Comparison of contemporary transcatheter heart valve prostheses: data from the German Aortic Valve Registry (GARY)

BACKGROUND

Various second-generation transcatheter heart valve (THV) prostheses with high clinical efficacy and safety are available, but there is limited large-scale data available comparing their hemodynamic performance and clinical implications.

OBJECTIVE

To compare the hemodynamic performance and short-term clinical outcome of four second-generation THV prostheses.

METHODS

24,124 patients out of the German Aortic Valve Registry who underwent transfemoral transcatheter aortic valve implantation (TAVI) (Evolut™ R n = 7028, Acurate neo™ n = 2922, Portico n = 878 and Sapien 3 n = 13,296) were included in this analysis. Propensity-score weighted analysis was performed to control for differences in age, left ventricular function, STS score and sex. Primary endpoint was survival at one-year, secondary endpoints were 30 days survival, pre-discharge transvalvular gradients, paravalvular leakage and peri-procedural complications.

RESULTS

Thirty-day and one-year survival were not significantly different between the four patient groups. Transvalvular gradients in Evolut™ R and Acurate neo™ were significantly lower as compared to Portico and Sapien 3 at hospital discharge. This difference exists across all annulus sizes. Paravalvular leakage ≥ II occurred significantly less often in the Sapien 3 group (1.2%, p < 0.0001). Rate of severe procedural complications was low and comparable in all groups. Permanent pacemaker implantation rate at one year was lowest in the ACUARATE neo group (13.0%) and highest in the Evolut™ R group (21.9%).

CONCLUSION

Albeit comparable short-term clinical outcomes there are certain differences regarding hemodynamic performance and permanent pacemaker implantation rate between currently available THV prostheses which should be considered for individual prosthesis selection.

Trend analysis and regional tumor incidence in Germany for testicular cancer between 2003 and 2014

BACKGROUND

Testicular germ cell tumor (TGCT) is one the most common solid tumors in men between the age of 15 and 35 with an overall incidence rate of 1-1.5 %. Epidemiologic studies have demonstrated different incidence patterns in western civilized countries with overall rising incidence trends.

OBJECTIVE

To analyze differences in regional tumor incidence rates for TGCT and perform a trend analysis for TGCT between 2003 and 2014 in Germany.

MATERIAL AND METHODS

TGCT cases in Germany which were diagnosed between 2003 and 2014 were provided by the Robert-Koch-Institute, Berlin. For statistical analysis, cluster and spatial scan tests according to Kulldorff were used for cases with seminoma and non-seminoma. Results are presented in administrative districts and graphically illustrated. We performed a trend-analysis in order to evaluate age-adjusted incidence trends in Germany. Tests were two-sided with a level of significance of α=0.05.

RESULTS

In total we included 35,066 patients. Overall, 22,634 cases had newly diagnosed seminoma and 12,432 were diagnosed as non-seminoma. Maximum incidence of seminoma and non-seminoma was observed for age-group 38-40 years and 26-28 years, respectively. No second peak for the incidences of seminoma and non-seminoma with respect to age were observed. Cluster analysis revealed areas with high and low incidence rates as well as slightly different spatial distribution in Germany between seminoma and nonseminoma. Furthermore, there was no significant increase in age-adjusted incidence rates over the reviewed time period in both cohorts.

DISCUSSION

In this study differences in reginal tumor incidence rates for seminoma and non-seminoma are reported with both tumor entities revealing distinct clusters. Furthermore, tumor incidence trends for seminoma and nonseminoma between 2003 and 2014 were stable which might indicate the beginning of a plateau phase for TGCT incidence rates in Germany.

CONCLUSION

In this analysis we were able to identify regions with significantly higher tumor incidence rates for both seminoma and non-seminoma which were specific for these two subtypes. Furthermore, trend analysis revealed a steady incidence rate for testicular cancer in Germany.

First isolation of Yersinia entomophaga in human urinary tract

Yersinia entomophaga is an insect pathogen first isolated from larvae of Coleoptera in New Zealand in 2011. We report here the first isolation of Y. entomophaga from human urine. Using whole-genome sequencing, we confirmed the presence of specific chromosomal virulence genes and identified a plasmid harbouring a quinolone resistance gene.

