[Scrotal pseudoabscess revealing congenital diverticulum of the anterior urethra in children]

The authors report a case of infected congenital diverticulum of the anterior urethra in a 6-week-old infant. This diverticulum presented clinically in the form of a scrotal abscess. Retrograde cystourethrography established the diagnosis. Two-stage treatment was preferred because of the infection: aspiration of the diverticulum and antibiotics, subsequently followed by surgical repair with resection of the diverticulum and immediate urethral reconstruction. The immediate postoperative course was marked by demonstration of hypertrophic pylori stenosis, which had not been previously investigated despite the presence of symptoms predating the diverticulum (repeated vomiting at the age of one month). Treatment was surgical. A brief review of diverticula of the anterior urethra is presented, defining the aetiological factors as well as the diagnostic and therapeutic features.

[Posterior urethral polyps in children. A case report]

Posterior urethral polyps are rare. A case is reported in a 7-year-old boy presenting with pain and burning micturition. Ultrasound and cystography revealed the diagnosis by showing a round solid structure in the bladder neck. Cystoscopy confirmed the diagnosis by showing its implantation base at the summit of the verumontanum. The polyp was removed by endoscopic resection and histological examination of the resection specimen showed a fibrous polyp. A brief review of the clinical features, diagnostic methods, natural history and treatment of this benign tumour is presented.

Semenogelin I: a coagulum forming, multifunctional seminal vesicle protein

Human seminal plasma spontaneously coagulates after ejaculation. The major component of this coagulum is semenogelin 1, a 52-kDa protein expressed exclusively in the seminal vesicles. Recently, a sperm motility inhibitor has been found to be identical to semenogelin I, suggesting that it may also be a physiological sperm motility inhibitor. The protein is rapidly cleaved after ejaculation by the chymotrypsin-like prostatic protease prostate-specific antigen, resulting in liquefaction of the semen coagulum and the progressive release of motile spermatozoa. Some of the cleavage products of Sg I may also have various biological functions. While the semenogelin I protein is unique to human and higher primates, it has recently been shown to belong to a gene family having a similar gene structure but encoding widely differing proteins. The recently elucidated characteristics of the semenogelin I gene as well as the biochemical and functional properties of the encoded protein are reviewed, and an attempt is made to integrate the various findings into a model for semen coagulation, sperm immobilization and potential other functions.

Piezoelectric lithotripsy of ureteral stones: influence of shockwave frequency on sedation and therapeutic efficiency

OBJECTIVE

The aim of this randomized study was to assess the relation between shockwave frequency, sedation, and efficiency in piezoelectric extracorporeal shockwave lithotripsy (SWL) for ureteral calculi.

METHODS

A random sample of 114 patients aged between 15 and 74 (mean 45) years were treated at the shockwave frequencies of 1 (N = 57) or 4 (N = 57) per second using the EDAP LT 02 lithotripter at maximum energy. The stones' largest diameter ranged from 5 to 18 mm (mean 7.6 mm). Lower ureteral stones were treated with the patient in the prone position and upper ureteral stones in supine position. The duration of SWL sessions and stone measurements were statistically similar for patients treated at low and high frequencies. The levels of required sedation (none, intramuscular analgesia, intravenous sedation-analgesia) and stone-free rates after one session were analyzed by Student's t-test or Fisher's exact test.

RESULTS

Sedation did not differ statistically with SWL frequency for mid and lower ureteral calculi. However, the use of intravenous sedation-analgesia was less common for patients with upper ureteral stones treated at low rather than high frequency (19% and 100%, respectively; P < 0.0001). The success rate was significantly lower (P = 0.04) for lower ureteral calculi treated at low v high frequency (65 % and 89%, respectively) but was not statistically affected by frequency for upper ureteral stones.

CONCLUSION

We recommend high frequency for piezoelectric SWL of lower ureteral calculi, especially for stones with a maximum diameter > or =8 mm. On the other hand, low-frequency SWL appears to be suitable for the treatment of upper ureteral stones.

High-affinity antibodies from hen's-egg yolks against human mannose-6-phosphate/insulin-like growth-factor-II receptor (M6P/IGFII-R): characterization and potential use in clinical cancer studies

The mannose-6-phosphate/insulin-like growth-factor-II receptor (M6P/IGFII-R) involved in trafficking of newly synthesized lysosomal enzymes, degradation of IGFII and activation of TGFbetaI, was suggested as being coded by a tumor-suppressor gene. No specific antibodies are currently available for clinical studies. Since M6P/IGFII-R is a highly conserved protein in mammals, we immunized chicken with human M6P/IGFII-R. Up to 200 mg of specific IgY from weekly pooled egg yolk was extracted by the polyethylene glycol procedure. Chicken IgY antibodies specifically recognized the human and bovine 270-kDa M6P/IGFII-R but not the 46-kDa M6P-R, as documented by immunoprecipitation and immunobloting. Using biosensor analysis, IgY antibodies were shown to bind M6P/IGFII-R with high affinity (K(D) = 7.5 x 10(-9) M). A solid-phase competitive ELISA using bovine M6P/IGFII-R coated on 96-well microplates, allowed us to titrate the M6P/IGFII-R in human sera at a sensitivity of 300 ng/ml. The M6P/IGFII-R was stained by immunoperoxidase in breast- and ovarian-cancer cell lines (T47D, MDA-MB231, MCF7 and BG1) and in frozen breast-cancer tissues, showing predominant localization in the trans-Golgi network. Staining specificity was shown with irrelevant IgY and by extinction with antigen excess. Quantitative immunohistochemical analysis of frozen sections from 40 invasive breast carcinomas indicated varying levels (from 5 to 400 units) of the M6P/IGFII-R protein which were not correlated with tumor size, histological grade and estrogen receptor or progesterone receptor. There was a trend (p = 0.08) between lymph-node invasiveness and low receptor level. Moreover, the M6P/IGFII-R level was significantly lower in cancer cells than in normal cells in 10 out of the 21 tumors in which the peritumoral normal glands could be quantified in parallel. These 2 last results agree with the hypothesis of a tumor-suppressor gene for this receptor and suggest more basic and clinical studies to prove it.

Harmful effects of UVA on the structure and barrier function of engineered human cutaneous tissues

PURPOSE

To investigate the effects of a single UVA exposure on engineered human cutaneous tissues.

MATERIALS AND METHODS

Skin equivalents (SE) were obtained by culturing keratinocytes on fibroblast-populated collagen gels; epidermal equivalents (EE) were obtained by seeding keratinocytes on non-populated collagen gels. After maturation and differentiation of the epidermis, SE and EE were exposed to 50 or 100 J/cm2 UVA. Structural damage and total epidermal lipids were analysed and diffusion of radioactive oestradiol was monitored 24 and 72h post-irradiation.

