Influence of urological complications on the prognosis of prostate cancer

Urological complications, essentially bladder outflow obstruction and hydronephrosis, are caused by the local extension and lymphatic spread of prostate cancer. Although bladder outflow obstruction is a very common finding at diagnosis, results from clinical studies have revealed that it is not a prognostic factor for response to androgen blockade. Hydronephrosis has been shown to have an independent prognostic value for progression after hormonal treatment and correlates also with time to death from prostate cancer. Furthermore, persistent or newly developed hydronephrosis during treatment also predicts a shorter time to progression. The incidence of bladder outflow obstruction is significant in advanced prostatic cancer and may be a source of morbidity, which will impact on the patient's quality of life. Decompression of ureteric obstruction in hormone-refractory cancer decreases the length of hospital stay, thereby improving quality of life. Finally, hydronephrosis, but not bladder outflow obstruction, can be considered to be an independent prognostic variable for the response to androgen blockade. This paper reviews the incidence of urethral and ureteric obstruction in patients with advanced prostate cancer, evaluates the prognostic significance of these urinary complications and discusses the therapeutic strategies available for treating patients with this disease.

[Prognostic value of a positive single ultrasound-guided prostatic biopsy regarding tumor volume and intracapsular nature of prostatic adenocarcinoma]

OBJECTIVE

Study of the value of a single positive prostatic biopsy in the staging of prostatic carcinoma and the significance of the tumour volume.

METHOD

The clinical, laboratory and pathological parameters were studied in 27 prostatectomized patients with a single positive prostatic biopsy.

RESULTS

The length of tumour invasion on the biopsy was 2.6 mm (evaluation on 25 biopsies). Six patients (23%) had an extracapsular tumour and 21 (78%) had a significant tumour volume. Among the 16 patients with a length of tumour invasion < or = 3 mm, 13 (81%) had a significant tumour volume. 25% of patients with less than 3 mm of invasion on the biopsy and a Gleason score < or = 6 and 12% of patients with less than 3 mm of invasion and a PSA < or = 10 ng/ml had a non-significant tumour volume.

CONCLUSION

The presence of a single positive prostatic biopsy is not sufficient to determine the pathological stage of a prostatic carcinoma. In this retrospective study, the majority of patients with a single positive biopsy had a significant tumour volume > 0.5 cc. No preoperative predictive factor of tumour volume was demonstrated.

Retroperitoneoscopy: a laparoscopic approach for adrenal and renal surgery

OBJECTIVES

Retroperitoneoscopy has gained acceptance for urologic surgery. We assessed the safety and efficacy of this procedure for renal and adrenal surgery.

METHODS

Since December 1994, 20 patients (18 to 75 years old) have undergone laparoscopic adrenalectomy and nephrectomy, including simple nephrectomy in 8, partial nephrectomy in 1, radical nephrectomy in 2, tumorectomy with cyst excision in 1, and adrenalectomy in 8. The retroperitoneal space was created by blunt dissection with the index finger, completed by insufflation, without balloon dissection.

RESULTS

Average kidney size was 65 m (range 50 to 108), and average adrenal tumor size was 31 mm (range 20 to 40). The average operating time was 127 minutes (range 60 to 180) for nephrectomy and 84 minutes (range 45 to 140) for adrenalectomy. The average hospital stay was 3 days (range 1 to 7) for nephrectomy and 2.4 days (range 1 to 4) for adrenalectomy. Average blood loss was 65 mL for both nephrectomy and adrenalectomy. Conversion from the laparoscopic procedure to open surgery was never required. Peritoneal effraction and ureteral injury occurred in only 4 patients and 1 patient, respectively.

CONCLUSIONS

The laparoscopic retroperitoneal approach is safe and effective for simple renal nephrectomy and for excision of small adrenal tumors. Perioperative morbidity and hospital stay are reduced.

[Antiandrogen withdrawal syndrome in the hormonal treatment of metastatic prostatic cancer in hormonal escape]

A fall in the PSA level after stopping antiandrogens has been described at the stage of hormonal escape of prostatic cancer treated by complete androgen inhibition. The authors report a new case. The patient was offtially treated by pulpectomy and nitulamide for N+ prostatic carcinoma (PSA: 165 ng/ml). At the stage of hormonal escape, discontinuation of nitulamide induced a reduction of the PSA. Replacement of nitulamide by cytoproterone acetate was followed by a renewed increase of PSA, which again decreased after stomming cyproterone acetate. Three years later, the PSDA level was 3.5 ng/mg. This syndrome is probably due to mutation of the androgen receptor. In hormonal escape, suspension of all antiandrogens apart from LHRH analogues is recommended and can be followed by a temporary fall of PSA. No other antiandrogen must be administered in the place of the previous drug.

[Cancer of the prostate. Should men be screened, how to screen, when to screen?]

The individual screening of the general population can only be envisaged after the age of 50 years when the incidence of prostatic cancer increases significantly. Individual screening by PSA in an asymptomatic subject must only be proposed to men likely to benefit from curative treatment, i.e. between the ages of 50 and 70 years, and only after performing digital rectal examination. The combination of these two methods detects 54% of prostatic cancers in men over the age of 50 years. PSA assay can be made more reliable by comparison with age-dependent normal limits, PSA density compared to prostatic volume, rate of progression, and assay of the free and bound fractions.

