Embolisation supersélective bilatérale des artères vésicales pour contrôler une hématurie abondante d’un cancer de vessie métastatique

L’hématurie chez les patients présentant un cancer de la vessie localement avancé ou métastatique est une situation assez fréquente et qui pose souvent un problème de prise en charge. L’embolisation percutanée est une option mini-invasive pour gérer cette situation. Nous rapportons un cas d'un patient ayant un cancer métastatique de la vessie et qui a présenté avec une hématurie abondante et une anémie sévère. Après l'échec des résections endoscopiques et des "flushs" de radiothérapie à visée hémostatique et après le refus de la cystectomie par le patient, on a réalisé une embolisation supersélective et bilatérale des artères vésicales supérieures avec d'excellents résultats immédiats. La technique est sûre et efficace à court terme. L’évaluation de l’efficacité à long terme nécessite une étude plus approfondie.

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Introduction : Les léiomyomes sont des tumeurs mésenchymateuses bénignes. La localisation vésicale de ces tumeurs est rare et représente moins de 0,5 % de toutes les tumeurs vésicales. Le léiomyome vésical est la plus fréquente de ces tumeurs mésenchymateuses et il représente le tiers des lésions bénignes de la vessie. Notre but était d’étudier les particularités épidémiologiques, cliniques, radiologiques, thérapeutiques et évolutives de ce type de tumeur.Matériel et méthodes : Nous rapportons une série de cinq cas de léiomyome vésical, colligés entre 2001 et 2014. Il s’agit de trois femmes et de deux hommes. La symptomatologie clinique est non spécifique et dominée par la cystite. Trois patients ont eu une énucléation et deux ont eu une résection endoscopique de la tumeur.Résultats : Le suivi moyen est de six ans. Un seul patient a présenté une récidive expliquée par la persistance d’un nodule vésical lors de la première intervention, avec une bonne évolution après la deuxième cure chirurgicale.Conclusion : Le léiomyome vésical est une tumeur bénigne et rare. Sa symptomatologie est peu spécifique. Son diagnostic est histologique. Son traitement est toujours chirurgical, offrant un excellent pronostic, sous réserve d’une exérèse complète pour éviter les récidives.

Retrovesical hydatic cyst: About 4 cases

INTRODUCTION

The hydatid cyst is a real public health problem in Tunisia. The retrovesical localization is rare. It is considered an aberrant or ectopic location defined by the development of the parasite in the subvesical and retrovesical fat.

METHODS

From 2004 to 2013, 4 patients with retrovesical hydatid cyst were hospitalized and operated in the Department of Urology at the Charles Nicolle hospital of Tunis in Tunisia. The average patient age was 40.75 years (range: 23-76). Signs of bladder irritation were the most frequent presenting complaint. No cases of hydaturia were noted. The diagnosis was made on the ultrasound and the computed tomographic urography. Hydatid serology was positive for 3 patients. In 3 cases, a hydatid cyst of the liver was associated. A total cysto-pericystectomy was performed for 1 patient, for others it was partial.

RESULTS

The postoperative course was uneventful. No urinary fistula or infection of the residual cavity was observed. One patient had a retroperitoneal cyst recurrence requiring reoperation.

CONCLUSION

Retrovesical location of hydatid cyst is rare and treatment is primarily surgical.

Discovery of Renal Tuberculosis in a Partial Nephrectomy Specimen Done for Renal Tumor

The association of renal cancer and renal tuberculosis is uncommon. While the incidental discovery of renal cell carcinoma in a tuberculous kidney is a classical finding, the discovery of tuberculous lesions after nephrectomy for cancer is exceptional. We report the case of a female patient aged 60 who had a partial nephrectomy for a 5 cm exophytic kidney tumor. Pathological examination concluded that renal clear cell carcinoma associated with follicular caseo tuberculosis.

Pseudotumoral Eosinophilic Cystitis

Eosinophilic cystitis is a rare inflammatory disease of the bladder which origin and pathogenesis are unknown. Since the first description in 1960, hundreds of cases have been reported, 20 Pseudotumor forms. We report a case of cystitis eosinophils in tumor-form, a patient of 72 years without urological or allergic history. The patient was treated with endoscopic resection alone. The outcome was favorable with disappearance symptoms and no recurrence at 1, 3 and 6 months controls. We carry a literature review of cystitis eosinophils on the different clinical manifestations, the means diagnostic and therapeutic modalities.

