Effect of impaction on third molar development and age estimation-A study in a Lebanese population.

BACKGROUND: The effect of impaction on third molar development is disputable as the scientific literature is not uniform. In parallel, population-specific studies have been encouraged in dental age estimation. This study aimed to investigate the effect of impaction on third molar formation in a sample of Lebanese individuals. MATERIALS AND METHODS: The sample consisted of 518 panoramic radiographs of females (n=229) and males (n=289) between 15 and 23.9 years. Mandibular third molars were classified based on their position as non-impacted and impacted (with horizontal, vertical, mesioangular, and distoangular impaction). Dental development was classified according to Demirjian's 8-level staging system. RESULTS: Most teeth presented mesioangular impaction (#38=29.7%, #48=33%). Developing third molars were predominantly distributed between stages D and G. The mean age of most developmental stages was higher among impacted teeth, meaning that third molar mineralization could be slower in the presence of impaction. In general, the delayed dental development did not have statistically significant effects (P<0.05). However, descriptive data pointed out differences between (impacted and non-impacted) mean ages of >12 months-suggesting a potential clinical significance (despite the lack of a statistical one). Furthermore, differences changed based on sex and side (#38/#48). CONCLUSION: Therefore, dental age estimation from third molars in the selected Lebanese population should preferably be performed in non-impacted third molars whenever available.

Comparison of the third molar maturity index (I3M) between left and right lower third molars to assess the age of majority: a multi-ethnic study sample.

The diagnostic accuracy of the I3M to assess the legal age of 18 years has already been tested in several specific-population samples. The left lower third molar has been extensively used for discriminating between minors and adults. This research aimed to compare the usefulness of lower third molar maturity indexes, from both left and right side (I3ML and I3MR), in samples originating from four distinct continents in order to examine possible differences in their accuracy values. For this purpose, a sample of 10,181 orthopantomograms (OPGs), from Europe, Africa, Asia and America, was analysed and previously scored in other studies. The samples included healthy subjects with no systemic disorders with both third molars and clear depicted root apices. Wilcoxon Signed Rank test for left and right asymmetry did not show any significant differences. Data about sensitivity, specificity, predictive values, likelihood ratio and accuracy were pooled together and showed similar results for I3ML and I3MR, respectively. In addition, all these quantities were high when only the I3MR was considered to discriminate between adults and minors. The present referable database was the first to pool third molar measurements using panoramic radiographs of subjects coming from different continents. The results highlighted that both I3ML and I3MR are reliable indicators for assessing the legal age of 18 years old in those jurisdictions where this legal threshold has been set as the age of majority.

Comparing laparoscopic and percutaneous renal biopsy for diagnosing native kidney disease: A matched pair analysis.

BACKGROUND: Percutaneous renal biopsy is a well-established diagnostic procedure in patients with underlying medical renal disease. Aim of this study is to compare the adequacy of the biopsy material, the diagnostic yield, and the complication rates of the trans-peritoneal laparoscopic approach and the image-guided percutaneous approach to renal biopsy in the diagnosis of native kidney disease. METHODS: We performed a matched-pair analysis matching 1:3 40 patients who underwent trans-peritoneal laparoscopic renal biopsy to 120 patients who underwent percutaneous renal biopsy in the same years. Patients were retrospectively analyzed. Differences in adequacy of biopsy material (i.e. number of glomeruli, continuous), diagnostic yield (categorical) and postoperative complications across the two groups were assessed using Wilcoxon Rank sum or χ2 test. RESULTS: Laparoscopic biopsy was associated with a higher number of harbored glomeruli (median 50, IQR 20-77) compared to the percutaneous approach (median 10, IQR 7-15), P<0.001. Adequate biopsies containing at least ten glomeruli were obtained in a significantly higher percentage of patients in the laparoscopic group versus the percutaneous group (92.5% vs. 57.1%, P<0.001). The laparoscopic approach was also associated with a significantly higher diagnostic yield than the percutaneous approach (82.5% vs. 63.5%, P=0.027). Patients who underwent laparoscopic biopsy had no perioperative or postoperative complications, resulting in a significantly lower complication rate than percutaneous biopsy (0% vs. 4%, P<0.001), particularly in the need for transfusion for post-procedure bleeding (0% vs. 1.8%, P<0.001). CONCLUSIONS: In this retrospective matched-pair analysis comparing patients undergoing renal biopsy for medical kidney disease, trans-peritoneal laparoscopic renal biopsy was safer and more effective for the diagnosis of medical renal diseases compared to percutaneous renal biopsy. Prospective trials with a good follow-up are needed to define the best candidate for each approach. LEVEL OF EVIDENCE: 4.