Insufficient Vitamin D Response to Solar Radiation in German Patients with Type 2 Diabetes or Gestational Diabetes

Vitamin D deficiency is highly prevalent in all forms of diabetes mellitus. Recently, we reported how ultraviolet B (UVB) radiation affected vitamin D [25(OH)D3] concentrations in patients with type 1 diabetes. Our aim was to analyze whether patients with non-autoimmune diabetes, such as type 2 diabetes mellitus (T2DM) and gestational diabetes mellitus (GDM) also show the same vitamin D profile in relation to environmental factors including ambient temperature as an indirect parameter for outdoor activities. We analyzed 25(OH)D3 concentrations of T2DM (n=349) and GDM patients (n=327) at the University Hospital Frankfurt from 2005 to 2007. Additionally, daily UVB and monthly outside air temperature measurements for Frankfurt/Germany were obtained. We detected a positive correlation between UVB irradiation and 25(OH)D3 concentrations of T2DM and GDM patients (rho=0.50 and rho=0.63, p=0.003 and p<0.0001, respectively). UVB irradiation was in summer (April-October) higher than in winter (November-March) (5.6 kJ/m² vs. 0.5 kJ/m², p<0.0001). However, the prevalence of vitamin D deficiency in summer remained high with 76% in T2DM and 59% in GDM. In a stepwise regression analysis for the 25(OH)D3 concentration, significant predictors were outdoor temperature (estimate=0.02, p<0.0001), UVB radiation (estimate=-0.0015, p=0.02), year (2006 vs. 2005 estimate=-0.06, p>0.05, 2007 vs. 2005: estimate=-0.13, p<0.0001) and diabetes type (estimate=0.06, p=0.03). In conclusion, the strong correlation between UVB radiation and 25(OH)D3 concentrations in T2DM and GDM patients determines the seasonal variation. Additional determinants for the 25(OH)D3 concentrations were outdoor temperature, year, and diabetes type. Despite the effects of solar radiation both patients groups remain largely vitamin D deficient during summers.

[Sexual function after transobturator tape procedure for stress urinary incontinence and overall patients' satisfaction]

OBJECTIVE

To evaluate the quality of sexual activity after a transobturator tape procedure for urinary incontinence and to examine the global satisfaction reported by patients.

MATERIALS AND METHODS

This is a bicentric retrospective study, postoperative questionnaires were sent to 247 women operated for urinary incontinence by TOT/TVT-O surgery, after 1 year, prolaps were excluded. Patients' overall improvement was assessed using the French version of Patient Global Impression and Improvement (PGI-I), urinary symptoms were assessed with the use of ICIQ-Fluts and quality of sexual function using Lemack and Zimmern questionnaire and ICIQ-Fluts-Sex. A logistic regression analysis was run to analyse the factors associated with women overall improvement.

RESULTS

One hundred and sixty-five patients answered the questionnaire (66.8%). Average age was 55 (±11), and the average postoperative period was 39 months (±17.9). After surgery, according to the

PGI-I

135 women (81.8%) found an overall improvement, 22 (13.4%) found their condition unchanged and 8 (4.8%) women found it worse. Among the 165 women, 118 were sexually active, 37 (31.4%) reported improvement in intercourse satisfaction whereas 11 (9.3%) complained about sexual function deterioration and 70 (59.3%) felt unchanged. The 37 women who reported sexual improvement described decreased coital incontinence in 54% of the cases. Eleven women who felt sexually worse, reported dyspareunia. Results of the logistic regression analysis suggested that overall improvement after surgery depended not only on the incontinence score (OR 0.83) but also on the quality of the postoperative sexual activity (OR 12.96).

CONCLUSION

One third of the women reported improvement of their sexuality after transobturator tape procedure. In fact, global satisfaction after surgery was as related to the improvement of urinary symptoms as it was to the quality of the sexual activity.

LEVEL OF EVIDENCE

5.

Does machine perfusion decrease ischemia reperfusion injury?