Genitourinary tuberculosis: rapid diagnosis using the polymerase chain reaction

We present the case of a patient with suspected genitourinary tuberculosis in whom confirmation by direct smear examination was negative. Detection of mycobacterial DNA by use of the polymerase chain reaction (PCR) established the diagnosis, which was confirmed by culture 4 weeks later. Given its very high sensitivity and positivity, PCR may become the method of choice for rapid diagnosis of genitourinary tuberculosis and institution of therapy.

[Renal colic]

The pathophysiology of renal colic is related to tension exerted on the excretory cavities by an obstruction, generally a stone, causing secretion of prostaglandins which, in turn, increase the renal blood flow and glomerular filtration rate. This results in a vicious circle explaining the effect of fluid restriction and NSAIDs.

[The current approach to the management of benign hypertrophy of the prostate]

Epidemiology. The incidence of benign prostatic hyperplasia (BPH) has increased in proportion to the life expectancy and has become the third leading cause of health expenditure in industrialized countries. Eighty per cent of men are treated for benign prostatic hyperplasia during their lifetime. In Europe, the mean age of diagnosis is 65 years. The clinical symptoms are assessed by the IPSS score (International Prostate Symptom Score) and by the maximum flow rate, where frank dysuria is defined as a flow rate of less than 10 ml/sec. Physiology. The prostate contains equal proportions of glandular epithelial structures and fibromuscular connective tissue stroma. The glandular prostate is innervated by cholinergic nerves, while the smooth muscle of the stroma and the urethra are innervated by adrenergic nerves. BPH arises in the transitional zone (fairly glandular). Androgen deprivation (castration, antiandrogens, progestogens, 5-alpha-reductase inhibitors) induces a 30% reduction of the prostatic volume (especially epithelial). BPH could be due to reactivation of the embryonic potential of the stroma. Certain growth factors appear to be involved in BPH. Inflammatory and immunological phenomena may also be involved. Evaluation. Plan of clinical interview, clinical examination and laboratory and radiological data. A 40-year-old man has one chance in 30 of being operated for benign prostatic hyperplasia if he lives to the age of 80. Medical treatments have been developed since 1980 which inhibit the course of BPH and minimize some of the clinical symptoms: plant extracts, alpha-blockers, 5-alpha-reductase inhibitors. Conventional surgical treatments, open prostatectomy and endoscopic resection, have been completed by laser therapy, thermotherapy and cryotherapy.

Transrectal and transurethral hyperthermia versus sham treatment in benign prostatic hyperplasia: a double-blind randomized multicentre clinical trial. The French BPH Hyperthermia

OBJECTIVE

To compare the safety and efficacy of hyperthermia for the treatment of benign prostatic hyperplasia (BPH), by either the transrectal or transurethral approach, relative to sham treatment.

PATIENTS AND METHODS

Two hundred patients from seven urological departments were randomized and treated in a single centre. Principal inclusion criteria were a peak flow rate (PFR) < 15 mL/s and residual urine < 300 mL/s. Comparisons were made between transurethral hyperthermia (TUH) and transurethral sham (TUS) and between transrectal hyperthermia (TRH) and transrectal sham (TRS) 12 months after treatment. Outcome was assessed by improvements in the Madsen score and PFR, and the incidence of side-effects.

RESULTS

After 12 months, 145 patients were evaluated; 12 patients withdrew during treatment, 43 withdrew during follow-up and two were lost to follow-up. Withdrawals were mainly due to side-effects during treatment (17% in the TRH and 1.5% in the TUH group) and to a lack of improvement during follow-up (14% in the TUH group, 19% in the TUS, 15% in the TRH and 10.5% in the TRS group received other treatments for BPH). Complications during treatment consisted mainly of local pain, urethral bleeding, urethral pain and acute retention, and were five times more frequent in the TRH than the TUH group (34% versus 6%). There was no improvement in PFR after TUH and TRH (response < 20%). Only TUH improved the Madsen score (TUH, +50% and TUS, +17%).

CONCLUSION

Hyperthermia was not an effective treatment for BPH.

Consecutive use of hormonally defined serum-free media to establish highly differentiated human renal proximal tubule cells in primary culture