Anatomical variations of renal venous vascularisation. A study of 71 three-dimensional kidney endocasts

BACKGROUND

A better understanding of the anatomy of the renal vein and its relationship with the arterial and excretory systems can prevent intra operative complications.

METHODS

Three-dimensional endocasts of intrarenal vessels and renal collecting systems were obtained from fresh cadavers, by injecting a polyester resin coloured with different pigments. A total of 71 endocasts were studied: 37 right kidneys and 34 left kidneys.

RESULTS

Renal vein was unique in 88% of cases and double in 11% of cases. It was formed in 52% of cases by 3 trunks. Intrarenal veins anastomosed together to form 2 levels of arcades in 28% of cases and 3 levels in 71% of cases. The venous drainage of the upper pole was provided by two anterior and posterior plexus in 38% of cases, and by a single anterior plexus in 61% of cases. In 22% of cases, the venous drainage of the lower pole was provided by both an anterior and a posterior plexus, and in 77% of cases, there was only an anterior plexus. Renal artery was posterior to the vein in 66% of cases. It was anterior to the vein in 29% of cases, and located directly above it in 4% of cases. In 60% of cases, we noted a close relationship between the anterior surface of the ureteropelvic junction and the lower branch of the renal vein.

CONCLUSION

Venous vascularisation of the kidney appears to be variable and its relationship with the arterial and the excretory systems may be complex.

[Medical therapies for locally advanced/metastatic kidney cancer]

AIMS

To analyze the medical literature concerning the results of the international randomized muticentric trials concerning therapeutic innovations, mainly targeted therapies in locally advanced and or metastatic renal cell cancer and to evaluate the benefit of these TT.

METHODS

We performed a review of publications that concerned this topic published from 2000 to 2014.

RESULTS

They concerned the large randomized trials have showed a benefit of the targeted therapies in the treatment of clear cell carcinomas in terms of progression-free survival.

CONCLUSION

Advances in molecular biology have allowed the development of these targeted therapies that have all proved their role in the treatment of metastatic renal cell carcinoma.

Social aspects of kidney donation in Tunisia: a study of 189 living related donors

INTRODUCTION

Our aim was to study the demographic and social characteristics of 189 living related kidney donors in Tunisia, and explore some of the social consequences of kidney donation.

METHODS

This is a descriptive retrospective study of 189 living related kidney donors who had their nephrectomy in Charles Nicolle Hospital between 1986 and 2009. The demographic and social characteristics at the time of donation were studied and changes in the social and occupational status after donation were assessed.

RESULTS

The average age at the time of donation was 41.8 ± 12.1 years (range: 20-67 years). Female predominance (59.2% of cases) was noted. Donors were siblings in 46% of cases, parents in 42% of cases and spouses in only 9% of cases. There were more mothers than fathers, more wives than husbands, but fewer sisters than brothers. Twenty-six percent of donors were illiterate and 40% were unemployed at the time of donation. After donation, the social status remained stable for 70% of donors. No divorces were reported. The occupational status was unchanged in 94% of cases. Sixteen percent of female donors had at least one pregnancy after nephrectomy. Nearly 90% of surveyed donors whose recipients were alive at the time of the survey were still in favor of kidney donation.

CONCLUSIONS

Women play an important role in living related kidney donation in Tunisia. Family situation and occupational status did not seem to be compromised after nephrectomy, and most donors were willing to donate if the decision was to be repeated.

Seminal vesicle agenesis: An uncommon cause of azoospermia

Seminal vesicle malformations are a rare cause of obstructive azoospermia, often associated with other internal genitalia and upper urinary tract birth defects. We report 5 new cases of seminal vesicle agenesis in men presenting with hypospermia and azoospermia.Imaging showed seminal vesicle unilateral agenesis in all patients.The remaining seminal vesicle was hypoplastic in 3 cases, dilatedin 1 case and with abnormally thick content in another case. Vasdeferens agenesis was observed unilaterally in 2 patients and bilaterally in 2 other patients. No renal malformations were detected. Genetic study showed in all cases a 46 XY karyotype without any microdeletions. A single heterozygous cystic fibrosis transmembrane regulator gene mutation was diagnosed in 1 man, but not found in his partner. Intracytoplasmic sperm injection using sperm from a testicular biopsy was performed in 3 couples, without success.