In 1990's, use of machine perfusion for organ preservation has been abandoned because of improvement of preservation solutions, efficient without perfusion, easy to use and cheaper. Since the last 15 years, a renewed interest for machine perfusion emerged based on studies performed on preclinical model and seems to make consensus in case of expanded criteria donors or deceased after cardiac death donations. We present relevant studies highlighted the efficiency of preservation with hypothermic machine perfusion compared to static cold storage. Machines for organ preservation being in constant evolution, we also summarized recent developments included direct oxygenation of the perfusat. Machine perfusion technology also enables organ reconditioning during the last hours of preservation through a short period of perfusion on hypothermia, subnormothermia or normothermia. We present significant or low advantages for machine perfusion against ischemia reperfusion injuries regarding at least one primary parameter: risk of DFG, organ function or graft survival.

The impact of antihyperlipidemic drugs on the viral load of patients with chronic hepatitis C infection: a meta-analysis

Several studies investigating the role of statins and fibrates in chronic hepatitis C virus (HCV) infection offered so far conflicting evidence regarding the antiviral potency of these medications, whereas combination of these drugs with pegylated interferon and ribavirin improved in some trials therapeutic outcome. We conducted a literature search to identify trials that included monoinfected HCV patients, treated with statins or fibrates as monotherapy with the primary end point of our meta-analysis being the quantitative change of HCV-RNA induced by these medications. Logarithmic changes of the viral load (ΔlogVL) and confidence intervals (CIs) were calculated according to the DerSimonian-Laird estimate. Statistical heterogeneity was assessed with the I² statistic. We identified eight observational studies that evaluated the potency of bezafibrate and different statins as monotherapy to induce a significant reduction of HCV-RNA in HCV-monoinfected patients (n = 281). Overall, a significant reduction of viral load with mean 0.19 [log10 IU/mL] (95%-confidence interval, (CI) 0.11-0.28) could be observed when antihyperlipidemic medications were administered. Bezafibrate featured the highest antiviral efficacy (0.45 log10 reduction, 95%-CI, 0.17-0.72) among all medications and fluvastatin (0.20 log10 reduction, 95%-CI, 0.09-0.31) among all statins tested. Based on meta-analysis, fibrates and statins induce a reduction of HCV viral load. We suggest that the addition of statins and fibrates to antiviral regimes, especially in HCV patients with concomitant dyslipidemia, could beside the established reduction of cardiovascular risk increase the potency of antiviral therapy.

Time trend of UVB irradiation and the vitamin D concentration in German type 1 diabetes patients

BACKGROUND

Type 1 diabetes (T1D) is an autoimmune disease which is characterised by the destruction of insulin-producing beta cells in human pancreas leading consequently to a hyperglycaemic metabolism. Recent studies have shown that low cholecalciferol (25(OH)D3) concentrations may contribute to the development of T1D. The 25(OH)D3 status depends mostly on human skin production influenced by exposure to UVB radiation. Our intention was to examine whether there was a change in UVB radiation in the past years and if this has an impact on patients' vitamin D status.

METHODS

We analysed the 25(OH)D3 concentration of blood samples from 287 T1D patients in the years 2004-2007 at the University Hospital Frankfurt. Moreover, daily UVB irradiation data of this time were received. Wilcoxon-Mann-Whitney test and Spearman correlation test were used for statistical analyses.

RESULTS

We observe a strong correlation between UVB irradiation and the 25(OH)D3 concentration of German T1D patients (correlation coefficient=rho=0.56, p=7×10(-3)). Moreover, 25(OH)D3 blood levels obtained in summer (Apr-Oct) were significantly higher than in the winter season (p=8×10(-3)). In the years 2004-2007 there was a significant decline of UVB radiation in the summers (rho=-0.21, p<10(-6)) but no change was found in (rho=-0.07, p=0.12). This corresponds to a significant decrease of 25(OH)D3 levels in T1D patients over the summers (rho=-0.24, p=2×10(-3)) but not in winters (rho=-0.03, p=0.73).

CONCLUSION

Our results reveal a significant correlation of UVB irradiation and the vitamin D concentration of German T1D patients. A decrease of UVB irradiation over the summers 2004-2007 is accompanied by a decline of 25(OH)D3 levels observed in those summer months which may indicate a local time trend requiring further investigation into the environmental factors of vitamin D deficiency. This article is part of a Special Issue entitled 'Vitamin D Workshop'.