RESULTS

Twenty-four hours after UVA irradiation, a disorganization of the living epidermis is observed. UVA also significantly reduced the skin barrier function and led to an increase in phospholipid and in a decrease of ceramide levels. However, both the structure and the barrier function of SE were recovered 72 h post-irradiation, thereby suggesting that an intrinsic repair process might exist within the irradiated SE.

CONCLUSION

This study provides a strong evidence that UVA radiation alters both the epidermal and dermal structures, the synthesis of epidermal lipids, and the permeability of the human skin.

Direct percutaneous approach to the upper pole of the kidney: MRI anatomy with assessment of the visceral risk

PURPOSE

In an attempt to determine the visceral risk secondary to a direct percutaneous puncture of the upper renal calix, the anatomic relations of the upper pole of the kidney were studied by magnetic resonance imaging.

METHODS

Examination was performed on 25 normal volunteers placed successively in the right and left prone oblique position. The kidney axis and minimal distances from the cutaneous plane at the level of the upper and lower poles were measured. Axial and tangential simulated percutaneous approaches to the upper renal calix were compared in term of risk of damage to the pulmonary, splenic, and hepatic parenchyma.

RESULTS

The transversal anteversion angle was statistically comparable for right and left kidneys, but the sagittal anteversion angle was significantly higher for right kidneys (p = 0.05). The minimal distance from the cutaneous plane was statistically comparable for the upper and lower poles. The lower pole was significantly deeper for left than right kidneys (p = 0.01). The visceral risk was statistically comparable for left and right kidneys and was significantly higher in case of an approach in the axis of the upper renal calix or through the 10th intercostal space compared to a puncture via the l1th space (p = 0.0001).

CONCLUSION

A percutaneous puncture of the upper pole of the kidney above the 11th rib increases the risk of visceral damage. Preoperative evaluation, with the aid of CT scan or MRI, of the risk of pulmonary, splenic, or hepatic injury could be carried out in these cases.

[Bladder paraganglioma (pheochromocytoma): a rare tumor in children. Apropos of a case]

The authors report the first case of bladder paraganglioma in a child admitted to their department successfully treated by partial cystectomy. The diagnosis was established histologically, after failure of clinical diagnosis. Retrospectively' the authors think that preoperative diagnosis should have been possible and emphasize the importance of a thorough clinical examination.

[Prognosis in pT3b infiltrating tumors of the bladder treated by adjuvant chemotherapy]

OBJECTIVE

To evaluate the prognosis of stage pT3bM0 invasive urothelial bladder tumours treated by cystectomy alone or combined with adjuvant chemotherapy according to the MVAC protocol (methotrexate, vinblastine, adriamycin and cisplatin).

MATERIAL AND METHODS

From 1987 to 1996, 90 patients with stage pT3M0 urothelial bladder tumours were treated with isolated cystectomy (n = 69) or followed by MVAC chemotherapy (n = 21). Lymph node stage was N0 (n = 55), N+ (n = 29) or Nx (n = 6). Essentially selected because of their good general status, patients treated with chemotherapy had a lymph node stage N0 (n = 7) or N+ (n = 14). Chemotherapy had to be suspended in 2 cases and with a fatal outcome during treatment in 4 cases, due to tumour progression, surgical complication or bone marrow aplasia.

RESULTS

65 deaths have occurred with a follow-up of 2 to 120 months (m = 15), including 2 postoperative deaths, 39 cancer deaths and 14 intercurrent deaths. The 1-year, 2-year and 5-year actuarial survival rates were 70%, 48% and 19% for stage N0 and 54%, 25% and 3% for stage N+, respectively, with corresponding median survivals of 20 and 12 months (p < 0.005). The recurrence rate increased from 40% at stage N0 to 62% at stage N+ (p = 0.05), and the corresponding recurrence-free survivals were 16 months and 7 months (p < 0.02). The median survival without chemotherapy ranged from 11 months at stage N+ to 20 months at stage N0 and, with chemotherapy, from 19 months at stage N+ to 67 months at stage N0. The median recurrence-free survival with and without chemotherapy, was 43 months and 17 months at stage N0 and 12 months and 7 months at stage N+.

CONCLUSION

The prognosis after cystectomy for stage pT3b bladder cancer is severe, especially in the presence of lymph node involvement. Adjuvant chemotherapy according to the MVAC protocol tends to improve survival, especially recurrence-free survival, and appears beneficial at stage N0. However, the value of this adjuvant treatment, which is associated with a high specific morbidity appears to be more relative at stage N+.

Inactivation of tumor suppressor p53 by mot-2, a hsp70 family member

The mortalin genes, mot-1 and mot-2, are hsp70 family members that were originally cloned from normal and immortal murine cells, respectively. Their proteins differ by only two amino acid residues but exhibit different subcellular localizations, arise from two distinct genes, and have contrasting biological activities. We report here that the two proteins also differ in their interactions with the tumor suppressor protein p53. The pancytosolic mot-1 protein in normal cells did not show colocalization with p53; in contrast, nonpancytosolic mot-2 and p53 overlapped significantly in immortal cells. Transfection of mot-2 but not mot-1 resulted in the repression of p53-mediated transactivation in p53-responsive reporter assays. Inactivation of p53 by mot-2 was supported by the down-regulation of p53-responsive genes p21(WAF-1) and mdm-2 in mot-2-transfected cells only. Furthermore, NIH 3T3 cells transfected with expression plasmid encoding green fluorescent protein-tagged mot-2 but not mot-1 showed an abrogation of nuclear translocation of wild-type p53. These results demonstrate a novel mechanism of p53 inactivation by mot-2 protein.

[Videoscopic resection of a thrombosed aneurysm of a patent ductus arteriosus in a neonate]

Aneurysmal dilatation of a patent ductus arteriosus is a rare condition. One hundred and fifty three cases have been reported, of which 59 (39%) were operated, with an operative mortality of 16%. The authors report a case detected in a premature neonate on chest X-ray showing a mass in the mid-mediastinal region. Surgical resection was undertaken by video-thoracoscopy. Peroperative analysis of the resected specimen suggested a vascular structure and this was confirmed by histological study, which showed spontaneous aneurysm of a thrombosed patent ductus arteriosus or cystic residue of a patent ductus arteriousus. The authors underline the importance of peroperative puncture of structures of uncertain origin and the possibility of conversion of such a procedure to that of an extreme emergency.

Phenotypic and genotypic variability in monozygotic triplets with Turner syndrome

Turner syndrome (TS) is a common disorder (1/2500 and 1/5000 female births) which is diagnosed at birth in approximately 20% of patients and during childhood (usually due to growth retardation) or later, (due to lack of pubertal development) for the remaining patients. Here we present a cytogenetic and molecular analysis of three monozygotic sisters. The diagnosis of TS was done for one of them (patient 1) who presented with a typical Turner phenotype. A first karyotype was established as normal and a second karyotype (carried out on 200 cells) revealed a 45,X/46,XX mosaicism with 6% of cells with a 45,X karyotype. Lymphocyte karyotype analysis showed the same mosaicism pattern for the two other sisters, one of them exhibiting only a mild (patient 2) and the other no clinical features of Turner syndrome (patient 3). Karyotype analysis was this time conducted on fibroblasts and showed that the 45,X/46,XX mosaicism pattern correlated with the clinical phenotype with 99, 43 and 3% of 45,X cells in patients 1, 2, and 3, respectively. These data suggest that different tissues other than lymphocytes should be subjected to a karyotype analysis when the observed genotype does not correlate with the clinical phenotype.