Piezolith extracorporeal shockwave lithotripsy: the Hotel-Dieu de France experience.

A total of 1500 patients underwent treatment with the Wolf Piezolith 2300 extracorporeal shockwave lithotripter for renal, ureteral, and bladder stones. Follow-up data were available at 3 months for 1435 patients. At that time, the overall stone-free rate was 82.7%: 82.4% for patients with renal stones, 81.0% for those with ureteral stones, and 100% for those with bladder stones. The overall success rate was 92.3%: 93.8% for patients with renal stones, 87.1% for those with ureteral stones, and 100% for those with bladder stones. The auxiliary treatment rate was 14.9%, and the retreatment rate was 53%. The effectiveness quotient was 49.2%. The Wolf Piezolith 2300 is an effective treatment for most stones smaller than 30 mm.

Treatment of staghorn calculi by percutaneous nephrolithotomy and SWL: the Hotel Dieu de France experience.

To evaluate the combined approach of percutaneous nephrolithotomy (PCNL) and extracorporeal shockwave lithotripsy (SWL) in the treatment of staghorn calculi, we carried out a retrospective review of 101 patients. The stone surface area ranged from 654 to 3042 mm2 (1535 mm2 on average). During PCNL, a single access tract was used in 22 patients, a double tract in 65 patients, and a triple tract in 14 patients. A double-J stent was placed percutaneously in 62 patients. Extracorporeal lithotripsy was scheduled at the patient's convenience on an outpatient basis approximately 2 weeks after PCNL. The mean hospital stay was 4.4 days. The combined approach showed a stone-free rate of 67% on the initial evaluation, an insignificant residual fragment rate of 26%, and a residual stone rate of 7%. With a follow-up of 52 months on average, the global stone growth rate was 17%, being 4.4% only among the stone-free group and 27% among the group with insignificant residual fragments. The global transfusion rate was 10%. Percutaneous stone debulking combined with SWL on an outpatient basis is an efficient, minimally invasive treatment for staghorn renal calculi. Reducing the number of access tracts, using the flexible nephroscope liberally, and placing a double-J stent frequently after PCNL increases the stone-free rate while reducing the morbidity and hospital stay.

[Emergency treatment of calculi of the lower ureter]. / Traitement en urgence des calculs du bas uretère.

Two-hundred patients were hospitalized as an emergency for lower ureteral calculi. Eighty-two of these patients has a less than 6 mm wide calculus which was evacuated by medical treatment; 5 had stagnant infected urine which was drained by endoprosthesis; 113 had an obstructive calculus which resisted medical treatment and was treated by ureteroscopy: the stone could be removed by means of a basket catheter in 58 cases, but this method failed in the other cases and the calculus has to be broken by laser. There were 6 failures due to the nature of the stone (monohydrated oxalate) in 3 cases and to technical laser problems in 3 cases. The success rate of ureteroscopy (basket catheter or laser) was 95 percent in patients whose pain had persisted under medical treatment.

[Arterial stenosis in the renal graft. Indication for endoluminal dilatation]. / Sténoses de l'artère du rein transplanté. Place des dilatations endoluminales.

One hundred and thirty eight patients with renal transplant artery stenosis were reported in a series of 1200 renal transplants. These cases included 47 patients in whom hypertension was well controlled by means of hypotensive drugs, 39 patients treated by surgical repair (SR) and 49 treated by percutaneous angioplasty (PTA). The long-term success rate was 81.5 percent in the SR group compared with 40.8 percent in the PTA group. PTA morbidity was greater than that of SR, and we believe that after the initial optimism, the results of this technique should be reevaluated according to the anatomical pattern of the renal artery stenosis.