Concentration and chain length of polyethylene glycol in islet isolation solution: evaluation in a pancreatic islet transplantation model

To improve graft preservation and consequently reduce conservation injuries, the composition of preservation solution is of outmost importance. It was demonstrated that the colloid polyethylene glycol (PEG), used in SCOT solution, has protective effects on cell membranes and immunocamouflage properties. The aim of this study was to optimize the concentration and chain length of PEG to improve pancreatic islet preservation and outcome. In a model of murine islet allotransplantation, islets were isolated with SCOT containing various concentrations of PEG 20 kDa or 35 kDa. Better islet yield (IEQ) was obtained with SCO +PEG at 15-30 g/L versus other PEG concentrations and control CMRL-1066 + 1% BSA solution (p < 0.05). Allograft survival was better prolonged (up to 20 days) in the groups SCOT + PEG 20 kDa 10-30 g/L compared to PEG 35 kDa (less than 17.8 days) and to control solutions (less than 17.5 days). In terms of graft function recovery, the use of PEG 20 kDa 15-30 g/L induced no primary nonfunction and delayed graft function contrary to CMRL-1066 and other PEG solutions. The use of the extracellular-type solution SCOT containing PEG 20 kDa 15 g/L as colloid could be a new way to optimize graft integrity preservation and allograft outcome.

Differentiation between benign and malignant adrenal mass using contrast-enhanced ultrasound

PURPOSE

Adrenal masses can be detected by ultrasound with high sensitivity and specificity. The aim of the present study was to evaluate CEUS in a large patient population using CEUS patterns identified in a previous pilot study.

MATERIALS AND METHODS

116 adrenal masses were evaluated by ultrasound, including CEUS with the contrast agent Sonovue®. The dynamic of contrast enhancement (CE) was analyzed using time-intensity curves. The time of the first CE in the adrenal mass was used to define four CEUS patterns: pattern I = early arterial CE, pattern II = arterial CE, pattern III = late CE, pattern IV = no CE. In addition, all patients received CT/MRI and hormonal testing. In suspicious cases biopsy or adrenalectomy was performed.

RESULTS

CEUS patterns I&II were seen in all patients with primary or secondary malignant lesions of the adrenal gland (n = 16). The sensitivity and specificity of CEUS for the diagnosis of malignant adrenal mass were 100 % (CI [75;100]) and 67 % (CI [56;75]), respectively. Overall histology was available as a reference method for 40 adrenal masses. In 68 % of histologically diagnosed adrenal masses, MRI/CT and CEUS were congruent concerning the characterization of malignant versus benign adrenal mass.

CONCLUSION

Contrast-enhanced ultrasound may be a useful method in the diagnostic work-up of adrenal mass with excellent sensitivity for the diagnosis of malignancy.

A glucuronidation pathway of capecitabine occurs in rats but not in mice and humans

Glucuronidation of 5'-DFCR, a metabolite of capecitabine, was confirmed in experimental models from rats whereas 5'-DFCR glucuronide was detected neither in bile or liver from mice nor in liver microsomes from human. Metabolic interactions at the level of the glucuronidation pathway between CAP and other drugs are unlikely in patients.

Polyethylene stent blockage: a porcine model

BACKGROUND

Endoscopic insertion of biliary stents is a useful treatment for obstructive jaundice resulting from unresectable tumors of the pancreas and biliary tree. The main drawback is the recurrence of jaundice due to clogging. The aim of this study was to establish an experimental model of polyethylene stent clogging in large white pigs.

METHODS

A straight polyethylene stent of 5F (group I), 7F (group II) or 10F size (group III) was inserted in the common bile duct. Animals were killed at 2 months, or earlier if physical signs suggesting stent clogging occurred. Chemicophysical analysis of stent deposition combined stereomicroscopy and identification of the contents by means of Fourrier transform infrared spectroscopy. Bacteriologic analyses included identification of aerobic and anaerobic bacteria and measurement of beta-glucuronidase, lecithinase and lipase activities.

RESULTS

Physical signs suggesting stent obstruction or death occurred in 8 of 8 animals in group I, 11 of 12 in group II, and 2 of 8 in group III (p < 0.001). The proportion of mucoprotein in the stent contents tended to fall with increasing stent diameter (mean 82%, 58% and 47% for 5F, 7F and 10F, respectively), whereas wheat starch and calcium bilirubinate content increased with increasing stent diameter (9% and 4%, 18% and 10%, and 29% and 23% for 5F, 7 F, and 10F, respectively), although none of these differences were statistically significant. A variety of bacteria were cultured from the stent deposits, including anaerobic strains. Clostridium species were associated with the highest enzyme activities.

