[Treatment by radiofrequency ablation for a renin-secreting juxtaglomerular tumour: a case report]

Juxtaglomerular cell tumors are rare and benign tumors, occurring in young patients. The standard treatment is partial nephrectomy. We report the case of a young 22-year-old patient with a renin-secreting tumor diagnosed during an exploration of severe hypertension associated with hypokalemia that we treated by radiofrequency ablation.

[Comparative study of radical prostatectomy versus external beam radiotherapy (75.6 Gy) combined with hormone therapy for prostate cancer of intermediate D'Amico risk classification]

INTRODUCTION

Thirty-three percent of the localized cancers belongs initially to the group of intermediate risk of D'Amico. The standard treatments validated by the French Association of Urology are the radical prostatectomy and the external beam radiotherapy.

OBJECTIVES

We retrospectively compared the carcinologic results of the radical prostatectomy±adjuvant treatment (RP) and the external beam radiotherapy combining high dose (75.6 Gy) and short hormonotherapy (RH), in the treatment of intermediate risk prostate cancer. The series consisted of 143 patients treated between 2000 and 2006 in the department of Urology and Kidney transplantation of the Conception Hospital, Marseilles. The main assessment criteria was the survival without biological recurrence (SBR).

RESULTS

The median follow-up was 90 months [59-51]. The 5 years and 8 years SBR were 85% and 73% in the RH group, versus 74% and 65% with RP (P=0.196). There was a significant difference between the series: on the age of diagnosis (63.9 versus 73.3 years, P<0.001), the Charlson score of comorbidity (2 versus 3, P<0.001) and the number of intermediate criteria per patients (one intermediate criteria: RP 74% versus 57%, P<0.01).

CONCLUSION

According to our study, there was no superiority of the radical prostatectomy±adjuvant treatment or the external radiotherapy combining high dose and concomitant short hormonotherapy on the survival without biological recurrence at 5 and 8 years. Many studies confirm that a concomitant hormonotherapy increases the carcinologic control, even with a high rate external beam radiotherapy.

An experimental porcine model of heterotopic renal autotransplantation

OBJECTIVE

The aim of the present study was to validate an experimental model of heterotopic renal allotransplantation. Such a model, more relevant to the human situation, has never been previously described.

MATERIALS AND METHODS

Pietrin pigs (40 to 50 kg) were used in the study. Through a midline incision, the left kidney was removed, washed, and preserved in a standard preservation solution (Celsior, Genzyme, France) for 20 hours at 4 °C. Heterotopic autotransplantation was performed into the right iliac fossa onto the external iliac vessels with an end-to-side anastomosis and a nonstented uretero-ureteral anastomosis was performed.

RESULTS

Twenty-five renal allotransplantations were performed over a 5-month time period. Mean operating time progressively decreased and stabilized after 15 procedures (mean ± SD: 78.2 ± 19 minutes and 187.4 ± 18 minutes for left nephrectomy and transplantation, respectively) as morbidity decreased concomitantly. Suturing times for end-to-side anastomosis of the renal artery and vein onto the external iliac artery and vein were 21.9 ± 7 minutes and 34 ± 8 minutes (mean ± SD), respectively. Ten pigs died before the end of the experiment.

CONCLUSIONS

We have developed and validated the first nonrodent animal model of heterotopic renal autotransplantation relevant to the human anatomy and physiology. The procedure was easy to learn and safe. This model could be used to teach junior surgeons renal transplantation techniques and could also be used as a model to study ischemia-reperfusion injury in renal transplantation.

[Treatment of detrusor-striated sphincter dyssynergia with permanent nitinol urethral stent: results after a minimum follow-up of 2 years]

OBJECTIVES

The aim of this study was to assess the outcomes of nitinol permanent urethral stents used in detrusor-striated sphincter dyssynergia (DSD) treatment on male patients with a spinal cord injury.

MATERIALS

We investigated retrospectively all patients treated from 2004 to 2012. A total of 22 patients were included, with an age ranging from 22 to 76 years old. The DSD syndrome was due to spinal cord injury (18) or various spinal cord diseases (four) and treated with a nitinol urethral stent (11 Ultraflex(®) and 11 Mémotherm(®)). Every patient had an urodynamical study. The follow-up reached at least 2 years.

RESULTS

The mean follow-up was 56 months (± 14). Complementary procedures after stenting included: five stent prolongation or displacement (mean interval 7.6 months), six bladder neck incisions (12.2 months), three urethrotomy (42 months), ten obstruction treated by laser (47.3 months). Eight patients had a change of their urinary pattern: four underwent ileal conduit diversion, one had a continent urinary diversion, one chose self intermittent catheterization, two were under indwelling catheterization waiting for another treatment. Stent retrieval was either harmful or impossible for four of them. Three patients were free of complementary procedures.

