Modified corporoplasty for penile curvature: 10 years' experience.

OBJECTIVES: To treat penile curvature, a modification of corporoplasty consisting of horizontal closing of a longitudinal incision of the corpora cavernosa was performed during the last 10 years in 55 patients. METHODS: The technique was used in congenital (32 patients) as well as acquired penile curvature patients (23 with Peyronie's disease). RESULTS: Successful results, up to 10-year follow-up, were achieved in 95% of the patients without any injury to the neurovascular bundle. CONCLUSIONS: The simplicity of this technique and its minimal aggressivity have the advantage of not removing corporeal tissue and being very flexible and adaptable to individual situations.

Endoscopic treatment of vesicoureteral reflux.

Since 1985 we treated 180 cases of vesicoureteral reflux with endoscopic injection of polytetrafluoroethylene (Teflon). Follow-up, from 1985 to 1990, was available for 256 refluxing ureters (93% primary reflux, 7% secondary after reimplantation or neurogenic bladder). The distribution according to the grade was the following: Grade I: 26 cases (always associated with higher grade contralateral reflux), Grade II: 94 cases, Grade III: 97 cases, Grade IV: 28 cases and Grade V: 11 cases. For primary reflux, correction was observed after a single injection in 87% of the cases and 93% after a second injection. So far no long-term morbidity and complications have been observed. The procedure is simple, reliable and successful. We are aware of the ongoing discussion about the safety of the polytetrafluoroethylene paste, particularly in children, and are waiting for the ideal substance preferably prepared from the patient's own tissue.

Neoadjuvant hormonal deprivation before radical prostatectomy.

Hormonal deprivation before radical prostatectomy remains controversial. The main purpose is to achieve downstaging, downgrading, improvement of the surgical results and increased survival. Experience with the last 100 patients who underwent radical prostatectomy, in whom 40 patients received complete preoperative androgen blockade (luteinizing-hormone-releasing hormone agonist and flutamide) prior to radical surgery, has shown a definitive decrease in volume of 40-50%). The significant reduction of volume seemed to facilitate the dissection of the prostate from closely vulnerable structures. Clinical downstaging was observed in one third of the patients, but the final pathological staging did not confirm the clinical impression and shows that it is difficult to solve this issue. There was one PT0 patient. Histological changes are observed in both the nonneoplastic tissue as well as in the prostatic carcinoma with more marked effects on the latter. Downgrading was not observed, but this is even more difficult to assess since biopsies cannot be considered as representative of the entire heterogeneous tumor. Prostate-specific antigen (PSA) dropped to undetectable levels in 59% of the patients 3 months after hormonal suppression. Among these, 80% had PT2 and only 13% had PT3 tumor. PSA, 3 months after neoadjuvant hormonal treatment, might have a useful predictive value in patient selection for radical surgery since 86% with undetectable PSA had tumors confined to the gland (PT2/B2). On the other hand, patients who still had PSA > 4 ng/ml after neoadjuvant therapy had all stage PT3-PT4 disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Neoadjuvant hormonal deprivation before radical prostatectomy.

Our experience with 40 patients receiving complete androgen blockade with luteinizing hormone-releasing hormone agonist and flutamide, prior to radical surgery, has shown a definitive decrease in prostate volume of 40-50%. This significant reduction in volume, induced by the neoadjuvant therapy, seems to facilitate the dissection of the prostate from closely vulnerable structures, with a reduction in blood loss (average 400 ml) and in time of surgery (average 135 min). Clinical downstaging was observed in one third of the patients, but the final pathological staging clearly showed that it is difficult to confirm this issue. Downgrading was not observed, but this is difficult to assess since the biopsies are not representative of the entire heterogeneous tumor. Prostate-specific antigen (PSA) dropped to undetectable levels in 59% of the patients 3 months after hormone suppression. Among these, 80% had pT2 and only 13% had pT3 tumors while there was 1 pT0 patient. Patients who still had a PSA of > 4 ng/ml after neoadjuvant therapy all had stage PT3-PT4 disease. Histological changes were observed in both the non-neoplastic tissue and the prostatic carcinoma, with effects being more marked in the latter. PSA, after 3 months of neoadjuvant hormone treatment, might have a useful predictive value in patient selection for radical surgery, since 86% of patients with undetectable PSA had tumors confined to the gland (pT2-B2). Large, prospective, randomized studies, comparing radical prostatectomy against radical prostatectomy with neoadjuvant complete androgen deprivation in locally advanced (T2-T3N0M0) prostatic carcinoma, are needed to assess the true influence of the combined approach on local control, time to progression and overall survival.