CONCLUSIONS

In this model the major component of early stent deposits was mucoprotein, and numerous aerobic and anaerobic bacteria were isolated. Formation of calcium bilirubinate was a late phenomenon and poorly related to bacterial enzymatic activities.

BTA stat and BTA TRAK: A comparative evaluation of urine testing for the diagnosis of transitional cell carcinoma of the bladder

OBJECTIVE

We compared the BTA (bladder tumor antigen) stat test with the BTA TRAK assay in patients highly suspicious of bladder cancer.

METHODS

The BTA stat and the BTA TRAK tests are two immunoassays that detect human complement factor H related protein in urine, employing the same antibody pair. The BTA stat is a qualitative test which can be performed in a consultation setting. The BTA TRAK is a quantitative test that is performed in the laboratory. Consecutive patients highly suspicious of bladder cancer were included in this prospective blinded trial to assess the clinical performances of the two methods.

RESULTS

A total of 81 patients were tested using BTA stat and BTA TRAK before cystoscopy. A tumor was identified in 49 patients. BTA TRAK (38/49 true-positive cases) was more sensitive than BTA stat (32/49) in detecting bladder cancer (p < 0.05). When considering the subgroups of bladder cancer by stage and grade, the difference remained significant for low-grade and low-stage tumors. There was no significant difference between BTA TRAK and BTA stat as regards specificity (20/32 and 23/32 true-negative cases, respectively; p = 0.2).

CONCLUSION

BTA TRAK with a cutoff of 14 U/ml had a significantly higher sensitivity than BTA stat in the detection of low-grade and low-stage bladder cancer.

[Technique for protecting the liver graft less tolerant than the small bowel to heat-induced ischemia in experimental liver + small bowel transplantation in swine]

Multivisceral and orthotopic liver/small bowel transplantations have been performed to treat patients with intestinal failure associated with liver failure induced by parenteral nutrition. The aim of this experimental study was to determine the experimental liver-small bowel harvesting and transplantation technique that achieves the best compromise between liver and intestine ischemia times in pigs. Initial portal revascularization of the liver which reduces the hepatic warm ischemia time after cold ischemia preparation of the graft immersed in lactated ringer's solution at 4 degrees C, reduce the risk of primary non function of the graft.

[Renal cancer and late pancreatic metastases. Apropos of 3 cases and review of the literature]

Renal cell carcinoma is a malignant epithelial tumour which can always give rise to metastases, usually situated in the lungs, bone and liver. In contrast, pancreatic metastases are exceptional and can occur late. The authors report three cases of metachronous pancreatic metastases, 1, 4 and 10 years after nephrectomy. The procedures performed consisted of Whipple procedure, tumour excision and total duodenopancreatectomy. Although rare when isolated to the pancreas, these metastases can justify even audacious pancreatic resection.

[Ureterosigmoidostomy after total cystectomy in cancer. Long-term results. Apropos of 60 cases]

OBJECTIVES

Restoration of continuity of the urinary tract after total cystectomy deserves discussion even if most authors currently opt for bladder replacement or transileal cutaneous diversion. Diversion into the colon, which was used for a long time, has possibly been unjustly abandoned.

METHODS

From 1974 to 1995, sixty patients (116 renal units) underwent cystectomy for cancer, followed by systematic ureterosigmoidostomy when age and local conditions allowed. The mean age of the patients (52 men and 8 women) was 60 years. They were reviewed at least every six months and surveillance consisted of annual clinical and laboratory examinations and intravenous urography for 5 years. Evaluation of the functional results and quality of life was based on the information recorded in the patients' files and on the answers to a questionnaire for the 19 patients alive without recurrence.

RESULTS

The median follow-up was 80 months. Thirty seven patients have died, 23 (38.38%) of them from bladder cancer. Forty patients (66.6% had an uneventful immediate postoperative course. The major late complications were septic reflux in the upper urinary tract stenosis of the ureteric reimplantation and febrile urinary tract infections, requiring either repeat reimplantation or another diversion. Nocturnal (82%) and diurnal (85%) continence was good and 17 of the 19 patients alive with no signs of recurrence are satisfied with their lifestyle.

