pregnancy are urinary tract infections, prematurity, malpresentations and genital prolapse. As far as the urological side is concerned the complications are of ureteric stones, metabolic troubles, stenosis or obstruction of the uretero-sigmoid anastomosis following Coffey's operation, and ileal prolapse if Bricker's operation had been undertaken. The ways in which the babies should be delivered are discussed, as are the risks of this malformation recurring in children who are born to mothers with vesical extrophy.

[Surgical treatment of benign hypertrophy of the prostate]. / Traitement chirurgical de l'hypertrophie bénigne de la prostate.

It has been calculated that 7% of the males living in France over the age of 65% will undergo a surgical procedure for benign prostatic hyperplasia within 5 years. Currently approximately 65000 patients are operated every year. The mean age of the patients is 71.8 years with an incidence much lower than that observed in the United states where the mean age is 66 years. According to the reports of the 87th congress of urology, 10 to 20% of the patients are operated because of urine retention.

[ The law, indispensible images and superfluous images in cancer of the kidney]. / La loi, les images indispensables et les images superflues dans le cancer du rein.

In France, a physician is considered liable for a medical error only if the appropriate diagnostic and therapeutic means were not used. The urologist who evaluates a patient is responsible for the diagnosis of renal carcinoma and for assessing the spread of the disease and deciding whether surgery is indicated. The urologist coordinates the various investigations and interprets results in the light of each individual patient's characteristics. In most renal carcinomas, only simple imaging techniques are needed: renal ultrasonography and an intravenous urogram or a CT scan. Further techniques may be required to assess disease spread according to the French Urology Association's Oncology Committee, only abdominal ultrasonography and a chest film are "absolutely required", the other imaging techniques being "desirable" or "optional".

[Imaging and the court of law: useful images and useless images]. / Image et tribunal: images utiles et images inutiles.

The expert who review a medical record in a liability suit is required to determine whether the tests performed were necessary and, above all, whether they were adequate. In France, physicians are legally required to use adequate diagnostic and therapeutic means, especially in complicated cases. When this obligation is not fulfilled, the urologist is often held responsible since he or she is in charge of interpreting the tests and drawing final conclusions. Urologists are rarely criticized for performing too many investigations. The urologist is not considered liable for complications that occur during the performance of a necessary test: in this case, the physician who performed the test is legally responsible.

[Discovery of a renal chromophobe cell carcinoma in a pregnant woman. Apropos of a case]. / Découverte d'un carcinome rénal à cellules chromophobes chez une femme enceinte. A propos d'un cas.

We report the case of a young pregnant woman with a malignant tumour of the kidney suggestive of oncocytoma. Because of the pregnancy, preoperative staging consisted of abdominal ultrasound and magnetic resonance imaging. Caesarean section was performed. Several days later, surgical exploration of the kidney was performed with tumourectomy and frozen section analysis: radical nephrectomy was finally performed. The definitive histology was chromophobe renal cell carcinoma. This is a rare tumour of the kidney, with its own characteristics allowing histopathological diagnosis and with a better prognosis than renal cell carcinoma. In the literature, pregnancy, a situation of immune depression, does not increase the prevalence of malignant neoplasms.

[Classification and treatment of ureteroceles in the adult]. / Classification et traitement des urétérocèles de l'adulte.

Ureterocele or congenital pseudocystic dilatation of the terminal portion of the ureter due to persistence of Chwalla's membrane is frequent in female adults (17-35%) in its orthotopic form. It expands the short submucosal segment of the normally situated ureter and may be intravesical or extravesical. The diagnosis is primarily radiological based on intravenous urography (IVU) and endoscopy (urethrocystoscopy). Treatment depends on the site of the ureterocele, the clinical context, associated anomalies and especially the dimensions. Endoscopic treatment has numerous advantages and deserved to be more widely used.

[Urologic surgery and risks of complaints in medical responsibility]. / Chirurgie urologique et risques de plaintes en responsibilité médicale.

The card-index study of specialized insurance companies allowed the analysis of 82 cases concerning urological surgical procedures. Forty-two cases went to the Civil Court, 10 to the Penal Court and 5 to the Administrative Tribunal, while 5 cases were simply declared to insurance companies without judiciary consequences. Sixty-two cases concerned private plaintiffs surgeons and 34 cases concerned non specialist urologic surgeons. Sixteen plaintiffs were compensated, 9 after a conciliatory agreement and 7 after trial. There were no penal condemnations (one case on the waiting list). Impotence was the most frequent cause for complaint which was compensated. Next, came incontinence generally secondary to endoscopic resection. Retrospectively, 19 cases seemed to be unwarranted due to the dishonesty of patients (3 patients were prosecuted for unwarranted procedures). On the other hand, 32 cases seemed to be due to a lack of information given to the patients themselves or to their families, either before of after the incriminated act. The risk of prosecution is relatively low in urology. It could be decreased by careful management of the medical chart, by rapid analysis of complications and by a constant effort to inform the patient and his family.