Regeneration of coconut (Cocos nucifera L.) from plumule explants through somatic embryogenesis

A protocol was developed for coconut regeneration using plumules from mature zygotic embryos as explants, and media with the synthetic growth regulators 2,4-dichlorophenoxyacetic acid and 6-benzylaminopurine. Evidence for the regeneration process from these tissues occurring through somatic embryogenesis is presented. The somatic embryos were capable of germination, subsequent development into plantlets and successful transfer to the nursery. The yields were larger, nearly twofold for calli and over tenfold for calli bearing somatic embryos, than those previously reported with inflorescence explants. The present protocol thus represents an improvement in time and yield over previous protocols. Even though plumule explants are not the ideal tissue source due to possible genetic heterogeneity, the improvements made here may be applicable to tissues from mature plants. In addition, micropropagation of coconut using plumules is potentially useful when they are obtained from fruit produced from selected parents of outstanding performance, such as those resistant to diseases.

Barrier function of reconstructed epidermis at the air-liquid interface: influence of dermal cells and extracellular components

To evaluate the epidermal barrier function of in vitro reconstructed epidermis, we measured the penetration of estradiol and water across human keratinocytes cultured in defined medium (DM), in the presence of proliferative fibroblasts (pF) or conditioned medium derived from pF, at the air-liquid interface on synthetic porous membrane, noncoated or coated with laminin, fibronectin, type I collagen or type IV collagen. Ultrastructural analysis showed a well-developed stratum corneum whatever the culture conditions. The permeability of reconstructed epidermis in DM on a noncoated porous membrane was 5- to 10-fold higher than human native epidermis, with both tracers. No significant change in barrier function was observed whatever the culture conditions.

[Urologic management of cystine lithiasis in the upper urinary tract. Modalities and indications]

Cystine urinary stones is a relatively rare hereditary disorder of dibasic amino acid transport characterized by frequent recurrences. The management of these stones remains problematical despite the remarkable progress in the urological treatment of upper urinary tract stones. Cystine stones are particularly refractory to extracorporeal shock waves and relatively inaccessible to dye pulsed laser (504 nm). Apart from this exception, endourological techniques often represent the most appropriate therapeutic solution, but they are associated with significant morbidity. The physicochemical characteristics of these stones also allow dissolution by urinary alkalinization or the formation of disulfide compounds. In parallel with oral treatments, which constitute the basis of prevention of recurrence, dissolution can be obtained by direct perfusion of the urinary tract. This approach often requires irrigation for several weeks with a risk of the specific complications of catheterization, especially percutaneous catheterization. Prophylaxis, essentially consisting of dilution and dissolution of urinary cystine, raises the problem of the potential adverse effects of drug treatment. Cystinuria is easily detectable and can be investigated either systematically or only in the families concerned. However, the incidence as well as the frequently benign nature of cystinuria tend to limit its value and its indications.

Random protein-creatinine ratio for the quantitation of proteinuria in pregnancy

OBJECTIVE

To compare random urine protein-creatinine ratios with 24-hour urine protein excretion rates in patients hospitalized with hypertensive disorders in pregnancy.

METHODS

All hospitalized, hypertensive patients requiring 24-hour urine protein excretion collections were eligible for the study. During the 24-hour urine collection a separate 2-mL aliquot was taken for a protein and creatinine determination.

RESULTS

Seventy-one samples were collected from patients with the following diagnoses: gestational hypertension (n = 56), preexisting hypertension and superimposed gestational hypertension (n = 11), and syndrome of hemolysis, elevated liver enzymes and low platelets (n = 4). The correlation coefficient between the random protein-creatinine ratio and the 24-hour urine protein excretion was 0.94. Calculated excretion rates with at least 300 mg protein in 24 hours had a sensitivity of 0.93, specificity of 0.90, and positive and negative predictive values of 0.87 and 0.95, respectively. For those samples with calculated excretion rates at least 5 g protein in 24 hours, the sensitivity was 1.00, specificity was 0.99, and positive and negative predictive values were 0.75 and 0.99, respectively.

CONCLUSION

In nonambulatory hypertensive pregnant patients, there is a strong correlation between random voided protein-creatinine ratios and 24-hour urine protein excretions.

Piezoelectric extracorporeal shock-wave lithotripsy of lower pole nephrolithiasis

OBJECTIVE

To evaluate the efficacy of the EDAP LT 02 lithotriptor for the treatment of lower pole nephrolithiasis.

METHODS

From January 1994 to September 1995, 91 patients presenting with solitary radiopaque calculi of the lower pole calix were treated by piezoelectric extracorporeal shock-wave lithotripsy (ESWL) with the EDAP LT 02. Among them, 82 were available for follow-up. The stones' largest diameter of these patients varied from 5 to 15 mm (mean = 8.1). Indications for ESWL were pain in 63 (77%), hematuria in 5 (6%), associated infection in 6 (7.5%) and stone size in 8 (10%) asymptomatic patients. Stone localization was assessed as very easy in 74 cases (90%) and difficult in 8 cases (10%) but no intraoperative IVP was needed. ESWL sessions were performed with intravenous sedo-analgesia in 69 cases (80%) and general anesthesia in 17 cases (20%). After ESWL we advised patients to combine a diuresis with postural drainage.

RESULTS

Most patients were treated with one session of ESWL: none required more that two (mean = 1.05). The mean hospital stay for one session was 1.2 +/- 0.7 days. Obstructive complication rate was 11% and auxiliary treatments were necessary in 6%. The stone-free rate of in situ piezoelectric ESWL monotherapy was overall 84%, and 95% of patients with pain were cured.

CONCLUSION

In the absence of abnormality of the upper urinary tract, the vast majority of small lower pole caliceal stones can be completely removed by piezoelectric ESWL without recourse to more invasive methods.

[Lymph node eosinophilic granuloma. Apropos of 2 cases of Langerhans-cell histiocytosis with isolated lymph node involvement]

The authors report two cases of isolated lymph node involvement by Langerhans' cell histiocytosis which affected two young children. The histologic aspect reveals that lymph nodes have been modified by a proliferation of large histiocyte-like cells, associated with eosinophils. An immunohistochemical study on paraffin sections and for one case on frozen sections, reveals the usual phenotype of Langerhans' cells: these cells stain positively with S 100 protein and CD1 and are negative for both lysozyme and al antichymotrypsine. After a period of two years for one child and four years for the other, these children are in total remission, one spontaneously, the other after chemotherapy.