CONCLUSION

After total cystectomy for cancer, implantation of the two ureters into the colon remains a good method of urinary diversion due to its simplicity and good tolerance sometimes at the cost of a second operation. Recent technical modifications should restore the value of this operation.

Patient tolerance of transrectal ultrasound-guided biopsy of the prostate

OBJECTIVES

To determine the acceptability by patients of ultrasound-guided prostatic biopsy without anaesthesia.

PATIENTS AND METHODS

From January 1995 to January 1996, 81 patients in our department undergoing transrectal ultrasound-guided prostate biopsy were asked to assess the tolerability of the procedure using an immediate post-operative questionnaire including a 10 cm linear visual analogue scale (VAS).

RESULTS

The mean VAS score was 3 (standard error 0.24) and 16% of the patients had a VAS score of > or = 5. Responses to the questionnaire showed that 6% of patients judged that the procedure should have been performed under general anaesthesia, while 19% would not agree to undergo it again without some form of anaesthesia.

CONCLUSIONS

Even when anaesthesia-free, transrectal ultrasound-guided prostatic biopsy was felt to be only mildly uncomfortable by most patients, but 19% judged that it should be accompanied by some form of anaesthesia. Consequently, local anaesthetic techniques to enhance tolerance to this type of intervention without sacrificing the advantages of the current out-patient setting should be reassessed.

Inflammation in benign prostatic hyperplasia: correlation with prostate specific antigen value

PURPOSE

We attempted to identify morphological parameters of benign prostatic hyperplastic inflammation that correlate with pre-biopsy prostate specific antigen (PSA) concentrations.

MATERIALS AND METHODS

Patients undergoing prostate biopsy at our department were prospectively studied between January 1995 and January 1996. preoperative blood and 24-hour urine samples were measured for PSA. Biopsy samples harboring exclusively benign prostatic tissue were graded on a 4-point scale for inflammation (0-no inflammatory cells, 1-scattered inflammatory cell infiltrate, 2-nonconfluent lymphoid nodules and 3-large inflammatory areas with confluence of infiltrate) and aggressiveness (0-no contact between inflammatory cells and glandular epithelium; 1-contact between inflammatory cell infiltrate and glandular epithelium; 2-clear but limited, that is less than 25% of the examined material, glandular epithelium disruption, and 3-glandular epithelium disruption on more than 25% of the examined material).

RESULTS

A total of 66 patients with exclusively benign prostatic tissue on prostate biopsies was analyzed. Difference between inflammation graded groups was not significant when considering serum or urinary PSA. There was a significant correlation between aggressiveness grading and serum PSA (rho = 0.51, p < 0.0001), whereas aggressiveness grading and urinary PSA did not correlate (rho = -0.06, p = 0.6).

CONCLUSIONS

Prostatic subclinical inflammation is not associated with high urinary PSA. Unless associated with glandular epithelial disruption, density of prostatic interstitial inflammatory cell infiltrate is not significantly correlated with serum PSA concentration. We believe that this issue should be considered when interpreting a prostate biopsy.

[Orbital metastasis of a prostatic cancer. A therapeutic emergency]

In the light of a case of left orbital metastasis, constituting the presenting sign of prostatic cancer in a 60-year-old man, the authors emphasize the rarity of this site, despite the high frequency of bone metastases in this disease. They discuss the diagnostic methods and stress the need for urgent treatment to save ocular function.

Patient acceptability of transurethral incision of the prostate under local anaesthesia

OBJECTIVE

To determine the acceptance by patients of transurethral incision of the prostate (TUIP) under local anaesthesia.

PATIENTS AND METHODS

The study comprised 30 consecutive patients who elected to undergo local anaesthesia for TUIP and were treated between December 1994 and September 1995. Twenty-two were considered a high risk for general anaesthesia and eight patients chose local anaesthesia for personal reasons. Patients were premedicated (opioid and benzodiazepine) and 1% lidocaine was infiltrated transurethrally using an endoscopic needle. The level of acceptance was determined using an immediate post-operative questionnaire which included a linear visual analogue scale (VAS) to rate pain.