[Tentative classification of the ultrasound symptomatology of the prostate by an anatomo-ultrasonic comparison of 34 cases]. / Tentative de classification de la sémiologie échographique de la prostate par confrontation anatomo-ultrasonique de trente-quatre cas.

Ultrasound and histological sections were taken of 34 prostate units removed from fresh cadavers. Ultrasonography seems to raise more problems than it solves; only 73% of the normal prostates were homogeneous under ultrasound. Ultrasonography visualized nodular structures requiring biopsy in 71% of the cases of prostatic adenoma. There were too few cases of malignant tumors in the sample to warrant a conclusion. They were highly evolved. Ultrasonography gave strong grounds for suspicion, but they could be easily diagnosed clinically.

[Bladder exstrophy and pregnancy. Apropos of 2 cases]. / Exstrophie vésicale et grossesse. A propos de deux observations.

The authors report two cases of pregnant women suffering from exstrophy of the bladder. One of the patients had been operated on in childhood for reconstruction of the bladder, and the other had undergone Coffey's operation, so that both were able to lead practically normal lives in adulthood. Three children were born by prophylactic cesarean. Exstrophy of the bladder is often associated with other urological, genital or, on occasion, orthopedic, malformations. This article analyzes the consequences of these malformations on the course of pregnancy and delivery, and the consequences of pregnancy on the urinary tract or on the different types of surgical reconstruction. The indications for the type of delivery (natural passages or cesarean section) are discussed in the light of the author's personal experience and a review of the literature.

[Epidemiology of tumors of the testis in Indre-et-Loire from 1978 to 1987]. / Epidémiologie des tumeurs du testicule en Indre-et-Loire de 1978 à 1987.

All the testicular tumors found among the inhabitants of the Indre-et-Loire department between 1978 and 1987 were reviewed. There was a total of 122 tumors, i.e. a direct standardised incidence rate of 4.55/100,000. The incidence increased over the years 1978-1982, with an abrupt decrease at 50% in 1983 and the increase since then has been minimal. There was an excessive morbidity rate of 22% for patients living in an urban environment. There was no preferential side for the tumor. The histological types of the tumors permit to distinguish three types of populations: non seminiferous germ cell tumors (51.3%) at the age of 30 years; seminoma (41.3%) at the age of 40 years and lymphoma (7.4%) at the age of 74 years. An indirect standardisation revealed an excessive rate of 22% for the socioprofessional category of employers and a rate of 28% for artisan, business men and company directors. The study confirms the known notions about the age and the histologic distribution of testicular tumors. The highest incidence rate of all the French departments, the drop in the rate of this growth curve in 1983 and the over representation of the employee category appear to be the most specific notions in the Indre-et-Loire department.

[Carcinoma in situ of the testis]. / Carcinome in situ du testicule.

Carcinoma in situ (C.I.S.) of the testis is the only known precancerous lesion of germ cell tumours. The prevalence and the incidence of C.I.S. are both unknown, although predisposing factors have been identified: history of germ cell tumour of the contralateral testis, cryptorchidism or history of ectopic testis, decreased fertility or sterility. The incidence is higher in the presence of a combination of several of these factors. No complementary investigations have been demonstrated to be of any value in the detection of C.I.S. which can only be diagnosed, at the present time, by means of surgical biopsy. Once C.I.C. has developed, it never resolves spontaneously. In one half of cases the C.I.S. evolves into an invasive tumour over a period of 5 years. There is no consensus concerning the population in which testicular biopsy should be proposed looking for C.I.S. A large scale C.I.S. screening and detection programme has been proposed in Denmark. However, it is not clear that there is any major gain in testicular cancer morbidity and mortality in comparison with a surveillance programme of patients at risk. Apart from conservative follow-up, two types of treatment can be proposed: orchidectomy or external beam radiotherapy which appears to eradicate the C.I.S. while preserving endocrine function.

[Malignant fibrous histiocytoma of the retroperitoneum]. / Histiocytome fibreux malin rétropéritonéal.

The authors report two cases of retroperitoneal malignant fibrous histiocytoma which is a rare tumour (200 cases reported in the literature). The clinical and radiological signs are nonspecific and the diagnosis is based on histological examination of the specimen. Surgical resection must be as complete as possible to prevent local recurrence. The efficacy of adjuvant therapy has not been demonstrated due to the low incidence of this tumour.