[Long-term results of Burch's cervico-cystopexy. Apropos of 40 cases]

Forty patients with stress urinary incontinence, treated between April 1982 and June 1988 according to Burch's technique, were reviewed. 24 (60%) successes, 8 (20%) major improvements and 8 (20%) failures were recorded with a mean follow-up of 85 months. Compared to the early postoperative findings, a marked deterioration in urinary continence was observed in 4 cases (10%). These results are in contrast with earlier papers reporting remarkable stability of the therapeutic performance of this type of cervicocystopexy. Although too brief to allow reliable statistical analysis, this series simply draws attention to the hypothetical long-term efficacy of Burch's operation.

[Piezo-electric extracorporeal lithotripsy of non-coralliform kidney calculi with a maximal measurement of greater than or equal to 25 mm. Apropos of 25 cases]

From June 1991 to April 1993, 25 non-staghorn renal stones with a maximal diameter greater than or equal to 25 mm were treated by piezoelectric extracorporeal lithotripsy (EDAP LT 01). The complete success rate was 56% after 1 (16%), 2 (12%), 3 (16%) or 4 sessions (12%). 14 double J ureteric stents were implanted (56% of cases) and 4 complications were observed (2 cases of acute pyelonephritis and 2 cases of ureteric silting). These results were inferior to those obtained with percutaneous surgery, but help to define the potential indications of extracorporeal shock-wave lithotripsy. This treatment modality can therefore be applied to large friable weddellite or even struvite stones, particularly when the anatomical conditions are unfavourable for percutaneous surgery.

[Early postoperative complications of rigid uretero-renoscopy: screening for iatrogenic vesico-ureteral reflux. 30 cases]

From April to September 1992, systematic screening for iatrogenic vesicoureteric reflux was performed in a series of 30 patients treated by rigid ureterorenoscopy. Most of these endoscopies were performed for renal stones using a Wolff Multiscope (7.5/12 F) without prior dilatation of the urinary tract. The study protocol was essentially based on pre- and postoperative retrograde and voiding cystography. The site and tone of the ureteric orifice and the compliance of the intramural ureter were also evaluated and the operating time was determined. Out of 33 ureteric endoscopies, only one case of type I pelvic vesicoureteric reflux was demonstrated following an operation with no particular technical problems. This rare and benign deferred complication draws attention to the potential consequences of rigid ureterorenoscopy on the vesicoureteric antireflux device.

Treatment of 150 ureteric calculi with the Lithoclast

From May 1992 to October 1993, 150 ureteral stones, impervious to piezoelectric extracorporeal shock wave lithotripsy (ESWL) with ultrasound localization (EDAP LT.01), were treated with the Lithoclast. The maximum dimensions varied from 5 to 25 mm with a mean of 11 mm. 46 calculi were situated in the pelvic ureter, 82 in the abdominal ureter, and 22 were stuck in the ureteropelvic junction. There was no complete failure of fragmentation, but 39 abdominal calculi (48%) required additional treatment by ESWL due to migration of the fragments into the calyces. Apart from a few needle-sized perforations, ureteral tissue was not damaged by the Lithoclast. The use of this endoscopic lithotripter, which is highly efficient and painless, is, however, limited by the significant effect of retrograde propulsion of very mobile stones or fragments in the urinary tract.

[Urologic manifestation of Waldenström's disease. Apropos of a case with pyelo-ureteral location]

The authors report a case of Waldenström's disease in which the initial staging assessment reveals an isolated tumour of the left upper urinary tract. Combination chemotherapy (6 courses of protocol M2) induced a marked reduction in the monoclonal IgM peak and in the tumour mass. In the light of this atypical case, which emphasises the diversity of the potential sites of Waldenström's macroglobulinaemia, the authors review its potential for progression and the various therapeutic modalities available.

[Ballistic (Lithoclast) and hydro-electric (Riwolith) endo-ureteral lithotripsy. Report of 60 cases]

25 hydroelectric endoureteric lithotripsies (Group 1, Riwolith) and 35 ballistic endoureteric lithotripsies (Group 2, Lithoclast) were analysed. 60 stones were treated, including 18 pelvic stones (Group 1 : 10, Group 2 : 8), 39 iliolumbar stones (Group 1 : 14, Group 2 : 25), and 3 stones of the ureteropelvic junction (Group 1 : 1, Group 2 : 2). The mean maximal diameter was 9.9 mm (Group 1 : 8.2, Group 2 : 11). Complementary Dormia extraction was performed in 24 cases (Group 1 : 8, Group 2 : 16), 55 double J stents were implanted (Group 1 : 24, Group 2 : 31) and 23 immediate ECL sessions were performed (Group 1 : 8, Group 2 : 15). Overall, 57 good results were recorded, but 3 complete failures of fragmentation and 2 severe ureteric lesions were attributed to hydroelectric lithotripsy. The Lithoclast, much less traumatic, had a greater stone fragmentation potential, but its efficacy on very mobile stones is limited due to its more intense stone propulsion effect.