Highly differentiated human proximal tubule (HPT) cells in primary culture were established from heterogeneous suspension of tubules prepared from the human renal cortex by an original two-step procedure. First, gluconeogenic-competent HPT cells were selected by using a hormonally defined serum-free medium without glucose or insulin; then, the selected HPT cells were grown in a medium containing a low concentration of glucose (1 mM) and insulin (0.5 micrograms/mL) but no antibiotics. HPT cells grown on plastic support formed confluent, cobblestone-like monolayers with numerous mitochondria and pinocytosis vacuoles, solitary cilia, junctional complexes, and a well-developed brush border consisting of densely packed microvilli. Compared with cell monolayers on plastic support, HPT cells grown on porous filter membranes showed better morphologic differentiation. HPT cell monolayers expressed the following differentiated functions of the proximal tubule in situ: a low-affinity, high-capacity Na(+)-dependent glucose transport system inhibited by phlorizin, a high-affinity Na(+)-dependent phosphate transport system, a basolateral organic cation uptake inhibited by mepiperphenidol, parathyroid hormone-sensitive cAMP synthesis, brush-border hydrolase activities, gluconeogenesis-associated enzymes, glutathione-S-transferases and N-acetyl-beta-D-glucosaminidase. The medium containing low glucose and insulin concentrations markedly limited the increase in glycolysis but did not prevent the falls in gluconeogenesis and brush-border hydrolase activity at any time of the culture period. Similar decreases of brush border enzyme activities were obtained for HPT cells grown either on plastic or on porous filter membrane. A thorough characterization study demonstrated that this simple and preparative experimental approach makes it possible to establish highly differentiated HPT cells in primary culture suitable for investigating human renal proximal tubular cell function.

Expression of MAGE genes in transitional-cell carcinomas of the urinary bladder

Human genes MAGE-1 and MAGE-3 code for distinct antigens, which are recognized on melanoma cells by autologous cytolytic T lymphocytes (CTL). These antigens may constitute useful targets for anti-cancer immunotherapy, since no expression of MAGE genes has been observed in normal tissues other than testis. Out of 57 samples of primary transitional-cell carcinomas of the bladder, 12 (21%) expressed MAGE-1 and 20 (35%) expressed MAGE-3. All but one of the tumors expressing MAGE-1 also expressed MAGE-3. Genes MAGE-2 and MAGE-4, which are closely related to MAGE-1 and MAGE-3, were expressed by 30% and 33% of the tumors respectively. MAGE expression was more frequent in advanced tumor stages: 61% of the invasive tumors (stage > or = T2) were positive for expression of at least one of the four genes, whereas only 28% of the superficial tumors (stages Ta and T1) expressed these genes.

Prognostic value of epidermal growth factor-receptor, T138 and T43 expression in bladder cancer

Tumour-associated markers defined by monoclonal antibodies have proven useful to phenotype bladder tumours. In order to evaluate the prognostic value of such markers, we performed an immunohistochemical study on 57 transitional cell carcinomas (23 infiltrative and 34 superficial tumours) and ten healthy bladders using monoclonal antibodies against the external domain of the epidermal growth factor receptor (EGFR) and against the tumour-associated antigens T43, 19A211 and T138. Immunohistochemistry was performed on frozen sections using a two-step alkaline phosphatase method. The staining pattern obtained with each antibody was analysed according to the TNM classification, and results were analysed according to the subsequent clinical course. 19A211 preferentially stained superficial tumours, and T43, T138 and EGFR preferentially stained invasive tumours. Three monoclonal antibodies appeared to have prognostic value, since progression rate survival was significantly (log-rank test) associated with their expression of EGFR (P = 0.017), T138 (P = 0.0009) and T43 (P = 0.031). T138 expression was found to have an independent significant prognostic value using a stepwise logistic regression. T138 antibody may add significant information to classical pathological parameters.

A comparison of direct and liposomal antibody conjugates of sulfonated aluminum phthalocyanines for selective photoimmunotherapy of human bladder carcinoma

There is a need to improve the selectivity of photodynamic therapy and for better targeting of tumor cells within specific tumor compartments. Selective in vitro phototoxicity of a human bladder carcinoma cell line 647V has been achieved by targeting sulfonated aluminum phthalocyanines (AlSPc) with monoclonal antibodies. Aluminum tetra-3 sulfonyl chloride phthalocyanine (PC) or rhodamine sulfonyl chloride were directly coupled to antibodies by a sulfonamide linkage and AlSPc or carboxyfluorescein were encapsulated in liposomes of the small unilamellar vesicle type (SUV) bearing antibody. Antibody E7 (IgM subclass), which recognized an antigenic determinant expressed on 647V but was absent on T24 a control human bladder carcinoma cell line, and a control IgM antibody were used. The effects of the two types of conjugate were compared. Immunofluorescence studies on living cells demonstrated specific cell surface localization of conjugates at 4 degrees C and internalization at 37 degrees C. Phototoxicity was measured by 3-(4,5-dimethylthiazol-2-5-diphenyltetrazolium) bromide assay after exposing AlSPc-sensitized cells to red light. Significant AlSPc dose-dependent phototoxicity of the order 4 degrees C < 4 degrees C plus 37 degrees C < 37 degrees C was observed with E7-SUV and E7-PC in the range 1-8 microM AlSPc. At equimolar AlSPc doses absolute toxicity was similar for the two conjugate types, but at equimolar antibody doses, the liposomal conjugate was more effective by up to 13-fold. Addition of urine during illumination decreased toxicity, which was attributed to the presence of protective elements. The results suggest that photosensitizers such as AlSPc could be used for antibody-directed therapy and in particular for selectively damaging tumor cells of the epithelial cell compartment in bladder carcinoma by intrabladder administration. The therapeutic ratio, which takes into account both specific and nonspecific toxicity, was greater for the liposome conjugate than for the direct conjugate indicating their greater suitability for in vivo instillation.