Obesity and renal cancer: Role of adipokines in the tumor-immune system conflict

Epidemiological studies link obesity, as measured by increased body mass index (BMI) to the incidence of renal cell carcinoma (RCC) as well as to the cancer-related mortality of RCC patients. RCC is the third cancer most robustly associated with increased BMI. Understanding the role of the adipose tissue in renal carcinogenesis is therefore of major importance for the development of novel paradigms of RCC prevention and treatment. Here, we discuss the current knowledge on the impact of obesity on the development and progression of RCC as well as the role of adipose tissue-derived hormones (adipokines) in the conflict between growing tumors and the immune system.

Primary testicular non-Hodgkin lymphoma. a 10-year Tunisian single-institute experience

BACKGROUND

Primary testicular non-Hodgkin lymphoma (NHL) is an uncommon extra nodal presentation, accounting for 1% of all NHL and 1 to 9% of testicular neoplasms. Median age at time of presentation is 60 years old. Anthracycline based chemotherapies are most frequently used.

AIM

To analyze baseline characteristics, treatment modalities and survival of six cases of primary testicular non-Hodgkin lymphoma.

METHODS

We screened 46 testicular neoplasm cases registered from January 1999 to January 2009 and found six primary testicular lymphoma patients. These six cases were analyzed for baseline clinical features, investigations, treatment and outcome variables.

RESULTS

Median age was 50 years old and median duration of symptoms was 4 months. All patients had testicular swelling. Four patients had abdominal lymphadenopathy. Most patients had diffuse large B-cell histology. All patients underwent high inguinal orchidectomy and five were treated with anthracycline based chemotherapy. Four patients completed therapy and one of them relapsed two years later.

CONCLUSION

Primary testicular NHL is an uncommon entity and with current combined modality treatment, the outcome may be as good as nodal NHL.

Evaluation of urolithiasis in Crohn's disease in Tunisian patients

AIM

To investigate the characteristics of urolithiasis associated with Crohn's disease (CD) in a sample of Tunisian population.

METHODS

We retrospectively studied 184 patients with CD to reveal any urolithiasis during evolution. Evidence for the presence of renal calculi was obtained from plain films, ultrasonography or intravenous urography and computed tomography.

RESULTS

Renal calculi were found in only three patients with CD. All patients were woman. Mean time from diagnosis of CD to diagnosis of calculi was 22 months (range 6 to 48 months). Clinical features were not specific. Calculi were bilateral in two cases.

CONCLUSIONS

The rate of concurrent urolithiasis was very low in the present series of Tunisian patients. Although rare, efficient treatment and prevention of calculi formation are mandatory in CD patients'.