CONCLUSIONS

Nitinol urethral stent was an effective treatment initially. However, by the third year, urethral stenosis and hypertrophic growth of the urethral mucosa usually require iterative endoscopic procedures (0.31 per patient per year). Patients treated with permanent uretral stent deserve a yearly endoscopic follow-up. Safety and effectiveness of permanent uretral stent compared to surgical sphincterotomy to treat DSD are discussed.

[Female stress incontinence treatment: urethral slings]

Female stress incontinence is often the consequences of obstetrical traumatisms. They are responsible of a weakness of perineal musculoaponevrotic structures. Until 1996, the reference treatment of this pathology was the "Burch" colposuspension, by laparotomy, then laparoscopic way. After 1996, a new procedure was developped by Ulmten, reproducible, easy, safe and mini-invasive: the tension free-vaginal-tape (TVT) followed by the trans-obturator-tape (TOT). This therapeutic tool has become the reference for the treatment of the female stress incontinence. There are now 15 years from the beginning of this procedure and still 80% of the patients are improved.

[Partial nephrectomy for cancer and percutaneous biopsy: Oncologic results]

OBJECTIVES

To evaluate the results of partial nephrectomy (NP) for cancer in 60 patients selected by the biopsy of the tumor by analyzing the information, oncologic follow-up.

PATIENTS

It was a cohort study unicenter retrospective from 1994 to 2006. The biopsy was systematically done for patients who were candidates for elective NP. The criteria for elective indications NP tumors were less than 4cm, low grade Fuhrman (I and II). The tubulopapillary tumors (TBP) on biopsy were excluded from the elective indications. The parameters studied were the biopsy data, overall survival, disease-free survival.

RESULTS

The median age was 59 years (32-79 years) and 69% of tumor were fortuitous discovery. Indications of need accounted for 30% of cases (single kidney, bilateral tumors and chronic renal failure [CRF]). Biopsy allowed a diagnosis in 89% of cases. There was one death in specific postoperative immediately. A final histology was 75% of clear cell carcinoma, 13.3% of chromophobe and 11.7% of TBP, 96.6% of T1a including 86.6% of low grade and no surgical margin. The median follow-up was 49 months with 98.5% of specific survival at 5 years, one local recurrence and no general recurrence.

CONCLUSION

The study has shown that the selection of patients by biopsy gives satisfactory carcinologic results with 98.5% specific survival at the end of follow-up; it is between 89 and 100% in the literature.

[Local recurrence of renal carcinoma after laparoscopic partial nephrectomy]

We report the case of an early local recurrence after a laparoscopic partial nephrectomy (LPN) for a Furhman grade 1-2 clear cell renal carcinoma (CCRC). CT scan at 6 months revealed a local recurrence. An open total nephrectomy was performed. There were six nodules in the perirenal fat from a grade 3 CCRC. Twenty-six months after the LPN, the patient had a wound recurrence, which was surgically removed. Four months after the wound recurrence, the patient had pulmonary, liver and adrenal glands metastasis. He received an oral treatment with sunitinib. At 4 months after the initiation of the sunitinib, he had a total response.

[New perspectives in prostate cancer management]

The treatment of prostate cancer is experiencing important innovations. Hormone therapy includes a new class of drugs: LHRH antagonists, which induce a rapid, fast and sustained reduction of testosterone levels. Active surveillance enables to avoid an aggressive treatment without decreasing survival, provided that strict eligibility and follow-up criteria are applied. New imaging techniques and laboratory assays lead to early diagnosis of small size tumors. Lastly, focal therapy has the potential to target localized cancers without deterioration of surrounding structures. These concomitant improvements offer the clinician and the patient attractive options for prostate cancer management. However, they are not devoid of limitations and constraints. Thus, it is crucial to define the most appropriate patient's profile for each therapeutic option, taking into account the objective characteristics of the tumor and the psychological features of the patient.

[Pelvic kystic schwannoma evoking a tumor of the right seminal vesicle]

We present the case of a pelvic schwannoma in a 36 year old man. It was discovered by chance during the medical assessment of a prostatitis. A computed tomography scan and magnetic resonance imaging revealed a 8 centimeters cystic pelvic tumor, closed to the right seminal vesicle. The patient underwent a transrectal ultrasound-guided biopsy, which showed a proliferation of neural peripheric cells with nuclear abnormalities. A tumorectomy was performed by laparotomy. The histological study diagnosed a benign cystic schwannoma. The patient was free of disease 12 months postoperatively.