[Proper use of prostate specific antigen]

Prostate specific antigen (PSA) has become the best marker for prostatic carcinoma. PSA is secreted by the glandular cells of prostatic epithelium and is specific for any normal, hyperplasic and tumoral prostatic tissue. PSA is excreted in blood that render its dosage accessible for clinical purpose. Two different tests are now used: Tandem test R is a radioimmunological test (N1:0-4 ng/mL), and Pros check test uses an immunoenzymatic method and is considered to be more sensitive (N1: < 2.5 ng/mL). PSA increases of 35 ng/mL for every other gram of hyperplastic prostatic tissue and of 3.5 ng/mL by gram of prostatic cancer. This test allows detection of prostate carcinoma with a positive predictive value of 49% when PSA > 4 ng/mL and 75% when PSA > 10 ng/mL. However, only biopsies will confirm the diagnostic of prostate cancer. For the patients with an increased PSA and no cancer founded by random biopsies, an increase of PSA level in the next year suggests prostate carcinoma. When the diagnostic of prostate cancer has been made, a PSA < 15 ng/mL suggests a low stage carcinoma (B1 or B2). When PSA > 75 ng/mL, there is a high probability that this cancer is node positive. Between this values, PSA cannot make the difference between stage B, C or D. The more sensitive test (Pros check) must give undetectable level after radical prostatectomy. For high stage lesion treated by hormonotherapy, or chemotherapy or radiation therapy, PSA is a good indicator of response to therapy and recurrence after therapy.

Computer assisted image analysis of bladder tumour nuclei for morphonuclear and ploidy assessment

Morphonuclear analysis using a quantitative image analysis system has been demonstrated to be a potentially useful technique in the prognostic evaluation of bladder carcinoma. The integrated optical density parameter permits DNA content evaluation in addition to 15 other morphonuclear parameters. We assessed the reliability of morphonuclear analysis by image analysis and flow cytometry for 46 bladder carcinomas and 14 normal bladder specimens. Frozen sample material was obtained from endoscopic resection, radical cystectomy and from cadaveric donors. The grade and staging of the tumours according to the World Health Organization was as follows: 8 G1, 18 G2, 20 G3 and 28 T1, 7 T2, 7 T3, 4 T4. Quantitative image analysis was made on imprint smears stained by the Feulgen method. Simultaneously cell suspensions were obtained by mechanical dissociation and stained with propidium iodide for Flow cytometry analysis. There was a good agreement between quantitative image analysis and flow cytometry for DNA content measurement indicating that image analysis is a reliable method for the quantitation of DNA content (P = 0.001). Moreover we found a good correlation between five of the morphonuclear parameters: surface (P < 0.001), chromatin clumps distribution (P < 0.001), frequency of small (P < 0.001) to large chromatin clumps (P < 0.001) and the grade of bladder tumours. These results indicate that morphonuclear analysis may be a valuable method of quantitating DNA and morphonuclear parameters in a single analysis to provide information which may have some prognostic significance for patients with bladder carcinoma.

Increased immunodetection of acidic fibroblast growth factor in bladder cancer, detectable in urine

Acidic fibroblast growth factor is a regulatory peptide involved in cell proliferation, differentiation and motility. We used a polyclonal antiserum raised against purified native bovine acidic fibroblast growth factor, with no cross-reactivity for basic fibroblast growth factor to detect acidic fibroblast growth factor in tissue extracts and urine samples by means of a competitive enzyme immunoassay. Histochemical analysis was also performed on 10 specimens of normal urothelium and 50 of bladder cancer. Acidic fibroblast growth factor immunoreactive material was found in normal urothelium (1.77 +/- 2 ng./gm. tissue) and was increased more than 10-fold in patients with transitional cell carcinoma of the bladder (20.36 +/- 12 ng./gm. tissue). Immunohistochemical analysis localized immunoreactivity in the epithelial compartment of bladder tumors. Acidic fibroblast growth factor was assayed in urine from 579 individuals comprising a control group (114) and patients with benign prostatic hypertrophy (133), carcinoma of the prostate (96) or transitional cell carcinoma of the bladder (236). There was a significant difference in the frequency of urinary acidic fibroblast growth factor detection among the patients with invasive transitional cell carcinoma, the control group (p < 0.001) and the patients with prostatic disease (p < 0.01). The sensitivity was 72% and the specificity was 91%. Furthermore, the frequency of acidic fibroblast growth factor detection by enzyme immunoassay in the urine and the intensity of immunostaining was correlated with the stage of the disease. These data strongly suggest that acidic fibroblast growth factor is a potential marker for bladder tumors that may be of use in the noninvasive followup of patients with bladder cancer. We present a simple and reliable enzyme immunoassay for the detection of acidic fibroblast growth factor in voided urine that might be useful to quantitate this marker.