RESULTS

No patient required conversion to another type of anaesthesia and there were no complications related to the local anaesthesia. The mean (SE) VAS score was 3.2 (1.7) and the questionnaire results showed that 83% of the patients did not consider that general anaesthesia was necessary for the operation and that 90% would agree to undergo the procedure again under local anaesthesia.

CONCLUSION

TUIP under local anaesthesia was well tolerated in motivated patients. We recommend it as the operation of choice for the relief of obstruction in high-risk patients with a small benign prostatic hyperplasia.

Radiographic prognostic criteria for extracorporeal shock-wave lithotripsy: a study of 485 patients

OBJECTIVES

We studied 485 patients treated by extracorporeal shock-wave lithotripsy (ESWL) using an ultrasound electrohydraulic apparatus in an effort to define radiographic criteria for better patient selection for ESWL.

METHODS

Results were assessed according to plain x-ray nephrotomography and ultrasound. The criteria for measuring success (stone free [SF]) excluded all residual fragments. After per-criteria analysis of the results, a multivariate analysis as well as an analysis of stone composition by infrared spectroscopy were performed.

RESULTS

The SF rate was 57.5% (279 of 485). Calculi that were smooth, denser than bone, located in the lower calyx, and larger than 15 mm had less satisfactory results despite a greater number of impulses. A correlation was established between the radiographic appearance of the calculus, its composition, and ESWL results. Rough, less dense calcium oxalate dihydrate yielded satisfactory results (65%), whereas smooth, dense calcium oxalate monohydrate led to less conclusive results (41%). Multivariate analysis demonstrated the predominant influence of radiographic calculus profile on the results: rough, less dense calculi yielded a 79.4% SF rate, whereas smooth, dense calculi yielded a 33.6% SF rate.

CONCLUSIONS

We propose that patients with dense, smooth calculi located in the lower calyx and larger than 15 mm be treated by other techniques, such as percutaneous nephrolithotomy. This would not only increase the ESWL effectiveness rate, but would also reduce the cost of treating kidney stones.

[Results of extracorporeal lithotripsy with ultrasonography-guided hydroelectric lithotriptor: study on 546 patients, prognosis factors]

OBJECTIVE

To investigate the existence of simple radiographic prognostic criteria, applicable on an outpatient basis, predictive of the result of extracorporeal lithotripsy (ECL).

METHODS

This study was based on 546 patients treated by ECL using a hydroelectric apparatus. The results were evaluated on plain nephrotomographies and ultrasonography performed at the third month. Success was defined as the elimination of all residual fragments, regardless of their size, without fragments (WF). Analysis concerned 485 files after exclusion of patients lost to follow-up. Prognostic factors were evaluated criterion by criterion, and then by multiple ascending regression multivariate analysis.

RESULTS

The fragment-free rate according to our criteria was 57.5%. Significantly poorer results were obtained for stones denser than bone (p < 0.001), smooth (p < 0.001, larger than 12 mm (p < 0.01), situated in the inferior calyx (p < 0.005), despite an increased (p < 0.005) number of ECL sessions and the number of shocks received. A correlation was established between the radiographic appearance of the stone, its predominant spectrophotometric nature (> or = 50%) and the results of ECL. Good results were obtained in 65% of spiculated, low-density Weddellite stones versus 41% of cases of dense, smooth Whewellite stones. Multivariate analysis of the predominant radiographic appearance of the stones showed that spiculated, low-density stones were completely eliminated in 79.4% of cases, and dense, smooth stones were completely eliminated in 33.6% of cases (p < 0.001).

CONCLUSION

In this study, smooth, dense stones larger than 12 mm, situated in the inferior calyx appear to be particularly resistant to ECL. On the basis of this result, the authors propose a prospective clinical trial to compare the results of ECL and primary percutaneous nephrolithotomy in this type of stone with a high risk of failure.

Systematic removal of catheter 48 hours following transurethral resection and 24 hours following transurethral incision of prostate: a prospective randomized analysis of 213 patients

The interval before removal of the catheter used in prostatic transurethral surgery depends to a great extent on the surgeon, with a frequently empirical orientation. We conducted a prospective, randomized and controlled study of 213 patients who underwent transurethral surgery for benign prostatic hyperplasia. The catheter was removed systematically 24 hours after transurethral incision and 48 hours after transurethral resection of the prostate (group 1-52 and 54 patients, respectively) or the catheterization interval was determined by each surgeon in accordance with the usual criteria (group 2-52 and 55 patients, respectively). No statistically significant differences were noted between these 2 groups in regard to complications. We conclude that systematic removal of the catheter at the aforementioned periods is cost-effective, safe and comfortable for the patient.