[First line indications for hormonal therapy in prostate cancer]

The utilization of androgen deprivation therapy in prostate cancer has evolved over time. Unquestionably considered first line treatment in metastatic cancers or in case of lymph node involvement, it is increasingly used in locally advanced and high-risk cancers, combined with radiation therapy. However, the practical modalities of treatment are still controversial (neoadjuvant, concomitant/adjuvant) and should be discussed on a case-by-case basis, taking into account tumor stage and risk level, which depends mainly on Gleason score and PSA levels and kinetics. Hormone therapy is also indicated in case of systemic relapse, especially if PSA doubling time is less than 12 months. LHRH agonists have become the standard care; antiandrogens can be added at the beginning of the LHRH agonist therapy to obtain a complete androgen blockade. Intermittent androgen deprivation therapy has recently proved efficacious and might be more widely used in the future, provided that strict prescription and follow-up recommendations are clearly established.

[PSA and spironolactone]

The spironolactone is a diuretic of potassium savings. It is also used in the treatment of the hirsutism for its antiandrogenic action. Its use and its effects on the patients affected by a prostate cancer are less known. We report the case of a 72-year-old man having a cancer of prostate which normalized its PSA after institution of a treatment by spironolactone for ascites. This patient had a biological recurrence of a prostate cancer, arisen 7 years later after a treatment by hormonal radiotherapy. Nine months after the implementation of the treatment by spironolactone, there were no clinical and biological signs of disease progress.

[Renal epithelioid angiomyolipoma]

Renal epithelioid angiomyolipomas (ReAML) are rare tumors (identified in less than 0,1 per thousand in general population) and represent 8% of operated angiomolipomas (AML). The diagnostic is histological, with an epithelioid cell component among the typical AML cells. ReAML are tumors derived from perivascular epithelioid cells (PEComa). There are benign PEComas, potentially aggressive PEComas and malignant PEComas. Most malignant PEComas are ReAML. There are two ReAML clinical entities, sporadic or associated to Tuberous Sclerosis Complex (TSC). ReAML are unique, localized and sporadic solid tumors of the kidney of variable size that can be revealed as classical AML with local symptoms or a complication (hemorrhage). Revelation mode is mostly radiologic. ReAML are fat-poor on CT-scan. They can be misdiagnosed with renal cell carcinoma (RCC). (One third of ReAML are malignant with a locoregional, nodal or metastatic evolution that can lead to death. ReAML treatments are multimodal depending of histology, clinical-radiological entity, evolution and the patient. Partial nephrectomy or follow-up are the benign entity treatment. Radical nephrectomy eventually followed by doxorubicine or rapamycine treatments are recommended for potentially aggressive and malignant entities.

[Retrograde endopyelotomy using Holmium-Yag laser for uretero-pelvic junction obstruction]

OBJECTIVE

To evaluate our results of retrograde laser endopyelotomy for uretero-pelvic junction obstruction.

MATERIAL AND METHODS

Retrospective study of 27 consecutive retrograde laser endopyelotomies performed on 24 patients over a six years period (June 1999 to July 2005). Sixteen stenoses were primary. The level of obstruction was severe in 13 patients and moderate in 14 patients. A polar pedicle was diagnosed by pre-operative CT-angiography in seven cases. Balloon dilatation was performed in 17 procedures. A double J ureteral stent remained in place for six weeks mean. We evaluated results by a clinical examination and an excretory urography (at 1 and 6 months then annually). Mean follow-up was 35+/-22.7 months.

RESULTS

Mean operating time and mean length of hospital stay were 49.8+/-17.9min and four days (range: 2-10 days). Two cases of pyelonephritis were observed. The overall success was 70%. In the eight unresolved cases, the failure appeared at 2.7+/-1 month mean. Success criteria were moderate level of obstruction and primary junction. Here, patients so selected have 100% of success.

CONCLUSION

Study confirmed retrograde laser endopyelotomy was safety with a short length of hospital stay. This minimally invasive procedure should be reserved to primary moderate stenoses without polar pedicle.