Prognostic factors in superficial bladder cancer

A large body of evidence suggests that intravesical prophylaxis using bacillus Calmette-Guérin can favorably alter the natural history of superficial bladder cancer. The search for prognostic factors impacting the clinical alternative between conservative and radical treatment has been the subject of numerous efforts and remains a major objective in improving the carcinological results and the quality of life patients with superficial bladder cancer. In this regard, information is available on three levels: clinicopathological parameters, quantitative analysis, and biological markers. Recent advances in as well as the limitations and pitfalls of the use of three kinds of information in prognostication are reviewed. The proper use of prognostic factors will modify our attitude toward superficial bladder cancer in the near future.

Orchiectomy and nilutamide or placebo as treatment of metastatic prostatic cancer in a multinational double-blind randomized trial

The efficacy and tolerance of the nonsteroidal antiandrogen nilutamide in the treatment of prostatic cancer were studied in a large double-blind clinical trial initiated in 1986. Patients with metastatic prostatic cancer without prior endocrine manipulation underwent orchiectomy and were randomized to 1 of 2 groups receiving nilutamide (225 patients) or placebo (232). Nilutamide and placebo were evaluated for efficacy in 207 and 216 patients, respectively. Progression-free survival was significantly longer in the nilutamide group (median time to progression 20.8 months on nilutamide and 14.9 months on placebo, p = 0.005). Median time to death from prostatic cancer was 30.0 months in the placebo group and 37 months in the nilutamide group. Objective regressions were higher in the nilutamide group (41%) than in the placebo group (24%). Significant differences in favor of the nilutamide group were found at several intervals for bone pain, prostatic acid phosphatase, prostate specific antigen, alkaline phosphatase and bone scan isotope uptake. Nilutamide and orchiectomy constitute a more effective treatment for metastatic prostatic cancer than orchiectomy alone, and the adverse effects of nilutamide, usually minor, are outweighed by the significant improvements in most disease measures and progression-free survival.

[Double liver-kidney transplantation in the presence of a positive T cross-match]

Kidney transplantation, when performed across a positive T lymphocyte cross-match, is always followed by the occurrence of a hyperacute rejection. On the other hand, successful hepatic allografts have been reported under these same conditions. Furthermore, clinically and experimentally hepatic allograft has been reported to induce tolerance of other organs from the same donor. Thus, combined liver-kidney transplantation constitutes an ideal application of these immunological events. We report here the case of a sequential liver-kidney transplantation in which liver transplantation performed prior to kidney transplantation with an organ from the same donor induced kidney tolerance despite an initial positive T lymphocyte cross-match.

Immunohistochemical detection of acidic fibroblast growth factor in bladder transitional cell carcinoma

Acidic fibroblast growth factor (aFGF) is a regulatory peptide which, on account of its structural homologies with the products of oncogenes, is involved in cell proliferation, differentiation, and motility. We previously reported the presence of aFGF in the urine of patients with transitional cell carcinoma (TCC). aFGF can also induce the motility of a rat-derived bladder carcinoma cell line (NBTII). This immunohistochemical study used polyclonal rabbit antibodies against acidic and basic FGF and peroxidase detection. Native NBTII nude mice xenografts and aFGF transfected NBTII (NFS14) nude mice xenografts were used as tissue controls for antibody specificity. The samples included 4 normal urothelia and 12 TCC. In addition, cytospins of 4 different tumoral cell lines of human bladder and normal bladder cells were stained. The results showed strong immunostaining in all tumoral urothelium samples using anti-aFGF and a very low amount of staining or none at all in healthy tissues. A primary analysis suggested that the strongest reaction was obtained in high-grade tumors (3 + vs + for lower-grade tumors). Using bFGF antibody, strong immunohistochemical staining was detected on basal membranes and stromal vessels and none in urothelium. These data confirm aFGF expression in the epithelial cell compartment of bladder cancer and the likely involvement of this regulatory peptide in the biology of TCC.

Immunohistochemical markers defined by monoclonal antibodies and response to bacillus Calmette-Guérin endovesical immunotherapy for superficial bladder tumors

As bacillus Calmette-Guérin (BCG) immunotherapy is highly effective for most but not all superficial bladder tumors, there is a need to define predictors of response to this mode of treatment. We have investigated a panel of markers defined by monoclonal antibodies, directed against tumor-associated transitional cell carcinoma antigen (G4 and E7), epidermal growth factor receptor, cytokeratin (CK) 18 and blood group antigens A, B and H, using an indirect immunoperoxidase staining on paraffin sections. Twenty superficial bladder tumors (T1) treated with intravesical BCG therapy (10 responders and 10 nonresponders) were tested with this panel. Among the responders, expression of CK18 antigen was positive in 7 and negative in 3, whereas in the nonresponder group it was positive in 2 and negative in 8. The difference was statistically significant (p less than 0.05). Loss of expression of CK18 antigenicity was associated with recurrence or progression of superficial bladder tumors following BCG therapy, indicating that changes in CK patterns should be investigated as potential predictive markers for response to BCG.