Expression of the interleukin 6 receptor in primary renal cell carcinoma

AIMS

Interleukin 6 (IL-6) is expressed in the majority of renal cell carcinomas and has an important role in the proliferation of some renal cell carcinoma cell lines. This action is mediated by two membrane proteins, gp80 (the IL-6 receptor; IL-6R), which binds IL-6, and gp130, which transduces the signal. The soluble form of gp80 (sIL-6R) is able to activate gp130 when complexed to the IL-6 molecule. These considerations prompted an investigation of IL-6R expression in this malignancy. IL-6, C reactive protein (CRP), and sIL-6R were also measured in serum and correlated to clinical and pathological features.

METHODS

Immunostaining was performed on cryostat sections from renal cell carcinoma tumours with M91, an anti-IL-6R monoclonal antibody, using the alkaline phosphatase antialkaline phosphatase technique. The proliferation index was measured using the KI-67 monoclonal antibody. CRP, IL-6, and sIL-6R were measured in serum before nephrectomy, using an immunoenzymatic or immunoradiometric assay.

RESULTS

There were significant differences in survival in patients with tumours larger than 8 cm, metastasis at diagnosis, high nuclear grade tumours, detectable serum concentrations of IL-6 (correlated to CRP serum concentration), more than 4% proliferating cells, and the presence of the IL-6R in situ. Furthermore, the serum IL-6 concentration correlated with tumour size and stage. The mean serum sIL-6R concentration was not significantly different from that observed in 40 normal subjects. Tumour IL-6R expression was present in 10 samples. There was a significant association between the presence of the IL-6 receptor in tumours and tumour stage, nuclear grade, proliferation index, and serum IL-6.

CONCLUSIONS

This study revealed the importance of IL-6/CRP and IL-6R expression in situ as potential new prognostic factors and opens the way to new therapeutic strategies in renal cell carcinoma.

Interaction of S100A1 with the Ca2+ release channel (ryanodine receptor) of skeletal muscle

In the present report we studied the interaction between the skeletal muscle ryanodine receptor and the ubiquitous S100A1 Ca2+ binding protein. S100A1 did not affect equilibrium [3H]ryanodine binding to purified rabbit skeletal muscle terminal cisternae at 100 microM free [Ca2+]. At nanomolar free [Ca2+], however, S100A1 activated by 40 +/- 6.7% (mean +/- SE, n = 5) the [3H]ryanodine binding activity; the half-maximal concentration for stimulation of [3H]ryanodine binding was approximately 70 nM, a value well below the estimated S100A1 concentration in skeletal muscle fibers. Scatchard analysis of [3H]ryanodine binding performed in the presence of 100 microM EGTA indicates that S100A1 increases the apparent affinity of the receptor for ryanodine (Kd = 191 vs 383 nM in the presence and in the absence of 100 nM S100A1, respectively). The effect of S100A1 was also tested on the single-channel gating properties of the purified ryanodine receptor after reconstitution into a lipid planar bilayer. Currents carried by purified ryanodine receptor channels were modulated by both cis Ca2+ and ruthenium red. In the presence of nanomolar [Ca2+], S100A1 activated the channel by increasing (6.0 +/- 2.8)-fold (mean +/- SE, n = 3) the normalized open probability. The interaction between S100A1 and the purified RYR was verified using the optical biosensor BIAcore: we show that the two proteins interact directly both at millimolar and at nanomolar calcium concentrations. We next mapped the regions of the skeletal muscle RYR involved in the interaction with S100A1 by performing ligand overlays on a panel RYR of fusion proteins in the presence of 100 nM S100A1. Our results indicate that the skeletal muscle RYR contains three potential S100A1 binding domains. Binding of S100A1 to the RYR fusion proteins occurred at both nanomolar and millimolar free [Ca2+]. S100A1 binding domain 1 binds the ligand in the presence of 1 mM free [Ca2+] or 1 mM EGTA. Maximal binding to S100A1#2 was achieved in the presence of 1 mM free [Ca2+]. The S100A1#3 domain, which overlaps with calcium-dependent calmodulin binding domain 3 (CaM 3), exhibits weak and strong S100A1 binding activity in the presence of either millimolar or nanomolar Ca2+, respectively. The interaction between S100A1 and the purified RYR complex was also investigated by affinity chromatography: in the presence of nanomolar Ca2+, we observed binding of native RYR complex to S100A1-conjugated Sepharose. This interaction could be inhibited by the presence of RYR polypeptides encompassing S100A1 binding sites S100A1#1, S100A1#2, and S100A1#3.

[Management of stage I testicular nonseminomatous germ cell tumors with an embryonic carcinomatous component. 18 cases]

OBJECTIVE

To evaluate the prognosis and therapeutic modalities of stage I nonseminomatous germ cell tumours of the testis (NSGT) with an embryonic carcinomatous component (EC).

MATERIAL AND METHODS

18 patients with stage I nonseminomatous germ cell tumour of the testis with an embryonic carcinomatous component were treated between 1987 and 1995. EC represented more than 50% of the testicular tumour mass in 15 cases. This tumour contingent constituted the only potential prognostic factor in 4 cases, but vascular or lymphatic emboli (n = 3), tumour stage > pT1 (n = 5) or absence of endodermal sinus component (n = 9) were observed in 14 cases. The first 3 patients underwent retroperitoneal lymph node dissection and the following 15 patients were submitted to surveillance (n = 4) or chemotherapy (n = 11) according to the PVB [Cisplatin, Vinblastine, Bleomycin] (n = 7) or BOE [bleomycin, Etoposide, Cisplatin] (n = 4) protocols.

RESULTS

With a follow-up of 10 to 110 months (mean: 46), the survival rate is 100% and the recurrence rate is 22%. None of the patients with a local stage exceeding pT1 relapsed after chemotherapy. 2 patients in whom the EC contingent represented less than 50% of the tumour mass and who were simply watched, did not relapse. 4 relapses, detected 3 to 14 months after orchidectomy (mean: 8.5), during surveillance (n = 2) or after chemotherapy (n = 2), required surgical resection or complementary chemotherapy. They occurred in patients in whom EC represented more than 50% of the testicular lesion. The tumour of initially conservatively managed patients did not contain an endodermal sinus component (n = 2) or presented vascular emboli (n = 1). The subjects treated by chemotherapy were characterized by the presence of emboli (n = 1) or the absence of endodermal sinus component (n = 1). The course after recurrence was favourable in 3 cases and the last patient is currently receiving chemotherapy.

CONCLUSION

EC is an independent risk factor whose presence justifies proposal of complementary treatment by retroperitoneal lymph node dissection or chemotherapy, possibly limited to 2 courses of BOE. Surveillance can only be considered in the case of a minority of EC in the tumour, in the absence of any associated risk factors.