[Renal cell carcinoma: management of venous thrombus]

Radical nephrectomy with vena cava thrombectomy remains the treatment of choice in patients with renal cell carcinoma and inferior vena cava involvement. Surgery is performed with curative intent in patients without evidence of metastases or for cytoreduction, followed by possible immunotherapy in patients with distant metastases. The role of magnetic resonance imaging for evaluating the renal vein and/or IVC to detect thrombus and the proximal extent of thrombus is fully established. Surgical removal of these cancers through a transabdominal approach, even in patients with a level 2 thrombus (involving the retrohepatic IVC with close proximity to the main hepatic veins) is possible, avoiding the potential added morbidity of a throacoabdominal approach or median sternotomy. The application of liver transplant techniques and liver mobilization procedures not generally familiar to urological surgeons facilitates wide exposure and proximal control of the IVC for tumors cephalad to the confluence of the hepatic veins. As an initial step we believe that cephalad retraction of the liver with mobilization of the IVC by securing the lumbar, small hepatic and other unnamed venous collaterals may be tried to gain exposure of the retrohepatic IVC. Overall survival in patients with IVC involvement after complete surgical removal in the absence of metastatic disease justifies aggressive surgical management.

[Surgical aspects and innovations in localized prostate cancer]

In 1983, Walsh introduced anatomical radical retropubic prostatectomy. With the surgical modifications that preserve neurovascular bundles, excellent cancer control can be achieved, while preserving erectile function and urinary continence in most appropriately selected patients. Since them, radical prostatectomy has become the most common treatment for clinically localized prostate cancer. Treatment results following radical prostatectomy will most likely continue to improve in the future as early detection is more widely practiced.

Tolerance of pain during transrectal ultrasound-guided biopsy of the prostate: risk factors

Transrectal ultrasound-guided needle biopsy of the prostate is routinely performed to diagnose prostate cancer. We performed a prospective study to assess the pain and identify risk factors of pain during prostate biopsy. Prospectively, 131 patients were enrolled. Transrectal ultrasound-guided needle prostate biopsies were performed without any anesthesia. Pain was assessed by using an immediate postbiopsy anonymous questionnaire including a linear visual analog scale (VAS). Six factors were studied (age, prostate volume, cores number, operator, previous biopsy and first core location). Most of the patients tolerated the biopsy with acceptable discomfort. Among the risk factors studied, only first core location influenced the pain. Apex biopsy first was more painful. We recommend starting biopsy with the base.

[Rare kidney tumors in an adult]

Rare kidney tumors can either be benign or malignant. Benign tumors include epithelial tumors and mesenchymatous ones developed from kidney cells. Malignant tumors are represented by the carcinoma of the collecting tubes as well by the sarcoma. Other malignant tumors of the extra-renal origin are also observed as lymphomas and neuro-endocrine tumors.

Comparative study on two kidney graft rinsing and preservation solutions in terms of the post-transplantation risk of delayed graft function and cost

OBJECTIVE

To determine whether Belzer solution (Viaspan, Bristol-Myers Squibb, Brussels, Belgium), which is more expensive than Eurocollins solution, was better at preventing delayed graft function (DGF) and whether it was cost-effective as it could potentially reduce post-transplantation complications.

METHOD

The risk of occurrence of complications associated with the use of these two rinsing and preserving solutions was estimated from a survey of 106 patients undergoing renal transplantation between 1 January 1993 and 31 March 1998. Both efficacy and adverse outcomes were recorded along with the costs directly associated with the transplantation procedure in the hospital setting: hospitalization, rinsing and preserving solutions, medical and technical interventions and diagnostic tests.

RESULTS

For the 45 kidney grafts rinsed and preserved with Eurocollins (strategy S1: n1 = 45) the cost/graft was estimated at 40 euros. With Viaspan (strategy S2: n2 = 61) the corresponding cost/graft was 424 euros. Logistic regression analysis showed that Viaspan was better than Eurocollins solution (ebeta = 0.437; P = 0.05) in preventing DGF. Overall, S2 was less expensive than S1, from the hospital's perspective. The mean difference per patient was 278 euros, which amounts to a saving of 2% of the total cost per renal transplantation. For rinsing and preserving kidney grafts Belzer solution is therefore preferable to Eurocollins solution.

[Kidney tumors: clinical and pathological findings and detection]

The detection and the clinical and pathological findings of kidney tumors have much progressed over the last 15 years. The incidence of asymptomatic renal masses has increased up to 30% during this time. This is mostly due to advances in ultrasound and computed tomography imaging. So, the therapeutic management of these masses has also been significantly changed. A better knowledge of their clinical and anatomical features allowed a more efficient mutlidisplinary approach and a better assessment of their prognosis.