Conservative treatment of renal allograft rupture with polyglactin 910 mesh and gelatin resorcin formaldehyde glue

Renal-sparing treatment of spontaneous renal allograft rupture remains a surgical challenge, since profuse hemorrhage may result from these friable kidneys during surgical repair. A technique is proposed to achieve control of local bleeding with a synthetic glue (gelatin, resorcin and formaldehyde) and external compression with a polyglactin 910 absorbable mesh. We report 4 cases of spontaneous allograft rupture associated with rejection and bleeding was controlled in all 4. Three grafts were preserved with more than 1 year of followup. The other graft had to be removed for uncontrolled vascular rejection despite satisfactory control of renal fractures. Renal wrapping with external compression is proposed to improve results of conservative management of renal allograft rupture.

Use of vena cava to obtain additional length for the right renal vein during transplantation of cadaveric kidneys

During cadaveric organ harvesting removal of the right renal vein and a segment of the vena cava may facilitate venous anastomosis of the right kidney. The technique to obtain adequate length of the right renal vein using the vena cava is simple, physiological and effective. A segment of the inferior vena cava should be harvested with the right but not necessarily with the left kidney. The use of a long segment of vena cava makes the renal transplantation much easier and does not interfere with multiorgan procurement. The method is most useful when the right renal vein is extremely short or when the recipient has a large abdomen and a deep pelvis.

Conservative treatment of bladder carcinoma by partial cystectomy and interstitial iridium 192

From 1971 to 1984, 85 patients with bladder carcinoma were treated conservatively at the Henri Mondor Hospital by a combination of short course of pre-operative external pelvic irradiation, iliac node dissection, partial cystectomy, and iridium 192 implantation. There were 79 transitional cell carcinomas (G1: 12, G2: 25, G3: 36, Gx: 6) and 6 squamous cell carcinomas. By clinical stage, based on endoscopic resection, there were 43 T1, 30 T2, 5 T3, and 7 Tx. After partial cystectomy the pathologic stage distribution was: 41 pT1, 31 pT2, and 13 pT3. Crude disease-free survival at 5 years is 72% for T1 tumors and 55% for T2, but overall only 16% of patients died of bladder carcinoma. Local failures were seen in 11.5% of T1 and 0% of T2 tumors, and second bladder tumors developed at a distance from the treated site in 11.5% of T1 and 7% of T2. There is a non significant trend for intravesical recurrences (both local failures and second tumors) to occur more frequently for G1 tumors (25%) than for G2 (16%) or G3 (7%). At 5 years 95% of disease-free survivors have a functioning bladder. Regional or distant metastases occurred in 54% of patients with pT3 tumors and 10% of those with pT1 or pT2; within each stage there was no apparent influence of grade on metastatic risk. The four patients with histologically positive iliac nodes received additional post-operative external pelvic irradiation; three died of metastases and one is disease free at 10 years. No abdominal scar recurrences were seen. Late complications occurred in 6% of the population. For T1 tumors we suggest modification of the described protocol, eliminating the pre-operative irradiation and the lymph node dissection. If there is no doubt as to the pathologic stage after complete endoscopic resection, iridium 192 implantation delivering a dose of 60 Gy, without partial cystectomy, may be sufficient management. By contrast, for T2 tumors, all elements of the protocol seem important to obtain optimal results.

Treatment of bladder tumors by iridium 192 implantation. The Créteil technique

The technique and results of a treatment protocol for bladder cancer combining low dose pre-operative external beam irradiation followed by external iliac nodal dissection, limited partial cystectomy and curietherapy with iridium 192 are described. In 55 patients treated from 1971 to 1979, 37/45 (67%) are alive NED at 5 years--23/31 pT1, 10/14 pT2, 4/10 pT3--with 9/55 bladder recurrences at 5 years--7/31 pT1, 1/14 pT2, 1/10 pT3. Only two patients (total cystectomy) have not retained a functional bladder. These favorable results have been obtained in a carefully selected population; our indications for the technique being T1, T2, T3a tumors with a total surface area not exceeding 5 cm, not involving the bladder neck and unifocal or in some cases plurifocal, but closely grouped. The advantages and precise details of each stage of the technique will be described and compared with large series in which radium 226 is utilized and results of curietherapy will be compared with other modalities of treatment employed under similar circumstances for similar patient groups. We feel that curietherapy has certain advantages over other methods in the treatment of bladder cancer and that an afterloading technique employing iridium 192 wires permits the curietherapy to proceed under optimal conditions, allowing combination with partial cystectomy, optimal placement of sources, precise radiographic control and dosimetry, dose reduction in many cases, optimal conditions of radioprotection and widening of the indications for the technique.

[Percutaneous nephrolithotomy in 1984. Technics, results, indications]

Percutaneous nephrolithotomy - PCNL - was made possible by technological progress, with the introduction of nephroscopes, lithotomy forceps, and mechanical, ultrasonic or electrohydraulic lithotriptors. The procedure includes four stages. First needle puncture of the inferior or middle calyx. Secondly, dilatation of the pathway and creation of a tunnel. Thirdly, investigation of the collecting system. And, finally, extraction of the stone. The results of 302 published cases show a success rate of 87 per cent, a complete failure rate of 13 per cent, and residual stones in 10 per cent of cases. The complication rate is 7 per cent, with hemorrhage and sepsis in roughly equal proportions. A few other complications are occasionally reported, such as colic wounds, perirenal collections, traumas of the ureteropelvic junction, pneumothorax, or a stone left in the lumbar wall. There was one case of death. The hospitalization period is the same as for lombotomy, but the return to work is more rapid. The best indications are pelvic and inferior calyceal stones (with a success rate of over 80 per cent). Despite their enthusiasm for this procedure, the authors feel that is still remains to be seen or whether it will in turn be superseded by ultrasound lithotripsy.