Sleep polygraphic studies using cystomanometry in twenty patients with enuresis

Polygraphic exploration during sleep using cystomanometry was performed in 20 patients aged 7-17 years with primary (17) or secondary (3) enuresis. In this group of patients, 9 presented with isolated nocturnal enuresis while 11 patients had associated diurnal micturition troubles. During this study we documented 24 episodes of enuresis. There was no disturbance in sleep architecture or correlation between the uncontrolled micturition and any particular state or stage of sleep. Most episodes of enuresis occurred in a unique pattern in which a sudden or progressive intravesical increased pressure was associated with an awakening reaction. From a physiopathologic point of view, our findings are in favor of immaturity of the central system of inhibition of micturition reflex during sleep.

[Leiomyosarcoma of the inferior vena cava]

The authors report a case of leiomyosarcoma of the infrarenal inferior vena cava presenting as an abdominal mass. CT and MR imaging and immunotyping led to the diagnosis of retroperitoneal leiomyosarcoma whose origin in the inferior vena cava was only confirmed by histological examination of the resection specimen. Surgical resection was followed by radiotherapy (4,500 rads) with a favourable course after 12 months. The progress in medical imaging and histology has considerably simplified the diagnosis of these rare retroperitoneal tumours. In the absence of any truly effective adjuvant therapy, treatment essentially consists of surgery and the clinical course is characterised by a high incidence of local recurrences.

[Piezoelectric extracorporeal lithotripsy in children: first results and reflections after 18 sessions]

From 1988 to 1990, we treated 13 children between the ages of 2 and 15 years with stones of the upper urinary tract. These stones were treated by means of 18 sessions of piezoelectric extracorporeal lithotripsy: 14 under general anaesthesia and 4 without even any analgesia. We obtained an 84.5% success rate with no particular adverse effects. These results are similar to those reported for hydroelectric or electromagnetic shock wave lithotripsy, which are associated with a higher morbidity. The efficacy of extracorporeal lithotripsy in paediatrics is remarkable, but clinical studies in adults as well as animal experimentations have demonstrated severe renal contusion and do not formally exclude the possibility of delayed complications. At the present time, this technique should therefore be used very cautiously and must be accompanied by systematic prevention of recurrent stones.

[Endo-urologic treatment of ureteral fistulas occurring after pelvic surgery for carcinoma: report of 5 cases]

The authors report 5 cases of ureteric fistula after radical pelvic cancer surgery. Three patients had a recurrent tumour and 3 had received radiotherapy. Endourological methods achieved 4 immediately satisfactory results, but only one complete long-term success. Isolated percutaneous drainage of the pyelocaliceal cavities effectively dried up the urine leak, but carried a high risk of secondary stenosis of the excretory tract in the absence of concomitant intubation of the fistula zone. However, endourological treatment, combined with urinary diversion and catheterisation of the pathological ureter, represented a reliable alternative to conventional surgery.

[Abdominal injuries in children. Diagnosis and treatment of renal lesions. Apropos of 26 cases]

During the past ten years, we have treated 26 children with closed renal injuries. Hematuria appeared in 19 cases, but was not detected in 7 other cases, 6 of which corresponded to severe, especially pedicular, lesions. The diagnostic means for the lesion included IVP in 24 cases, ultrasonography in 23, angiography in 8 and computed tomography in 7. The treatment was medical for 18 children and surgical for 8. Observation revealed 4 cases of renal atrophy, including 1 of general atrophy without residual arterial hypertension. On the basis of this series and of a review of the literature, we study the evolution of the diagnosis and treatment of this condition with the development of new medical imaging techniques, especially of CT.