Characterization of prostate-specific antigen proteolytic activity on its major physiological substrate, the sperm motility inhibitor precursor/semenogelin I

The protease prostate-specific antigen (PSA) is a marker widely used clinically for monitoring prostatic malignancies. Under normal conditions, this enzyme is mainly involved in the post ejaculation degradation of the major human seminal protein, the seminal plasma motility inhibitor precursor/semenogelin I (SPMIP/SgI), which is the predominant protein component of human semen coagulum. PSA primary structure and activity on synthetic substrates predict a chymotrypsin-like activity whose specificity remains to be established. The present study was aimed at characterizing the proteolytic processing of the SPMIP/SgI by PSA. Purified SPMIP/SgI was incubated with PSA in the presence or absence of protease inhibitors. General serine protease inhibitors, heavy metal cations (Zn2+ and Hg2+), and the heavy metal chelator 1,10-phenanthroline partially or totally inhibited the proteolytic activity of PSA toward SPMIP/SgI. Under identical conditions, other proteins, such as bovine serum albumin, ovalbumin, and casein, were very poor substrates for PSA. Hydrolysis products were separated by reverse-phase high-performance liquid chromatography, assayed for sperm motility inhibitory activity, and analyzed by immunoblotting and mass spectrometry. The region responsible for the sperm motility inhibitory activity and containing an SPMI antiserum epitope was localized to the N-terminal portion of the molecule between residues 85 and 136. On the other hand, a monoclonal antibody against a seminal vesicle-specific antigen (MHS-5) recognized fragments derived from the central part of the SPMIP/SgI (residues 198-223). PSA hydrolysis occurred almost exclusively at either leucine or tyrosine residues, demonstrating directly for the first time a restricted chymotrypsin-like activity on a physiological substrate. The results suggest that PSA is the main enzyme responsible for the processing of SPMIP/SgI in human semen and that this protease manifests unusual specificity with respect to hydrolyzable substrates and sites of hydrolysis.

[The value of retrograde ureterorenoscopy in the treatment of bulky kidney calculi]

OBJECTIVE

To assess the value of retrograde endoscopic lithotripsy for very large pyelocaliceal stones.

MATERIAL AND METHODS

Eighteen patients between the ages of 28 and 80 years (mean : 52) and presenting a staghorn renal calculus (n = 7) or with a maximal diameter greater than or equal to 20 mm (n = 11) were initially managed by rigid or flexible retrograde ureterorenoscopy, with ballistic (Lithoclast) or electrohydraulic (Riwolith) stone fragmentation. In 16 cases (89%), an additional extracorporeal shock-wave lithotripsy (ESWL) session was performed immediately after the endoscopic procedure. Early complications consisted of 3 cases of bacteraemic discharge rapîdly responding to medical treatment and 1 death from septic shock on the 8th postoperative day. Twelve patients (67%) were subsequently treated by ureteroscopy (n = 4) or ESWL (n = 11).

RESULTS

17 patients were evaluated after this therapeutic procedure, with a follow-up of 3 to 6 months (mean : 4). Stone elimination was complete for 8 patients (47%), 3 of whom initially presented a staghorn calculus. A residual stone was observed in 9 cases (53%), with a maximal diameter < 5 mm in 7 cases (41%). One patient (5%) underwent secondary percutaneous nephrolithotomy.

CONCLUSION

Technological progress has clearly facilitated the ureteroscopic approach to very large pyelocaliceal stones, but fragmentation and stone elimination remain problematical. This unconventional approach constitutes a potential field of technical progress, but does not represent a really efficient alternative to PCNL at the present time.

Double-J ureteric stent encrustations: clinical study on crystal formation on polyurethane stents

OBJECTIVE

To evaluate the crystalline composition of encrustations on double-J ureteric stents in order to prevent their formation on the base of urolithiasis prophylaxis.

PATIENTS

40 patients had a polyurethane double-J ureteric stent inserted between June 1994 and March 1995. Group 1 comprised 22 stone formers whose stents were placed in support of endourological treatment or extracorporeal shock wave lithotripsy of renal or ureteric calculi. Group 2 comprised 18 patients whose stents were inserted for advanced and obstructive malignancy (n = 8) or as an adjunct to reconstructive surgery or endourological techniques (n = 10). After removal, stents were examined for encrustation and obstruction. A biochemical semiquantitative analysis was performed for deposits > 5 mg, and smaller sediments were examined with a polarizing optical microscope.

RESULTS

The incidence of encrustation was significantly higher (p = 0.009) for stone formers. In addition, in this group indwelling times of encrusted and obstructed stents were significantly shorter (p = 0.03 and 0.02, respectively). No particular relationship was found between the incidence of encrustation and indwelling times for stone formers. Conversely, for patients without urolithiasis, indwelling times were significantly longer for encrusted or obstructed stents than for unaffected ones (p = 0.05 and 0.02, respectively). Biochemical and optical analyses of encrustations mainly revealed calcium oxalate, calcium phosphate and ammonium magnesium phosphate. Calcium oxalate was the main crystalline phase, especially in the absence of urinary infection.

CONCLUSION

Calcium oxalate represents the principal component of double-J ureteric stent encrustations. Thus, prophylaxis of encrustation may consist of preventive measures usually applied in cases of recurrent idiopathic calcium oxalate urolithiasis.

[Degradation of soil quality: health and environmental risks]

This is a general survey of soil quality degradation and its consequences on human health and environment quality. The first part deals with the large complexity and reactivity of soil and its specific position as an environmental interface. The origin and behaviour of the main pollutant accumulated in soils are treated in the second and third parts. A special attention is paid to the main pollutants i.e., anions, cations (trace elements), pesticides, persistent organic pollutants (POP), bacteria, DNA... As they are closely linked to the soil constituents (clays, humus...), their real toxicity or effectiveness is examined. In the last part, the risks of soil pollutants for the environment and human health are shortly considered. Direct risks for health are few and mainly concern the ingestion of polluted soil by children; as regards the ecotoxicological and toxicological risks, the Critical pollutant loads have to be defined. The main risks are indirect and involve pollution of either the food chain or of the water and sediments by vertical or lateral (erosion) transfers.

Characterization of afferent mechanisms in ileoanal pouches

OBJECTIVES

The afferent innervation of ileoanal pouches plays an important role in perception and in reflex regulation of pouch function. We aimed to characterize afferent nerve function in ileoanal pouches and thereby explain the clinical presentation of patients with such pouches.

METHODS

In eight patients who underwent surgery for active ulcerative colitis, perception of balloon distention of the pouch was measured using an electronic visceral distention device. In addition, pouch compliance and ileoanal reflex function were determined. Studies were performed during the initial stage of pouch creation (pouch without connection to proximal ileum, study 1) and a mean of 6.6 wk (range = 2-12 wk) after the second stage of the surgery (proximal ileum in continuity with the pouch, study 2). Nine normal volunteers made up the control group.