[Arterio-ureteral fistula: diagnostic and therapeutic approach]

The diagnosis of arterio-ureteric fistula must be considered in the case of sudden onset of abundant or intermittent haematuria occurring in a particular context (history of aorto-iliac vascular surgery, prolonged ureteric stenting, ilio-pelvic radiotherapy). Emergency treatment must control bleeding. Endovascular stenting may be a useful technique, followed by reconstructive surgery with vascular bypass graft and treatment of the ureteric lesion.

[Renal onococytic adenoma]

Renal oncocytic adenoma. Renal oncocytic adenoma is a rare neoplasm now considered as a benign tumour. The purpose of this paper is to describe the radiological features of this tumour and to assess the value of imaging work-up in the diagnosis and management of patients with renal oncocytic adenomas.

CD44s and CD44v6 expression in localized T1-T2 conventional renal cell carcinomas

To assess the prognostic value of CD44s and CD44v6 tumour expression for patients with T1-T2 conventional renal cell carcinomas, a retrospective immunohistochemical analysis of 95 patients was undertaken. These patients had undergone a radical nephrectomy, performed in three institutions in France between 1987 and 1993. The mean age of the patients was 62.9+/-10.2 years (range from 37 to 85 years) with 66.3% males. At the time of surgery, 84 patients had a T1 and 11 a T2 renal tumour. Fuhrman nuclear grading showed 44 (46.3%) tumours of grade 1, 39 (41.1%) of grade 2, and 12 (12.6%) of grade 3. The mean follow-up period was 58.1+/-36.1 months. At the end of follow-up, eight patients (8.4%) had metastatic disease and no local recurrence was seen. Immunohistochemistry showed that 26 tumours (27.4%) expressed CD44s, but none expressed CD44v6. Statistical analysis showed that CD44s expression was correlated with tumour size (p=0.006) and Fuhrman grading (p<10(-4)). Among the various parameters tested for the multivariate analysis, CD44s expression correlated only with disease-free survival (p=0.04). It is concluded that CD44s expression, but not CD44v6, is of potential prognostic interest in patients with localized T1-T2 conventional renal cell carcinomas.

Pax-2 expression in adult renal tumors

To assess the expression of the homeogene Pax-2 in adult renal cell carcinomas, we did a retrospective immunohistochemical analysis of 56 frozen tumor samples representing all major histologic subtypes of renal tumors. There were 33 conventional renal cell carcinomas (58.9%), 12 papillary renal cell carcinomas (21.4%), 4 chromophobe cell renal carcinomas, 4 urothelial cell renal carcinomas, and 3 oncocytomas. Forty-five tumors (62.5%) were localized, and 21 tumors had extrarenal involvement. Eight patients (14%) had metastatic disease at the end of the follow-up. We searched for relationships between Pax-2 expression and nuclear grading, TNM staging, Ki-67 proliferation index, expression of transforming growth factor-beta1 (TGF-beta 1), an in vitro down-regulator of Pax-2 expression, and finally cytogenetic abnormalities. All histologic subtypes expressed Pax-2 protein, except urothelial renal carcinomas. The highest expression was in papillary renal cell carcinomas. In this subtype, all tumors and 83.3% +/- 12.3% of tumor cells were immunoreactive for Pax-2. All but 2 conventional renal cell carcinomas expressed Pax-2, but with 26.3% +/- 29.6% of immunoreactive cells (P <.001). Pax-2 expression was not correlated with nuclear grading (P =.6), tumor size (P =.3), and TGF-beta 1 expression (P =.1). Nevertheless, Pax-2 expression correlated with the Ki-67 proliferation index only for the conventional histologic subtype (P =.03). In this histologic subtype, Pax-2 expression was higher in patients with metastatic disease than in those without (P =.02). Pax-2 expression was not associated with specific cytogenetic abnormalities like trisomy 7 (P =.1), 3p deletion (P =.5), and hyperdiploidy (P =.2). TGF-beta 1 expression, positive in 33 tumors (59%), was not correlated with either Pax-2 expression (P =.1) or current prognostic factors such as nuclear grading (P =.2). Interestingly, we also observed an expression of TGF-beta RI and TGF-beta RII in the tumors with high nuclear grading (P =.005). We conclude that Pax-2 protein is expressed in all major histologic subtypes of renal cell carcinomas. The pattern of expression differs between these subtypes. Pax-2 expression in conventional renal cell carcinomas is correlated with the proliferation index and is significantly higher in patients with metastatic disease. HUM PATHOL 32:282-287.

[CT-guided percutaneous fine needle biopsy of solid tumors of the kidney]

OBJECTIVE

This study was designed to evaluate the reliability and the role of percutaneous needle biopsy in the diagnosis of renal masses.