Risk factors and consequences of delayed graft function

The impact of delayed graft function (DGF) on the outcome of renal transplantation remains controversial. We analyzed the risk factors for DGF and its impact on graft and patient survival. A total of 354 renal transplants performed between June 1986 and April 2000 were analyzed. Variables analyzed included donor and recipient age, method and duration of renal replacement therapy, HLA mismatch, cold and warm ischemia times, biopsy-confirmed acute rejection, length of stay in the hospital, serum creatinine at the end of first hospitalization as well as graft and patient survival at one, three, five and ten years. The study patients were divided into two groups: patients with DGF (G1) and those without DGF (G2). DGF occurred in 50 patients (14.1%), and it was seen more frequently in patients transplanted from deceased donors (60% vs. 40%, P <0.0001). The cause of DGF was acute tubular necrosis, seen in 98% of the cases. Univariate analysis showed a statistically significant difference between the two groups G1 and G2 in the following parameters: average duration on dialysis (52.3 vs. 36.4 months, P = 0.006), HLA mismatch (44.9% vs. 32.11% P = 0.015), donor age (35.9 vs. 40.2 years, P = 0.026), cold ischemia time (23 vs. 18.2 h, P = 0.0016), warm ischemia time (41.9 vs. 38.6 mn, P = 0.046), length of stay in the hospital during first hospitalization (54.7 vs. 33.2 days, P <0.0001), serum creatinine at the end of first hospitalization (140 vs. 112 μmol/L, P <0.0001) and at three months following transplantation (159 vs. 119 μmol/L, P = 0.0002). Multivariate analysis revealed the following independent risk factors for DGF: deceased donor (RR = 13.2, P <0.0001) and cold ischemia time (RR = 1.17, P = 0.008). The graft survival at one, three, five and ten years was 100%, 93%, 88.3% and 78.3% in G1 versus 100%, 95.9% 92.8% and 82.3% in G2; there was no statistically significant difference. The patient survival at one, three, five and ten years was 100%, 91.3%, 83.6% and 74.4% in G1 versus 100%, 95.9%, 94% and 82.6% in G2 with a statistically significant difference (P = 0.04). Prolonged cold ischemia time and transplantation of kidneys from deceased donors were the main risk factors for DGF in our study. Also, DGF significantly affected patient survival but had no influence on graft survival.

Impact of smoking intensity on outcomes of patients with non muscle invasive bladder cancer treated by BCG immunotherapy

BACKGROUND

Cigarette smoking is a well-known risk factor of bladder carcinogenesis. The clinical impact of smoking on bladder cancer recurrence and response to BCG immunotherapy remains unclear. We sought to investigate the effect of smoking intensity on bladder cancer response to BCG therapy, and the interactions between smoking and clinicopathological factors on bladder cancer recurrence.

METHODS

Clinical information was obtained from 81 smokers patients (smokers at diagnosis) with NMIBC treated with transurethral resection of the bladder tumor followed by BCG immunotherapy. The distribution of smoking intensity on patient age (≥60 years or <60 years), gender, tumor grade, tumor stage, carcinoma in situ, multiplicity and tumor size was assessed. The effect of cigarette smoking on cancer recurrence was estimated using Cox proportional hazard models and Kaplan-Meier analysis.

RESULTS

The results showed that smoking intensity was significantly associated with response to BCG immunotherapy (p = 0.010). Univariate Cox regression analysis of clinicopathologic characteristics showed that PT1 stage, tumor size more than 3 cm and smoking intensity significantly increased the risk of recurrence (respectively, p = 0.006; p = 0.008 and p = 0.012). These results were confirmed by Kaplan-Meier survival curves. In addition, multivariate analysis using Cox regression selected the model involving stage, tumor size and smoking intensity as the quasi-independent predictor of recurrence.

CONCLUSION

These findings suggest that cigarette smoking is an independent predictor for patients with NMIBC. Although the current evidence supports a positive link between smoking intensity and the risk of recurrence on NMIBC treated by BCG immunotherapy, additional studies, are needed before definitive conclusions can be drawn.

Carcinome épidermoïde de l’urètre masculin révélé par une rupture spontanée de l’urètre

Le carcinome épidermoïde de l’urètre masculin est une tumeurrare, les tumeurs de l’urètre tous types confondus représentantmoins de 1 % des tumeurs de l’appareil urinaire. Le pronosticreste défavorable malgré un traitement chirurgical énergique. Laradiochimiothérapie semble être un traitement prometteur, maisson rôle doit être défini par d’autres études.Nous rapportons un cas rare de carcinome épidermoïde del’urètre bulbo-membraneux découvert à un stade localement avancéaprès observation d’une rupture urétrale transtumorale chez unhomme âgé de 70 ans. Le patient a été traité, après drainage vésical,par une irradiation externe associée à une chimiothérapie parcisplatine, et est décédé après progression de la maladie sur un an.La rupture spontanée de l’urètre transtumorale est un modede découverte exceptionnel témoignant d’une évolution localedéfavorable, ce qui rend ces tumeurs difficilement opérables.Cependant, l’espoir actuel réside dans des protocoles thérapeutiquesassociant radiothérapie et chimiothérapie.