Neoadjuvant hormonal deprivation before radical prostatectomy.

Hormonal deprivation by combination therapy before radical prostatectomy has been recently introduced. The main purpose of such treatment is to achieve downstaging, downgrading, improvement of surgical results, and prolonged survival. Our experience with the last 100 patients who underwent radical prostatectomy at our hospital, of whom 40 received complete androgen blockade (luteinizing hormone-releasing hormone (LHRH) superagonist and flutamide) before radical surgery, has shown a definitive decrease in prostatic volume of 40-50%. Of these 40 patients, 25 were clinical stage T2 and 15 stage T3 at diagnosis. The reduction in volume facilitates dissection of the prostate from close vulnerable structures, resulting in reduced blood loss and operating time. Also, return of urinary continence is more rapid. Combination therapy resulted in clinical downstaging in one third of the patients; at histopathology, upstaging occurred in 12.5% (5 of 40) of patients, compared with the expected 30-50% upstaging in patients untreated before surgery. Serum prostate specific antigen (PSA) dropped to undetectable levels in 59% of the patients 3 months after hormonal suppression. Among these, 80% had PT2, and only 13% had PT3, tumor; one patient had a PT0 tumor. On the other hand, all patients who still had PSA > 4 ng/ml after neoadjuvant combination therapy had stage PT3-PT4 disease. Histological changes were observed in both the non-neoplastic tissue and the prostatic carcinoma, with more marked effects in the latter. The surgical margins were positive in 32% of the treated patients, compared with 57% in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Personal experience with the Nissenkorn endo-urethral prosthesis. Preliminary report]. / Notre expérience de la prothèse endo-uréthrale de Nissenkorn. Rapport préliminaire.

Relying on Nissenkorn preliminary report (J. of Urology, July 89), we inserted this intraurethral device in 11 patients. This new urethral prostheses resembles a double Malecot 16 F. catheter, available in 45.55 and 60 mm lengths. It is inserted through a 21 F. cystoscope sheath under local anesthesia. We reserved this prostheses for selected patients who presented a urinary retention due to cervico-prostatic obstruction, with anesthetic contraindications to an operation, or limited life expectancy. The follow-up is from 1 to 4 months. Of the 11 patients, 8 were able to void without incontinence or postvoiding residual. 2 patients had partial micturition. We noticed 2 early and one late migration of the prosthesis to the bladder. There were no macrohematuria or clinical urinary tract infection.. We believe that this urethral prosthesis is a valid alternative to a long term indwelling catheter. With additional experience and follow-up, we would be able to appreciate the real benefits of this prosthesis.

[The role of neoadjuvant treatment prior to radical prostatectomy]. / Rôle du traitement néoadjuvant avant la prostatectomie radicale.

Preoperative hormonal therapy has been recently advocated, but remain controversial. The aim purpose is to achieve downstaging, downgrading and improvement of the surgical results. In the last 80 patients undergoing radical retropubic prostatectomy, 28 had preoperative androgen deprivation, for a period ranging from 2 to 12 months with a mean treatment time of 3 months. Medical castration was obtained with total androgen deprivation. Return to normal value of PSA level in 90% cases and to undetectable level (< 0.25) in 39% of cases, expressing probably reduction of the tumor activity. Total prostatic volume is reduced by 30-50% after three months of treatment. The operative procedure was facilitated by an easier dissection, reducing operative time and blood loss. Recovery of postoperative continence was achieved in a significantly shorter period of time (3 months) as compared with the untreated patients (9 months). Immediate continence was obtained in 70% of patients treated preoperatively. No tumor was found in one specimen but no change was observed in the histological grading of the tumor in all the patients. This present study indicates the interest of a large scale randomized study, in order to show the real benefits of neoadjuvant hormonal treatment in prostate cancer patients.