[Arterial stenosis in the renal graft. Spontaneous evolution in 40 cases]. / Sténoses de l'artère du rein greffé. Evolution spontanée de 40 cas.

From January 1976 to June 1989, 138 renal artery stenoses (RAS) occurred in a population of 1,200 renal transplantations in a single center (11.5 percent). An interventional procedure was performed in 89 patients: surgery in 39 and transluminal angioplasty in 50. Six other patients were excluded from the study because of complications and RAS spontaneously disappeared in 3 patients. Finally, 40 patients were treated medically with a mean follow-up of 57.6 months (range 12 to 116 months). In this group, the actuarial graft survival rate did not significantly differ from that of the 2 other groups. One patient only lost his graft from renal artery thrombosis. The mean serum creatinine level at the time of RAS diagnosis (140 +/- 8.6 mumol/l) was not significantly different from the mean serum creatinine level at the last follow-up (146 +/- 14.6 mumol/l). The degree of hypertension, graded on the number of anti-hypertensive drugs, was not different at the time of diagnosis and at the end of follow-up. In conclusion, in our experience, the spontaneous course of RAS does not result in an increased rate of graft failure or impaired long-term renal function.

[Urologic complications in kidney transplantations. Indication for endo-urologic techniques]. / Les complications urologiques des transplantations. Place des techniques endo-urologiques.

We report the incidence of urological complications in a series of 1,200 kidney transplant: 3.8 percent of the patients developed a urinary fistula, due to ureteral necrosis in 48 percent of cases, and 6.5 percent had urinary obstruction. Urinary fistulas are early complications appearing 20 days after the transplantation, while obstructions appear about one year after grafting. These complications are now usually treated by percutaneous and/or endoscopic techniques.

[Principles of organ preservation]. / Bases de la préservation d'organes.

Hypothermia remains the basic principle of all organ preservation. This review shows some main cellular mechanisms involved with normo and hypothermia, particularly during ischemia. Different pathways and target sites concerned in preservation are explained. Commonly used preservation techniques and cold storage solutions are also discussed. Cryopreservation especially vitrification seems to be promising perhaps in the near future; it allows a state of almost a cellular metabolic arrest and consequently a theoretically unlimited preservation time.

[Lymphocele and kidney transplantation]. / Lymphocèle et transplantation rénale.

The authors report fourteen cases of lymphocele in a series of one thousand consecutive renal transplantations (1.4%). The prevention of these lymphoceles depends on rigorous lymphostasis. The diagnosis is based on ultrasonography. The treatment indicated in cases of voluminous lymphoceles consisted in marsupialization and omentoplasty.

[Harvesting multiple organs]. / Les prélèvements multiples.

The development of organ transplants is limited by the shortage of organs. The improvement of this situation depends on two factors: increased awareness by the general public that refraining from refusing the removal of organs from the body of a patient with brain death is the most modern form of solidarity; and increased awareness by the medical profession that removal of organs should be proposed for every patient with brain death and that adequate resuscitative techniques should be used to preserve the organs in these patients. When the decision to harvest organs is taken, the transplant specialists must decide whether an organ should be used or not. Advances have been made in preservation techniques but are still insufficient to allow a reduction in immunosuppression. The UW solution is a major advance for liver, kidney and pancreas transplants. During harvesting, the separation of the vascular pedicles requires a good knowledge of surgical anatomy. Furthermore, the needs of the other surgical groups should be taken into account and concessions made to allow the harvesting of the greatest possible number of organs and consequently the treatment of the largest number of patients awaiting organs.

[Comparative study of the University of Wisconsin solution versus Eurocollins in kidney transplant]. / Etude comparative de la solution de l'Université de Wisconsin versus Eurocollins en transplantation rénale.