RESULTS

When expressed as intrapouch pressure, thresholds for stool and discomfort sensations were similar in patients with a pouch and controls. However, during ramp distention, patients with a pouch had a lower volume threshold for stool sensation (143 +/- 45 ml vs 300 +/- 30 ml, p = 0.009). The initial sensation of discomfort was experienced in the perineum at the S3 dermatome in all eight patients. At higher distention pressures, all patients with a pouch referred sensations to the abdomen, as opposed to only one of nine controls with such a referral pattern (p < 0.0001). Pouch compliance was markedly reduced during study 1 but normalized after continuity was established with the proximal ileum. Anal sphincter function in patients with a pouch was similar to that in controls.

CONCLUSIONS

Afferent pathways from both the ileum and rectum play a role in the mediation of sensations during mechanical distention of the ileoanal pouch and can explain a number of clinical features of patients with a pouch. The thresholds for activation of these pathways are not significantly altered by long-standing colorectal inflammation or by creation of the ileoanal pouch. Continuity with the proximal ileum significantly influences pouch compliance.

[Diagnosis and treatment of cystic tumors of the adrenal gland. Report of 2 cases]

Two cases of cystic tumour are reported. The first consisted of a pseudohaemorrhagic cyst of the right adrenal gland discovered during aetiological assessment of HT refractory to medical treatment. Plasma and urinary assays did not reveal any abnormality suggestive of secreting adrenal tumour. Imaging (ultrasonography. CT and MRI) was in favour of a necrotic malignant tumour and a normal isotope scan (MIBG iodine 131) eliminated phaechromocytoma. Adrenalectomy was easily performed via a subcostal laparotomy and the postoperative course was uneventful. The second case consisted of a right adrenal cyst detected incidentally on ultrasonography. The laboratory assessment demonstrated only a slight elevation of urinary metanephrine and imaging (CT and MRI) was not suggestive of a malignant lesion. Simple annual CT follow-up was decided in this case. The various pathological types of rare cystic lesion of the adrenal gland are described with particular emphasis on their diagnostic and therapeutic modalities.

Purification and characterization of the active precursor of a human sperm motility inhibitor secreted by the seminal vesicles: identity with semenogelin

Human seminal plasma contains a sperm motility inhibitor that originates from seminal vesicles as a precursor form. This precursor is degraded into smaller peptides by prostatic proteases shortly after ejaculation. The seminal plasma sperm motility inhibitor (SPMI) precursor was purified by a combination of cation-exchange chromatography on S-Sepharose followed by C4 reverse-phase high-performance liquid chromatography directly from seminal vesicle fluid or washed seminal coagulum. The purification procedure yielded a protein of apparent homogeneity, with a molecular mass of 52 kDa by SDS-PAGE. It migrated as a 105-kDa protein by molecular sieving under denaturing conditions. The purified SPMI precursor was digested by the prostatic protease prostate-specific antigen (PSA), causing a 76 +/- 4% drop in biological activity and transformation into low molecular mass SPMI polypeptides (5-20 kDa) similar to those observed in liquefied semen. The N-terminal amino acid sequences of three degradation peptides were obtained by Edman degradation and found to correspond to residues 45-50, 85-90, and 137-143 of semenogelin, a protein characterized as the major structural component of semen coagulum. The amino acid composition of SPMI precursor was found to be almost identical to that of semenogelin. Moreover, the mass of the precursor was estimated at 49,620 daltons by electrospray-ionization mass spectrometry, a value in close agreement with the expected mass of semenogelin according to its cDNA sequence. The SPMI precursor was found to inhibit sperm motility in a dose-dependent manner, with complete immobilization at 500 U/ml of SPMI. The motility of completely immobilized spermatozoa was partially recovered after washing of the cells. The results suggest that SPMI precursor is the major component of the seminal vesicle secretions and seminal coagulum. It can be degraded by PSA in a manner reminiscent of its processing in whole semen. Taken together these results indicate that the SPMI precursor is semenogelin and that intact semenogelin can immobilize spermatozoa.

Aorto-colonic fistula as a late complication of colon interposition for oesophageal atresia

A 22-year-old man developed severe haematemesis 21 years after colon interposition for long-gap oesophageal atresia. A fistula, from an anastomotic ulcer to the descending thoracic aorta, was discovered and treated successfully by surgical resection. This previously unreported complication highlights the need for the prevention of peptic complications following oesophageal replacement in children.

The gender difference in orienting liquid surfaces and plumb-lines: its robustness, its correlates, and the associated knowledge of simple physics

In comparison between male and female psychology students, a greater proportion of female students fail to represent liquid surfaces and plumb-line objects as invariably horizontal and vertical, respectively. However, the occurrence of this perplexing gender difference has not been ascertained among young adults enrolled in science programs, who should ostensibly be more fully equipped in terms of academic competence, irrespective of their gender. The present large sample of undergraduates (N = 1412), majoring in natural and applied sciences, and social sciences or humanities and arts, completed water-level and plumb-line items, along with other simple physics problems, indicating how and in reference to which principle they had solved these tasks. They also answered questions pertaining to possible personal proficiency correlates of a biological, experiential, perceptual, and sociocognitive nature. The data revealed not only that women's achievement was consistently poorer than men's across discipline categories, but surprisingly that this was so even within specific fields requiring and providing the most visuo-spatial skills as well as physical knowledge and training. Especially for women, mastery was predicted by success in simple physics problems, and to a lesser degree by perceptual, sociocognitive, and experiential variables. Biological variables did not contribute to proficiency for either gender, though the data fitted a recessive gene model. Responses based on relevant physics principles were more accurate, but men and women generally adopted the same procedural strategies. The present compelling demonstration of a gender gap in achievement that is not compensated by formal science education, extending thus even to future physical scientists, invites further investigation into its perceptual and cognitive determinants, as well as into those more distally connected with early aptitudes, interests, and experiences.

[Urethral recurrence after cysto-prostatectomy for bladder tumor]

OBJECTIVE

To evaluate the frequency, predictive parameters and prognosis of urethral recurrence after cystoprostatectomy for urothelial bladder cancer.

MATERIAL AND METHODS

From 1989 to 1994, 8 of a series of 185 patients (4.3%) treated by cystoprostatectomy for bladder carcinoma between 1988 and 1993 developed urethral recurrence revealed by urethral bleeding, with a follow-up of 6 to 36 months (m = 16).

RESULTS

The initial bladder tumour was localized in 3 cases and multifocal in 5 cases. The posterior urethra was not involved in 5 cases, but presented lesions of CIS in 1 case and neoplastic infiltration also involving the prostate in 2 cases. These recurrences were treated by urethrectomy, as first-line treatment in 7 cases and after failure of endoscopic treatment in 1 case. A balanic recurrence required distal penectomy following insufficient urethral resection. The course was very rapidly unfavourable for 3 patients with generalized cancer and an intercurrent disease was fatal in 1 other case. With a follow-up of 12 to 44 months (m = 26), 4 patients are alive with no obvious signs of disease progression.