MATERIALS AND METHODS

85 biopsies were performed in 74 patients (mean age: 62 +/- 14 years). The median tumour diameter was 4.44 +/- 2.53 cm. Biopsies were performed with an 18G ASAP* needle with CT guidance. 2 to 4 cores were obtained per patients. All biopsies were performed as an outpatient procedure.

RESULTS

Biopsies were uninterpretable in 15 cases (17%) (13 with normal or no renal tissue and 2 necrotic samples). A benign lesion was detected in 8 cases (4 fibrous lesions, 4 infectious lesions). In 3 cases, biopsies were suspicious of cancer, which was confirmed on definitive histology. In 59 cases, biopsies were neoplastic: 6 benign tumours (4 oncocytomas, 1 angiomyolipoma, 1 cystadenoma), 42 renal cell carcinomas (RCC) (conventional: 32, chromophobe: 3, tubulopapillary: 7), 5 urothelial carcinomas, 3 metastases, 2 lymphomas and 1 sarcoma. The median Fürhman grade was 2. 30 RCC were operated. The correlation coefficient for the biopsy and pathology histological type was 0.90. The median pathological Fürhman grade was 2. The biopsy results modified therapeutic management in 38% of cases. There was no morbidity, post-biopsy medical management was never required.

CONCLUSION

Biopsy of renal masses is reliable for evaluation of the histological type. The introduction of the CT scope should increase the accuracy of biopsies. The morbidity is low compared to that of diagnostic surgery.

Molecular cytogenetics of t(X;1)(p11.2;q21) with complex rearrangements in a renal cell carcinoma

We report a new case of renal cell carcinoma with the translocation (X;1)(p11;q21) and complex structural rearrangements in a female patient of 64 years of age. We analyzed abnormalities using FISH to identify chromosomal rearrangements, and wonder whether the translocation (X;1) could represent a particular subentity in renal cell carcinoma with distinct histologic features.

Fine-needle percutaneous biopsy of renal masses with helical CT guidance

PURPOSE

To evaluate the feasibility, accuracy, and clinical role of fine-needle percutaneous biopsy of renal masses, with helical computed tomographic (CT) guidance.

MATERIALS AND METHODS

In 63 patients (mean age, 62 years), 73 biopsies were performed. The median tumor size was 4.0 cm. Tumor biopsy was performed with an 18-gauge needle by using helical CT guidance in an outpatient setting. Two to four cores per tumor were obtained.

RESULTS

Biopsy material was insufficient for analysis in 15 (21%) procedures. The median tumor size of failed or successful biopsies was 3.0 or 4.8 cm, respectively (P =.03). A benign lesion was found at eight biopsies. Two samples were suspicious for renal cell carcinoma (RCC). RCC was found in 38 biopsy samples. The remainder were transitional cell carcinoma, metastasis, lymphoma, or sarcoma. Twenty-six patients underwent nephrectomy. The accuracies of biopsy for histopathologic and Fuhrman nuclear grade evaluation were 89% and 78%, respectively. For tumors of 3.0 cm or smaller or larger than 3.0 cm, 37% (11 of 30) or 9% (four of 43) had failure of biopsy, respectively (P =.006). No substantial morbidity occurred.

CONCLUSION

Fine-needle biopsy with helical CT guidance is accurate for the histopathologic evaluation of renal masses without morbidity. Indications are renal lesions that do not have the typical radiologic features of RCC, Bosniak category III or IV cystic lesions, and locally advanced or metastatic RCC.

[Ureteral replacement with non-modelled isoperistaltic ileoplasty]

OBJECTIVES

To study the long-term morbidity and efficacy of ureteroileoplasty in a retrospective series of 18 patients.

MATERIALS AND METHODS

12 men and 6 women with a mean age of 50 years underwent ureteroileoplasty with unilateral replacement in 15 patients and bilateral replacement in 3 patients. A total of 21 units renoureteral units were repaired by this technique. The pelvic ureter was replaced in 16 renoureteral units, the lumbar ureter was replaced in 1 case and the entire ureter was replaced in 4 cases. The commonest ureteral lesions were strictures secondary to ureteroscopy or ureterolithotomy (40%). All patients had normal renal function, except for one patient with serum creatinine of 224 mumol/l.

RESULTS

With a mean follow-up of 25 months (range: 3 to 64 months) all ureteroileoplasties were patent with no major morbidity. Only the patient with preoperative renal failure developed hyperchloraemic acidosis with deterioration of her renal function.

CONCLUSION

In the absence of renal failure, ureteroileoplasty is an operation with low morbidity achieving good medium-term results.