[Value of PSA in the staging of prostatic cancer]. / La valeur du PSA dans le staging du cancer prostatique.

The clinical value of Serum Prostate Specific Antigen (PSA) in the staging of prostatic carcinoma was evaluated in 62 patients who underwent radical retropubic prostatectomy. Preoperative levels of PSA were compared with the final pathological stage obtained from all surgical specimens examined for capsular penetration, seminal vesical invasion and lymph node involvement. PSA level was closely correlated with the volume and the stage of the prostatic carcinoma. 93% of the patients with PSA < or = 10 ng/ml had tumor confined to the gland. All patients with PSA > 20 ng/ml had extraprostatic tumor extension (stage C or D). Patients with histologically proved prostatic carcinoma, PSA > 20 ng/ml and negative bone scan can be assumed to have extraprostatic disease and/or lymphatic involvement. Patients with PSA (drawn in the requested conditions) < or = 10 ng/ml can be considered to have organ confined disease, and can be spared a bone scintigraphy. Our study indicate an increasing role of PSA in the clinical staging of patients with prostatic carcinoma.

Clinical use of prostate-specific antigen in the staging of patients with prostatic carcinoma.

The clinical value of serum prostate specific antigen (PSA) in the staging of prostatic carcinoma was evaluated in 62 patients who underwent radical retropubic prostatectomy. Preoperative levels of PSA (drawn in the requested conditions) were compared with the final pathological stage obtained from all surgical specimens examined for capsular penetration, seminal vesical invasion and lymph node involvement. PSA level was closely correlated with the volume and the stage of the prostatic carcinoma. 93% of the patients with PSA < or = 10 ng/ml had tumor confined to the gland. All patients with PSA > 20 ng/ml had extraprostatic tumor extension (stage C or D). Patients with histologically proved prostatic carcinoma, PSA > 20 ng/ml and negative bone scan can be assumed to have extraprostatic disease and/or lymphatic involvement. Patients with PSA < or = 10 ng/ml can be considered to have organ-confined disease, and can be spared a bone scintigraphy. Our study indicates an increasing role of PSA in the clinical staging of patients with prostatic carcinoma.

Intraurethral catheter in high-risk patients with urinary retention: 3 years of experience.

A new intraurethral catheter (IUC) developed by Nissenkorn has been inserted in 43 patients in the last 3 years. We reserved this device for very selected patients in urinary retention due to prostatic obstruction with operative contraindications or limited life expectancy. The device is simple, very easy to insert under direct cystoscopic control. Thirty-six patients (84%) were able to void without incontinence or significant post-voiding residual. We noticed 4 early and 5 late migrations of the prosthesis into the bladder. Symptomatic urinary infection occurred in 5 patients and bacteriuria occurred in 6 patients. The IUC remained in place up to 9 months without encrustations. It is well tolerated, easy to insert and remove and inexpensive. We believe that this IUC is a valid alternative to a long-term indwelling catheter for patients in poor general conditions unfit for surgery.

[Adrenal pheochromocytoma. Current aspects of diagnosis and treatment]. / Le pheochromocytome surrénalien. Attitude actuelle pour le diagnostic et le traitement.

Since 1984, 5 patients with pheochromocytoma were operated in our department. Diagnosis was suspected by clinical findings and symptoms, and confirmed by measuring catecholamines and metabolites in 24 hours urine specimen. CT Scan located all the tumors. Iodine 131-MIBG confirmed the diagnosis and the location since it was used for the last three cases. Patients were prepared with alpha-blockade with or without beta-blockade. Volume expansion and monitoring with Swan-Ganz catheter was performed 24 hours before the operation. The surgical approaches were: anterior trans-abdominal once, thoraco-abdominal twice, and retro-peritoneal twice with less morbidity. We propose the following attitude when pheochromocytoma is suspected: 1. 24 hours urine catecholamines and metabolites, 2. CT-Scan and RMN if available, 3. Iodine 131-MIBG scintigraphy, 4. Pre-operative alpha-blockade associated with beta-blockade if necessary, 5. Retro-peritoneal approach for the uni-lateral adrenal pheochromocytoma.