CONCLUSION

The indications for prophylactic urethrectomy can be reserved to patients with positive urethral resection margins, provided all other cases are submitted to strict surveillance. In the context of a replacement bladder, it is essential to exclude neoplastic involvement of the posterior urethra or prostate, especially in patients previously treated by intravesical instillations.

Type III-IV laryngotracheoesophageal cleft: report of a successfully treated case

This report presents a case of Stage III laryngotracheoesophageal cleft (LTEC). It is, to our knowledge, the fourth case in which the patient is still alive twenty months after surgery. We herein describe an initial symptomatology dominated by a bubbling hypersalivation, our surgical technique using a pleural shred of interposition and an endoscopic check during the operation and, finally, the clinical development dominated by a food intake refusal which was progressively improved through psychiatric help.

Rectal afferent function in patients with inflammatory and functional intestinal disorders

Chronic symptoms of abdominal pain and discomfort are reported by patients with inflammatory bowel disease (IBD) and functional disorders of the gut, such as Irritable Bowel Syndrome (IBS). It has recently been suggested that transient inflammatory mucosal events may result in long-lasting sensitization of visceral afferent pathways. To determine the effect of recurring intestinal tissue irritation on lumbosacral afferent pathways, and to identify a plausible mechanism that could account for the overlap in symptomatology between IBD and IBS, we compared rectal afferent mechanisms in patients with Crohn's disease (inflammation limited to the ileum) with those observed in patients with diarrhea-predominant IBS. Continuous volume ramp and phasic pressure step distension of a rectal balloon were performed in 9 healthy male control subjects, 12 male patients with isolated ileal Crohn's disease and 9 male patients with diarrhea-predominant IBS using an electronic visceral stimulation device. The response of rectal afferents to distension was evaluated by measuring thresholds for the perception of physiological (stool) and aversive (discomfort) sensations, viscerosomatic referral patterns, skin conductance responses, receptive relaxation, and rectoanal reflex responses. In response to slow ramp distension, thresholds for aversive sensations were significantly higher in Crohn's disease patients, but similar between the two other groups. In response to rapid phasic distension, IBS patients reported discomfort at lower distension pressures, while all other thresholds were similar between groups. Skin conductance responses to aversive distension were greatly reduced in Crohn's disease patients while IBS patients had greater responses when compared to normals. Changes in viscerosomatic referral patterns and receptive relaxation rate were similar in Crohn's disease and IBS patients. These findings demonstrate that chronic ileal inflammation is associated with increased thresholds for discomfort and greatly diminished systemic autonomic reflex responses. In contrast, IBS patients show lowered thresholds for discomfort associated with increased autonomic responses. The findings in Crohn's patients may result from descending bulbospinal inhibition of sacral dorsal horn neurons in response to chronic intestinal tissue irritation.

[Piezoelectric extracorporeal lithotripsy of calculi of the median ureter (EDAP LT 02)]

OBJECTIVE

To evaluate the performance of in situ piezolectric extracorporeal shock-wave lithotripsy (ESWL) in the middle part of the ureter.

MATERIAL AND METHODS

36 consecutive patients presenting with stones of the middle part of the ureter were treated by in situ piezoelectric ESWL (EDAP LT 02). The maximal dimensions of the stones ranged from 5 to 14 mm (m = 7.8). Moderate or severe ureterohydronephrosis was present in 19 cases (53%) and a double J stent had been previously implanted in 6 cases (17%). The ESWL sessions were performed in the ventral supine position without any anaesthesia or systematic premedication, but an IM injection of 100 mg of pethidine was administered during poorly tolerated treatments.

RESULTS

The stone was located easily in 23 cases (64%) and with greater difficulty in 13 cases (36%), as an intraoperative intravenous injection of contrast agent was performed in 6 cases (17%). The number of sessions per patient ranged from 1 to 2 (m = 1.16). The complete sucess rate was 75%, with a 64% success rate after a single ESWL session. The performances were statistically independent of stone dimensions and the degree of obstruction of the urinary tract. The complication rate was 5.5%, but no ancillary endoscopic or percutaneous treatment was required.

CONCLUSION

In situ piezoelectric ESWL allows effective management of most stones of the middle part of the ureter. However, the treatment of stones with a maximal diameter < 5 mm, especially poorly radiopaque stones, can raise problems of localization. Very large or impacted stones, especially when complicated by urinary tract infection, should be preferably treated by first-line ureteroscopy.

[Indicators of the risk of calcium oxalate urinary calculi: comparative study of the Parks' and Tiselius' indices, urinary citrate/calciuria ratio, and morning crystalluria]

Despite the progress in basic research, the precise assessment of the risk of calcium oxalate urinary stones and the detection of patients at particular risk of recurrent stones are often problematical. A population of 55 renal stone patients and 50 controls served as a basis for various comparative studies of Parks' index, Tiselius' index, the urinary citrate/urinary calcium ratio and the morning calcium oxalate crystalluria. Parks' index and the urinary citrate/urinary calcium ratio were highly discriminant, in contrast with Tiselius' index and crystalluria, which were statistically comparable in the 2 groups. A close correlation was observed for the 3 versions of Tiselius' index, which estimates diuresis, but no particular correlation was detected between crystalluria and the other parameters studied. Parks' index and the urinary citrate/urinary calcium ratio are potentially adapted to the detection and monitoring of renal stone patients at risk of recurrence. On the other hand, the various Tiselius' indices can be essentially used to evaluate urinary calcium oxalate oversaturation and possibly to control treatments interfering with this parameter. The formula simply based on diuresis, and the 24-hour urinary calcium and oxalate excretion (CaO.71.Ox.V-1.2) appears to be sufficient for this purpose. The absence of correlation between crystalluria and the other potential indicators of lithogenic risk raises the problem of their respective validity as well as the possible prevalence in the crystallization process of the powerful inhibitors which are currently unidentified, but probably macromolecular.

[Fibroepithelial polyps of the ureter and the kidney pelvis. Report of 3 cases]

The authors report 3 cases of fibroepithelial polyps, one of which was an incidental finding and 2 were symptomatic, presenting in the form of macroscopic haematuria and chronic back pain, respectively. These lesions required 2 nephroureterectomies because of their renal repercussions or their multifocal nature, combined with segmental resection of the ureter, including the base of the tumour. In the light of these cases, the authors review the literature and analyse the current management of this rare disease, in particular the indications for endourological techniques which appear to have a major diagnostic contribution as a complement to IVU and retrograde urography, but whose therapeutic value has yet to be defined.