Adult mesoblastic nephroma

We report a case of asymptomatic mesoblastic nephroma in a 54-year-old woman. The tumor showed immunohistochemical reactions similar to developing nephrons. Electron microscopy showed immature tubules with numerous intracytoplasmic intermediate filaments. Recent studies support the concept of pathogenesis of the mesoblastic nephroma originating from collecting ducts. However, this case exhibited a complex pattern of antigenic expression not restricted to the collecting ducts, but including the glycoprotein CD24 and the neural cell adhesion molecule (NCAM). The following differential diagnoses will be discussed: benign mixed epithelial and stromal tumor, metanephric adenoma, and nephrogenic adenofibroma.

[Diagnostic value of percutaneous biopsy of the renal masses. 73 cases]

The aim of this study is to evaluate the diagnostic value of percutaneous biopsies of renal masses with comparison of pathological data between the biopsies and the surgical specimens. Thus, we retrospectively studied 73 biopsies of patients, who were referred to our institution between 1995 and 1997. The mean age of the patients was 60 +/- 14 years with a male predominance (67%). Twenty per cent of the biopsies were negative. Eleven per cent of the biopsies were benign lesions (oncocytoma, angiomyolipoma, infectious lesions). For renal cell carcinomas, the correlation coefficient between biopsy histology and final pathology was 0.87. Conversely, it was only 0.36 for the Führman grading. Nevertheless, low (1-2) and high (3-4) grades were accurately separated (0.92). We conclude that the percutaneous biopsy is a useful tool for diagnosis of renal masses.

Effect of digital rectal examination on serum complexed and free prostate-specific antigen and percentage of free prostate-specific antigen

OBJECTIVES

To evaluate the effects of digital rectal examination (DRE) on serum total, calculated complexed, and free prostate-specific antigen (PSA) and the free/total PSA ratio and factors affecting variations of PSA.

METHODS

Serum total and free PSA and the percent free PSA ratio were determined in 91 urologically referred men (mean age 64 +/- 9 years) before and 30 minutes after DRE, with the Hybritech Tandem-R assay. Complexed PSA was calculated as the difference between total and free PSA. DRE effects on PSA were analyzed comparing pre-DRE and post-DRE values and by calculating the difference between pre-DRE and post-DRE PSA and the post/pre-DRE geometric ratio as a coefficient of variation.

RESULTS

Thirty minutes after DRE, the increase in total, calculated complexed, and free PSA and the percent free PSA ratio was statistically significant. The difference between post-DRE and pre-DRE values of serum total, calculated complexed, and free PSA and percent free PSA was +0.9, +0.3, and +0.6 ng/mL and + 10%, respectively. The post/pre-DRE ratio of serum total, calculated complexed, and free PSA and percent free PSA was x1.5, x1.22, and x2.5 and x1.7, respectively. Patient age, DRE findings, prostate volume, prostate histologic features, and the initial value of total PSA had no statistically significant effect on the change of percent free PSA after DRE. The initial percent free PSA had a statistically significant effect on the change of percent free PSA after DRE. The values of calculated complexed PSA before and after DRE were significantly higher in patients with a prostate volume greater than 40 cc, prostate cancer on biopsy, and an initial free/total PSA ratio greater than 18%.

CONCLUSIONS

In this study, DRE significantly increased total, calculated complexed, and free PSA and percent free PSA. The increase of PSA immediately after DRE was mainly due to the increase of free PSA. The change of percent free PSA after DRE depended on the initial percentage of free PSA. Complexed PSA seems less sensitive to DRE, and its changes after DRE were clinically modest. Free PSA measurement should be done before DRE and percent free PSA should be used only when the venipuncture is done before the DRE.

Retrograde Acucise endopyelotomy: long-term results

PURPOSE

We evaluated the long-term outcome of retrograde endopyelotomy with the Acucise cutting balloon as a first-line treatment of ureteropelvic junction obstruction (UPJO) in 36 patients (median age 44 years).

PATIENTS

Twenty-three patients had a primary UPJO. The median follow-up in the series was 24 (6-42) months.

RESULTS

Success, defined as a subjective and objective improvement, was obtained in 27 (75%). In multivariate analysis, only the presence of a crossing vessel (45% v. 81%) was a significant covariate for success. The success rates for primary and secondary UPJO were 74% and 77% respectively. The grade of obstruction had no impact on results. The median time to the nine failures was 3 months, and no failure occurred more than 6 months after the endopyelotomy. In 75% of the failures with no crossing vessel, redo retrograde Acucise endopyelotomy was successful.