[Renal oncocytoma. Apropos of 9 cases]

The authors report nine cases of renal oncocytoma which were observed in a series of 220 consecutive renal cell carcinomas. They share the general view concerning the clinical latency of these tumors which are rarely hematuric, and concerning the favorable prognosis, despite signs of locoregional malignancy. On the other hand, they do not share the opinion that arteriography or CT scan can provide a reliable preoperative differential diagnosis with the normal type of renal cell carcinoma.

Interstitial radiation therapy for carcinoma of the penis using iridium 192 wires: the Henri Mondor experience (1970-1979)

From 1970 to 1979, a group of 50 patients was treated for squamous cell carcinoma of the penis by interstitial irradiation using an afterloading technique and iridium 192 wires. The group included 9 patients with T1 tumors, 27 with T2 tumors, and 14 with T3 tumors. Forty-five patients presented with no metastatic inguinal nodes (N0), 3 patients with N1 nodes, and 2 patients had N3 nodes. After treatment, 11 patients (1 T1, 6 T2 and 4T3) developed local recurrences; 10 of these 11 patients underwent penile amputation which controlled the tumor in 7 of the patients. One patient refused amputation. Three patients developed post-therapeutic necrosis which necessitated partial amputation in 2 cases. Eight patients developed post-therapeutic urethral stenosis, which required surgical treatment in three of the cases. Overall, at their last follow-up examinations, 74% of the patients were free of disease with conservation of penile morphology and function. Most patients without metastatic nodes (37/45) at diagnosis did not receive prophylatic treatment of the groin. Two of these patients developed delayed metastatic nodes; one was successfully salvaged. All 5 patients presenting with metastatic nodes at diagnosis died, four with uncontrolled regional disease. Twenty-one percent of the patients died of their disease. We advocate interstitial irradiation using iridium 192 wires for the treatment of non-infiltrating or moderately infiltrating squamous cell carcinoma of the penis in which the largest dimension does not exceed 4 cm. Pre-implant circumcision and regular long-term follow-up are necessary. More extensive tumors are better managed surgically. When regular follow-up can be assured, it is reasonable to forgo prophylactic treatment of the inguinal nodes in patients presenting without groin metastasis.

[Modification of the infectious state following surgical treatment of primary vesicorenal reflux in adults. Apropos of a series of 17 patients]

Seventeen adult female patients with primary vesico-renal reflux were treated surgically (6 nephrectomies, 5 reimplantations and 3 ureteropelvic anastomoses). The risk of severe upper tract infection was eliminated in all seventeen cases, but lower urinary tract infection persisted in two cases.

[Disease of branches of the renal artery. Choice of a revascularization procedure]

In situ versus extra-corporeal and microvascular reconstruction are discussed in relation to the treatment of renal branch artery disease. Ten cases are reported: 4 aneurysms, 1 atherosclerosis, 1 trauma, 1 embolism and 1 dissection. In three cases, the disease involved only the segmental artery branches and in seven cases both the main artery and the branches. An in situ procedure was performed in 5 cases and extra-corporeal surgery was necessary in 5 others. Four of the kidneys were iliac autotransplanted. Anatomical and immediate functional results were good in ten cases, but there was one postoperative death by heart failure due to a mitral disease. In our series extracorporeal and microvascular surgery were not routinely used for the treatment of renal artery branch disease. But these procedures can widen the indications for renal revascularisation, which then replaces medical treatment or a nephrectomy.

[Acute renal insufficiency in spontaneous septicemia of renal origin. Analysis of a series of 17 patients]

Seventeen recent cases of spontaneous renal septicemia with acute renal failure are reviewed, confirming the need for a diagnostic and therapeutic strategy to restore the fluid balance, if necessary with the aid of an artificial kidney, and the urgency of treating local infection and the pathogenic agents involved. The case review also suggest that the high mortality rate of this infection, estimated by some observers at 50 p. cent, can be greatly reduced by early radical urological treatment.

[Atraumatic microsurgical nephrotomy. Experimental study on canine kidney (author's transl)]

Microsurgical transversal section and repair of canine kidney was presented as a model to study the condition required for an atraumatic nephrotomy. The investigation was carried out by two methods. In a first series five kidneys were injected by coloured resins after transection and microsurgical repair. Results were evaluated by cast examination of vascular net work. In a second series, transection and repair were made by an "ex-situ" procedure on seven dogs. The repaired kidney was autotransplanted in the opposite fossa iliaca. Long term renal function was evaluated after controlateral nephrectomy, by arteriography, biologic data and DMSA Tc 99 m scintiscan. The good results showed that microsurgery is useful in atraumatic nephrotomy and now a new tool in intrarenal access.