UW (University of Wisconsin) solution, formulated by Belzer's team in Madison, has already been proved to increase cold ischemia time in liver and pancreas preservation. A multicentre clinical trial is being conducted to compare renal preservation in human transplantation using two different solutions: UW and Eurocollins (EC). This paper, whose results will be included in the multicentre trial, reports local comparative results between UW and EC perfused Kidneys. The two donor populations UW (28 cases) and EC (47 cases) were not randomized. They were however comparable in renal function prior to harvesting but not in age (35 +/- 13.4 years EC versus 27.7 +/- 12.4 years UW). The two recipient populations (48 EC versus 48 UW) were more homogeneous. Comparative results were significant with better graft function in the UW group: creatinine at one week: 499.2 +/- 296.3 EC versus 277.6 +/- 226.2 mumol/l, p less than 0.0001; creatinine at one month: 228.7 +/- 135 EC versus 159.7 +/- 135.6 mumol/l, p less than 0.02 and a decrease in acute tubular necrosis (39.5% EC versus 14.5% UW) and hospital stay. These results justify the use of UW solution by intraaortic flush especially during multi-organ procurement.

[Treatment of hypospadias with a transverse preputial pediculated flap]. / Traitement de l'hypospadias par le lambeau pédiculé préputial transverse.

With a better understanding of the penile vasculature, many one-stage techniques were proposed for mid-shaft and posterior hypospadias repair including the Duckett's technique with the transverse preputial island flap (TPIF). We performed the Duckett's technique on 25 patients with penile hypospadias with the following results: no cases of meatal stenosis and three cases of urethro-cutaneous fistula (12%). The three cases of urethro-cutaneous fistula were reported in the first 15 patients where the neo-urethra was closed in one layer but no case of fistula was reported in the last 10 patients where the noe-urethra was closed in two layers: the difference is significative (p < 0.05). In conclusion, the Duckett's technique with the two-layer closure technique of the neo-urethra is a good alternative for penile hypospadias repair.

Dilemma of oxalosis in end stage renal failure: isolated kidney allograft or hemodialysis.

We report the case of a 10-year-old girl who received a cadaveric kidney transplant for oxalosis after a period of 12 months on hemodialysis. The donor was a 6-year-old child. Cold ischemia was four hours. Diuresis occurred immediately in the operating room. Mean daily diuresis was maintained at 8 liters: first by i.v. perfusion, then by nocturnal continuous nasogastric hydration. In addition to the usual immunosuppressive drugs, she received pyridoxine, sodium citrate, phosphate, hydrochlorothiazide and magnesium. Daily hemodialysis was performed from Day 1 to Day 9 and four additional sessions every other day. The postoperative course was satisfactory. Oxaluria was elevated initially at 1074 mg/24 h (normal < 50 mg/24 h). One year later, mean daily diuresis is still 8 liters, renal function is normal and oxaluria is at 296 mg/24 h. Repeated graft sonography showed no nephrocalcinosis, but mild oxalate deposits are noted on renal biopsy. Isolated renal transplantation was successful in our patient. It allowed us to stop hemodialysis and to avoid extra-renal accumulation of oxalate. Despite this success, we are convinced that long term prognosis is uncertain and liver transplantation should be realized to correct definitely the biochemical defect.

[Kidney transplantation in the child. Experiences of l'Hôtel-Dieu de France]. / La transplantation rénale chez l'enfant. Expérience de l'Hôtel-Dieu de France.

A retrospective study was conducted on all kidney transplantations performed between January 1993 and June 1996 in our multidisciplinary pediatric department. Thirteen children with a mean age of 6 years (3.5-12) were transplanted during the study period after an average waiting time of 2 years on dialysis for cadaveric transplants and 3.5 months for living related ones. No urologic complication was noted; however, intra-abdominal approach was decided to be performed only in children less than 9 kg. This decision was taken after the occurrence of one intestinal intussusception and two ileal obstructions. During these 3.5 years, five rejection episodes were treated: three were steroid responsive, two were resistant but responded respectively to plasmapheresis and to OKT3. The actuarial survival of the grafts and recipients were 100% for an average mean time of follow-up of 18 months. The latest serum creatinine and creatinine clearance averages were respectively 66 mumol/l and 105 ml/min/1.73 m2. In seven transplanted children for more than 18 months growth was satisfactory. Eleven children returned to school. Kidney transplantation is the optimal treatment for children and infants with chronic renal failure; however, this technique needs a highly experienced team and a permanent close follow-up. Some children with end stage renal disease can directly have preemptive transplantation which is becoming our recent choice to avoid the hemodialysis strain.