CONCLUSION

Retrograde Acucise endopyelotomy is an efficient long-term treatment of UPJO with low morbidity. This technique is a reasonable choice for first-line treatment of UPJO.

[Role of flexible mini-ureteroscopes in diseases of the upper urinary tract]

INTRODUCTION

The management of upper urinary tract disease has been improved by miniaturization of endoscopes. Our objective was to assess the value of flexible mini-ureteroscopes for the diagnosis and treatment of upper urinary tract lesions.

PATIENTS AND METHODS

33 consecutive patients (mean age: 49 +/- 16 years; 23 men) underwent first-line flexible ureteroscopy for upper urinary tract disease, consisting of: stones: 21, filling defect: 6, stenosis: 3, haematuria: 2, positive cytology: 1 and situated in the kidney + renal pelvis: 14 or ureter: 19. The 21 stones were situated in: the calyx: 5, renal pelvis: 1, lumbar ureter: 8, iliac ureter: 3, pelvic ureter: 4. Their mean dimensions were 9.7 +/- 4 x 5.3 +/- 2.3 mm. Previous treatment had failed for 13 stones. There 7.5 F flexible ureteroscopes of various brands were used.

RESULTS

All patients were operated under general anaesthesia. Antegrade ureteroscopy was performed in 2 patients. Advancement of the ureteroscope was considered to be difficult in 5 cases, including the 2 antegrade cases. 13 stones were fragmented by hydroelectric waves. The mean duration of ureteroscopy was 40 +/- 15 min. The mean hospital stay was 2.8 +/- 1 days. There was no intraoperative or perioperative morbidity. Ureteroscopy was considered to be successful in 27 cases (82%) and a failure in 6 cases: fragmentation: 3 and progression: 3. Fifteen patients were reviewed after more than one month (3 +/- 2 months) with no morbidity.

CONCLUSION

Ureteroscopy with flexible mini-ureteroscopes is an effective, reproducible and minimally traumatic diagnostic and therapeutic technique. It is particularly useful for lesions situated above the iliac vessels and is indicated for diagnostic assessment and stones, but also upper tract malformations and strictures.

[Pelvic endometriosis with urologic involvement. Therapeutic principles: apropos of 2 cases]

The authors report 2 clinical cases of vesicopelvic endometriosis. The urinary symptoms and the radiological appearance of endometriosis of the bladder are nonspecific. The diagnosis was established by histological examination of the resection specimen. The authors describe the therapeutic approach based on radical surgery designed to eradicate the endometriosis, while remaining as conservative as possible in order to allow subsequent pregnancy, and the place of urological surgery combined with medical treatment with LHRH analogue.

Kinetics of postbiopsy levels of serum free prostate-specific antigen and percent free prostate-specific antigen

OBJECTIVES

We evaluated the effects of transrectal ultrasound-guided biopsy of the prostate on serum total and free prostate-specific antigen (PSA) and the free/total PSA ratio and factors affecting variations in PSA levels.

METHODS

Serum total and free PSA levels and the free/total PSA ratio were determined in 48 men (mean age 66+/-7 years) before and 1 hour, 8 days, and 30 days after prostate biopsy. At least six cores were taken using a biopsy gun with an 18-gauge needle. The coefficient of variation of PSA was calculated as the postbiopsy/prebiopsy PSA ratio. Changes in PSA levels and the coefficient of variation were studied.

RESULTS

Fifteen (31%) of 48 men had adenocarcinoma on biopsy. Total and free PSA values were significantly increased 1 hour and 8 days after biopsy, and both returned to baseline 30 days after biopsy. The free/total PSA ratio was significantly increased (55%) 1 hour after biopsy and significantly decreased (12%) 8 days after biopsy. Thirty days after biopsy, the median of the free/total PSA ratio (18%) was not significantly different from the prebiopsy ratio (16%). The median of the coefficient of variation of the free/total PSA ratio was 3, 0.7, and 1 at 1 hour, 8 days, and 30 days after biopsy, respectively. Age, prostate volume, number of cores, and digital rectal examination and histologic findings were not significantly associated with variation in percent free PSA. Variation in percent free PSA at day 8 was associated with prebiopsy total PSA value and the free/total PSA ratio.

CONCLUSIONS

Prostate biopsy dramatically alters the percent free PSA. The free/total PSA ratio was decreased 8 days after biopsy and returned to prebiopsy levels in 75% of patients at 1 month after biopsy. Measurement of free PSA levels and the free/total PSA ratio should not be done within 4 weeks of prostate biopsy.