[Scintigraphy with technetium dimercaptosuccinic acid (99 m TC DMSA). Contribution to the functional assessment of individual kidneys (author's transl)]

Renal uptake of 99m Tc DMSA was used to evaluate the renal function of 16 healthy subjects (controls) and 115 patients with various urinary tract diseases. Scintigraphic examination was carried out 6 hours after an intravenous injection of the product. In the 16 controls Tc DMSA uptake was 25.7 +/- 2.48% in the right kidney and 24.4 +/- 2.86% in the left kidney. In 36 patients with one single hypertrophied kidney, there was a correlation (r = 0.850) between creatinine clearance and Tc DMSA uptake, which was higher than in normal subjects (39.23 +/- 9.9%). In the group of 68 patients with unilateral (31) or bilateral (37) renal disease, a significant correlation (r = 0,725) was observed between kidney-to-kidney ratios of urea clearance and Tc DMSA uptake, so that renal impairment could be quantified. Quantitative scintigraphy did not appear to be of assistance in the remaining 11 patients with obstructive uropathy, as it overestimated renal function. The results obtained with 99 m Tc DMSA scintigraphy should be helpful in choosing between nephrectomy and conservative surgery and in assessing the degree of compensatory hypertrophy in single kidneys.

[Surgical methods of cadaver nephrectomy prior to kidney transplantation (author's transl)]

Surgical technique during donor's binephrectomy is one of the most important parameters conditioning early success after kidney transplantation. Experimental studies showed that tractions on the renal pedicle during kidney removal had a detrimental effect upon renal cortical vascularization and subsequent kidney function. Cortical vasoconstriction is equivalent to acute warm ischemia and therefore impedes prolonged kidney preservation. The means of preventing such events are: administration of large volumes of intravenous saline to the donor, renal vasodilation during surgery with furosemide (8 mg/kg I.V.) repeatedly administered, continuous I.V. infusion of dopamine (less than 10 micrograms/kg/min) and last but not least, surgical technique. Renal pedicles should never be publed. Initial dissection of inferior vena cava, aorta and both renal pedicles is mandatory. Kidney dissection takes place at the very end of the operative procedure. In case of cardiocirculatory arrest, both kidneys are cooled in situ after retrograde cannulation of the aorta above the renal arteries with an indwelling probe inserted into the femoral artery in the groin. From January, 1876 to August 31, 1979, 83 cadavers have been operated upon according to these techniques. Warm ischemic time was less than 5 minutes in all cases. 85 kidneys have been sent to other kidney transplantation centers and 19 kidneys discarded. Sixty-two kidneys have been transplanted in our institution. Cold ischemic time ranged from 2 to 43 hours. Immediate post-transplant massive diuresis (greater than 2 ml/mn) was observed in all recipients but 3 (95%).

[Treatment of prostatic cancer with diethylstilboestrol and detection of the vascular risk (author's transl)]

A retrospective study of immunologic behavior of patients suffering from cancer of the prostate and treated with oestrogens permits the proposal of the utilisation of a test that separates a high thromboembolic risk population due to oestrogens from a population that can benefit from this hormonotherapy. The so-called "oestrogen tolerance test" consists of seeking the presence of immune complexes by the method of precipitation of serum by 25% saturated ammonium sulphate. The group of patients where precipitates exceeds 700 micrograms/ml has a thrombo-embolic risk above 30% (41% in our series with serious complications such as pulmonary embolus and arterial thrombosis. The group of patients where precipitates are less than 300 micrograms/ml has a lower risk of arterial thrombosis (2,5%) and the observed accidents are benign. Finally, a test test when precipitate exceed 700 micrograms/ml should exclude diethylstilboestrol treatment.

Ethinylestradiol and diethylstilbestrol induced antibodies and vascular thrombosis

Antiethinylestradiol antibodies were demonstrated in several oral contraceptive users. The antibodies could be precipitated from serum immune complexes by 25% saturated ammonium sulfate. This test of serum precipitation was applied to a comparative study of 116 women on O.C and 65 men treated with diethylstilbestrol for a prostatic cancer. Controls without hormones were included in each group. The test was shown to discriminate among the estrogen users reactive and unreactive persons. 34% of women and 41% of men had high levels of precipitated immunoglobulins in 25% saturated ammonium sulphate. Study of the specificity of the Igs purified from the precipitates in reactive cases, showed that they were binding ethinylestradiol with an affinity constant consistent with an antigen antibody reaction. It is concluded that the oral ingestion of two different synthetic estrogen compounds may induce antiestrogen antibodies. The relation of these antibodies with the increased incidence of vascular thrombosis is considered.

[Treatment of ureteral obstructions due to prostatic carcinoma. Prognostic value of response to medical treatment (author's transl)]

A retrospective study concerning 146 patients with prostatic cancer showed that 30 of them (20 p.cent) presented ureteral obstacles at some time during the evolution of the disease. The majority of these cases were T3-T4 tumors. When a strickly medical approach allowed to reduce the obstruction, the 1 year survived rate was 71 p.cent. When surgery became necessary due to persistent renal insufficiency, in spite of medical treatment the 1 year survival rate was 15 p.cent.