[Augmentation cystoplasty and intermittent catheterization in neurogenic bladder]. / Cystoplastie d'augmentation et cathétérisme intermittent dans les vessies neurogènes.

An enterocystoplasty was done on 17 paraplegic adults patients (Beit Chahab Hospital for Handicapped) with hyperreflexic neurogenic bladder secondary to an accident of the supra-sacral medulla. These patients were incontinent, had urinary tract infections, vesico-renal reflux or autonomic dysreflexia. Detubularized ileum was used in 16 cases and sigmoid in one. Ureteral reimplantation was performed on one patient; implantation of an artificial urinary sphincter for one patient and an injection of a periurethral Teflon paste was also done for one patient. After 16 months of follow-up all patients are continent on self intermittent catheterization. The upper urinary tract is stable or improved. No autonomic dysreflexia. Thirteen patients have an asymptomatic untreated bacteriuria.

Vein grafting of tunical incisions in the treatment of Peyronie's disease.

The effectiveness of vein grafting of tunical incisions of Peyronie's plaques in straightening the penis, with preservation of normal erectile function is evaluated. Eighteen patients with Peyronie's disease were surgically treated with a vein patch graft technique to correct their penile curvature. Transverse relaxing incisions were made on the tunica albuginea where a curvature was identified by an artificial erection. A vein graft from the saphenous vein was sewn into the defect created by relaxing incisions. If there was evidence of a residual curvature after the vein grafts were sewn in, a plication of the contralateral surface of the tunica albuginea was performed. The saphenous vein grafting alone was sufficient to straighten the penis 90 to 100% in 50% of patients. Of twelve patients who were potent preoperatively, one required postoperatively an occasional intracorporeal injection to maintain erection. Two of the impotent men regained their potency postoperatively. None of the patients lost sensation in the glans or shaft of the penis. Penile shortening was reported in three patients. No decrease in the penis rigidity was noted. Patients were discharged within 5 days of the procedure. There were no immediate complications. Fifteen of our sixteen followed patients resumed intercourse in eight weeks. We found that plaque incision in the venous grafting is much easier than the other incisional and excisional procedures described in the literature, and may lead to successful correction of penile deformity without compromising potency, penile length and sensitivity.

[Implantation of the Ultrex type inflatable penile prosthesis. Four years experience]. / Implantation de prothese pénienne gonflable type Ultrex. L'experiencede 4 ans.

During the last 4 years, 12 patients had an implantation of the AMS Ultrex2 penile prosthesis : 4 of these patients were impotent after a cystoprostatectomy, 4 patients had vascular insufficiency, 2 patients had psychogenic impotency, one patient was diabetic and one patient had a spinal cord injury. The complication rate was low (16%): one patient necessitated a surgical revision of the prosthesis after disconnection of the tubulure. A second patient had a urethral stenosis treated by dilation. The degree of satisfaction of both patient and partner was satisfactory.

Microsurgical high inguinal varicocelectomy with delivery of the testis.

This study describes the results of 50 consecutive cases of varicocelectomy by the inguinal approach. The testicle is delivered through a small inguinal incision, and all external spermatic and gubernacular veins are ligated. The testis is returned to the scrotum and the spermatic cord is dissected under optical magnification. The testicular artery, the lymphatics and the vas deferens are identified and preserved. All internal spermatic veins are ligated. 94 varicocelectomies were performed in 50 men. Follow-up period extended from 12 months to 24 months. No hydroceles, no clinical recurrences and no wound infection were found. One scrotal hematoma occurred and resolved progressively. Preoperative and postoperative semen analysis were obtained. The changes in sperm count mean value (million/cc) (20 to 28.6) (p < 0.005), per cent normal forms (42.9 to 52.1%) (p < 0.005) and per cent motility (31.5 to 39.2%) (p < 0.005) were significant. The pregnancy rate was 10 of 21 couples available for follow-up (47.6%). This technique results in a significant decrease in the incidence of hydrocele formation, testicular artery injury and varicocele clinical recurrence.