[Prognostic factors of success in renal transplantation]

From January 1984 to January 1989, 139 kidneys were retrieved from 74 brain dead donors in our institution. The transplantation was performed either locally (79), or in an other French institution (40). The five year actuarial survival rate, for the 139 kidneys retrieved in Montpellier, was 65 percent. Many factors about the donor, the retrieval and the recipient, which may affect the graft survival, were entered in a Cox multivariate analysis. The minimal follow up duration was 18 months. The risk factors studied included: donor parameters (age, sex, cause of death, haemodynamic parameters and renal function); retrieval parameters (kidney alone or multiorgan harvesting, discoloration and renal perfusion quality); organ characteristics (multiple arteries and cold ischemia time); recipients parameters (age, sex, prior transplantation, local transplantation or not, and HLA matching). A first multivariate analysis included only pretransplant risk factors. The risk factors for graft loss, as identified by the Cox model, were in the order: donor's age (P = 0.03), arterial pressure (P = 0.01), prior transplantation of the recipient (P = 0.01) and kidney discoloration quality during the retrieval (P = 0.008). Early post transplant parameters were included within this Cox model (poor early renal function, need for dialysis, serum creatinine level at one week). The need for dialysis therefore was identified as the main predictive value (P = 0.002). The 4 other risk factors, selectioned in the first model, always remained significant.

[Urination control during sleep]

The authors present their approach to the sleep factor in children with enuresis, based on a still on-going exploration of manometric changes in bladder activity. Twenty patients have already been examined by cystomanometry in day time and polygraphic sleep recording at night, combined with continuous measurement of bladder pressure. This method derives from the studies of Gastaut and Broughton, in 1963, but takes into account the concept of bladder immaturity. The patients studied fell into two homogeneous groups, depending on whether enuresis was obviously due to bladder immaturity (Group I) or was strictly isolated (Group II). No disorder of sleep organization has been found in none of these two groups, but both had apparently nonspecific irritant factors. The enuresis episode is described. It tends to occur frequently at the beginning of the night, is prepared by an increase in bladder pressure which is always very pronounced in Group I subjects, and is associated with insufficient awakening reaction due to an apparently exceedingly high awakening threshold. The physiopathological and therapeutic implications of these findings are discussed.

[Extracorporeal lithotripsy in gallbladder calculi. Results of a single-center experience of 31 patients]

The authors studied thirty one cases (18 women, 13 men) of extracorporeal shock-waves lithotripsy on symptomatic gallbladder stones realized with piezoelectric generators. There were one to six stones per patient with individual stone size from 8 to 40 mm; among them 16% were calcified. Any anesthesia was necessary. Shock-wave frequency was 1.25 and 2.5 Hz. The average number of shock waves administered was 4,600 per treatment. Fragmentation occurred in 67% after first treatment and in 74% after second treatment. Gallstones disappeared in 9.5% and 19.5% of patients after 6 weeks and 4 months respectively. There was no modification after four treatments in 22.5% of patients. Minor side effects were noted: back pain (29%) probably because of uncomfortable position during treatment; increased thickness of gallbladder wall (26%); biliary pain (22%). Two episodes of biliary tract obstruction by stone fragments (one mild pancreatitis, one jaundice with liver enzymes elevation) disappeared spontaneously. These results were comparable with those of other groups using the same shock waves lithotripter.

Pharmacodynamic and pharmacokinetic study of propranolol in patients with cirrhosis and portal hypertension

1. The aim of this study was to investigate the pharmacokinetics and the beta-adrenoceptor blocking activity according to time of conventional (C) and long acting (LA) propranolol in cirrhotic patients. Twenty-four patients with alcoholic cirrhosis and oesophageal varices were randomly assigned to receive either 160 mg C propranolol, 160 mg LA propranolol or placebo acutely and then following repeated administration (acute and chronic phases). Thereafter propranolol concentrations and beta-adrenoceptor blockade (resting and exercise heart rates) were measured at different intervals. 2. The Cmax was significantly higher with C propranolol in both phases. The time of Cmax was significantly later with LA propranolol in both phases. The AUCs were significantly higher after chronic administration with both formulations of propranolol. 3. The exercise peaks of beta-adrenoceptor blockade were similar between the two formulations and between the two phases of administration of propranolol. The duration of effective beta-adrenoceptor blockade was significantly longer in the chronic phase and seemed to be longer with LA than with C propranolol although this was not significant (72 +/- 31 vs 48 +/- 18 h, respectively). 4. There was a significant correlation between the log propranolol concentration and exercise heart rate but not with resting heart rate. No correlation could be demonstrated between pharmacological data and the Child Pugh score. 5. We conclude that in cirrhotic patients exercise testing was a reliable method in the assessment of beta-adrenoceptor blockade. Pharmacology of propranolol was found to be different according to the formulation or to the phase of administration.