[Metabolic investigation of calcium oxalate urinary lithiasis. Indicators of lithogenic risk: modalities, applications and perspectives]

Despite exhaustive metabolic investigations, calcium oxalate urinary stones often remain idiopathic and, in the absence of any objective aetiopathogenic parameter, the prevention of recurrences and follow-up are particularly problematical. Various indicators have been elaborated to quantify, the lithogenic risk, based on various parameters potentially involved in the crystallization process. Their disparity illustrates the difficulty of achieving such an objective as well as the progress in fundamental concepts and their frequent technical complexity penalizes their practical application. The performances of these indices, except in the hands of the team which has proposed them, often lack reproducibility and paradoxical or even contradictory findings are frequent. They may simply reflect the variability of the lithogenic process or may reflect the predominant role of potent inhibitors, especially macromolecules. The metabolic investigation of calcium oxalate urinary stones is initially limited to detection of lithogenic diseases amenable to specific treatment. After repeating the basic laboratory tests, recurrences, especially when they are unexplained, require more complex investigations. At the present time, applications of lithogenic risk indices are essentially confined to the field of clinical and basic research. Among the various indicators available, the urinary citrate/urinary calcium ratio and Parks' index appear to be particularly promising.

[Penal aspects of psychiatric intervention: management modes and impact of new criminal legislation]

Psychiatry and criminal justice have been closely related for a long time. Traces of such ties can already be found during the 19th century through the establishment of the contemporary systems of social control. Various questions that will mark the development of policies in this domain were important objects of discussion and analysis: Is mental illness a cause of criminality? Should the "insane" be held responsible for their crimes? What are the appropriate measures to heal, reform, control? In other words, should we consider the individual as sick or as criminal? If these questions are formulated differently nowadays they haven't lost any of their relevance. In this article, we will briefly present the forms of intervention available to the criminal justice system when dealing with persons suffering from mental health problems. This presentation is based on recent studies conducted in Montreal, elsewhere in Canada, as well as in the United States. The main stages of the criminal justice process will be examined, taking into account the recent modifications to the Canadian Criminal Code and its impact on the relations between the courts and psychiatric facilities. This type of situation is not without impact on community mental health for two main reasons. First, with the diminishing public funding of various health services there seems to be a growing practice of criminalization of persons suffering from mental health problems, especially the most vulnerable segments of this population. Secondly, there is a growing trend, in the criminal justice system, of requiring support from community groups or facilities to deal with these criminalized individuals. In the coming years criminalization will constitute an increasing and complex challenge for community mental health.

Evaluation of the risk of stone formation: study on crystalluria in patients with recurrent calcium oxalate urolithiasis

OBJECTIVE

The aim of this study was to determine the usefulness of the morning calcium oxalate crystalluria in detecting stone formers particularly prone to recurrence.

METHODS

Over a 24-hour period of urine collection, the morning calcium oxalate crystalluria was evaluated as well as the risk of stone formation, established with Tiselius and Parks indices, for 25 recurrent stone formers (group 1) and 25 normal controls (group 2).

RESULTS

Morning crystalluria (type, size, number/ml and state of aggregate) and the Tiselius index were comparable in the two groups. Conversely, calciuria as well as the citrate/ calcium ratio and the Parks index varied significantly for stone formers and normal controls. No particular correlation appeared between crystalluria and indices of Tiselius and Parks, calciuria, calcium-oxalate product or calcium/ oxalate and citrate/calcium ratios.

CONCLUSIONS

Morning calcium oxalate crystalluria does not enable an efficient characterization of recurrent stone formers. Its discordance with others potential indicators of the risk of stone formation poses the problem of their respective validity and evokes the prevalence of still unknown inhibiting agents in the phenomenon of crystallization.

Childhood urolithiasis: urological management of upper tract calculi in the era of extracorporeal shock-wave lithotripsy

OBJECTIVE

To evaluate the management of urolithiasis in children since the development of extracorporeal shock-wave lithotripsy (ESWL).

METHODS

Between 1988 and 1994, 37 children, aged from 2 to 15 years (mean 10), with upper tract urolithiasis were evaluated and treated. Lithogenic metabolic disorders or anomalies of the urinary tract were present in 11 children (30%) Urolithiasis was multiple in 9 cases and bilateral in 2 cases. A total of 47 renal (30) or ureteral (17) stones were managed, of which 5 were partial or complete staghorn calculi. Initial treatment was surgery in 4 cases (1 nephrectomy, partial nephrectomy and 2 pyelolithotomies) and piezoelectric ESWL in 43 cases.

RESULTS

The overall ESWL success rate was 82.2%, with auxillary endoscopic procedures in 3 cases. ESWL failures required surgical stone removal in 5 cases, endoscopic ureterolithotripsy in 1 case and electrohydraulic ESWL in 1 case. Residual fragments after pyelolithotomies were also treated by ESWL.

CONCLUSION

ESWL is the mainstay of treatment of childhood upper tract urolithiasis, but other therapeutic methods retain specific indications. Its application requires great vigilance and its long-term effects are uncertain. It is therefore important to rule out any underlying pathology and where possible to prevent further stone formation.

Management of major blunt renal lacerations: surgical or nonoperative approach?

OBJECTIVE

To evaluate changes in the management of major blunt renal trauma since the introduction of computerized tomographic diagnosis and follow-up.

MATERIAL AND METHODS

Twenty-three consecutive patients with deep blunt renal lacerations without major pedicle injury or shattered kidney were treated from 1986 to 1995. In group 1 (1986-1989, 12 patients), initial management was conservative, but with open surgery in cases of hemodynamic instability or persistent urinary extravasation. In group 2 (1990-1995, 11 patients), a plain conservative approach was followed and open surgery was reserved for major complications only.

RESULTS

In group 1, 6 patients required early renal exploration (4 nephrectomies, 2 renorrhaphies). A persistent urinary fistula led to late nephrectomy in 1 of the renorrhaphy patients. Retroperitoneal hematoma and urinary extravasation spontaneously resolved in 6 cases. Length of hospital stay was significantly lower (p = 0.02) for nonoperated patients. None suffered from hypertension at long-term follow-up (5-8 years, mean 7.2). In groups 2, all 11 patients were treated conservatively, with endoscopic ureteric stenting in 4 cases. Urinary extravasation always resolved, but 9 patients had residual perirenal hematoma at the time of discharge. Length of hospital stay was significantly higher (p = 0.0005) with ureteric stenting. Nine months after trauma, 1 patient suffered from recurrent pyelonephritis. Radiographic follow-up (1-30 months, mean 10.2) revealed minor sequelae in all evaluated patients.

CONCLUSION

In most patients with major blunt renal lacerations, a conservative approach is safe. Most extravasation spontaneously resolves and minimally invasive techniques will deal with nearly all complications. In our experience, open surgery usually results in nephrectomy.

Doctor, would you drink water from your dental unit?

Contamination of dental unit water lines is not new to dentistry, but this problem takes on a new dimension when considering immuno-deficient patients and existing infection-control measures. This study identifies the bacteria involved in the contamination process, estimates the contamination levels and reviews the methods that may be used to control the contamination.