[The treatment of stage I malignant non-seminoma tumors of the testis without systematic lumbo-aortic dissection. Results of a study begun 20 years ago. Apropos of 21 cases]

Over a 20-year period (1971-1991), the authors have treated 75 malignant testicular tumours, corresponding to 33 seminomas and 42 nonseminomatous tumours. The latter group included 23 stage I tumours according to Peckham's classification. The authors studied the therapeutic modalities of 21 of these patgients (2 non-protocol patients excluded) treated without lumboaortic lymph node dissection. Adjuvant therapy consisted of radiotherapy alone (2 cases), radiotherapy and chemotherapy (5 cases) and chemotherapy alone (14 cases). All patients are alive in complete remission (100%) with a follow-up of at least 24 months (range: 31-222 months, mean survival: 102.2 months). In line with what they already believed in 1971, the authors consider that systematic lumboaortic lymph node dissection is not essential in the treatment of stage I nonseminomatous testicular tumours, but propose systematic adjuvant therapy. Chemotherapy (PVB or, preferably, PEB) provides a guarantee of security and good acceptability.

[A technical device for the percutaneous extraction in monobloc of various renal calculi larger than 10 mm]

The authors present a technical device consisting of a modification of the operating channel for stone extraction by percutaneous nephrostomy. For selected stones, widening of the lips of the operating channel allows the stone to be rapidly and entirely removed without the need for ultrasound or hydroelectric fragmentation, which is always associated with a risk of leaving residual fragments. The aim of this technical device is to ensure complete absence of residual fragments with a minimum of risks for the renal parenchyma.

[Percutaneous nephrolithotomy after failure of extracorporeal shockwave lithotripsy. Indications, results, perspectives]

Eighty-one of the 579 extracorporeal lithotripsies (ECL) performed between 1987 and 1992 with an ultrasound-guided hydroelectric lithotriptor required the use of another treatment modality. 53 percutaneous nephrolithotomies (PCNL) were performed in these 81 patients after failure of ECL (21 for non-fragmentation, 32 for residual fragments). The authors analyse the factors responsible for failure in order to select the more appropriate type of treatment for different types of stones. The site of the stones, their size, their radiographic appearance, their chemical composition, the number of ECL sessions and the number of days spent in hospital were compared between the PCNL and ECL groups. Smooth, homogeneous stones denser than bone and larger than 15 mm in diameter were significantly more resistant to ECL, despite an increased number of shock waves. PCNL was successful in 92% of cases of non-fragmented stones (with no residual fragments). The success rate for multiple residual fragments was 64%. In view of the risk of complications associated with residual fragments, regardless of their size, the potential risks of ECL and cost imperatives, the authors recommend that these stones, considered to be resistant, should be treated immediately by PCNL, as the results of PCNL after ECL are less satisfactory.

[Prostatic cancer between 50 and 60. A more than 20-year-long retrospective study. Apropos of 65 case reports]

Sixty five 50 to 60 year old patients have been treated for prostatic cancer over a 21 year period. Twenty four had a local prostatic cancer (A1, A2, B1, B2) and 41 (63.2%) a locally advanced or metastatic (D1, D2 disease at diagnosis. The mean age was 56 years old. As being as retrospective study, miscellaneous treatments were done. The 5 and 10 years survival, analysed with the Kaplan-Meier method, was 61% and 31% respectively. According to the stage of cancer, the 10 year survival was 72% and 5% for (A-B) and (C-D) respectively. For well differentiated tumors, 5 years survival was 67% instead of 36% for undifferentiated ones. The 10 year survival was 36% for well differentiated tumors with 6 on 8 patients who survived with a mean of 11.6 ears. The authors discussed the benefit of an early diagnosis of prostatic in the 50-60 year old men group which is 4% of the total prostatic cancer diagnosed within the same period. They analysed the influence of PSA and transrectal sonography interest at this age.

[Ectopic ureteral orifice into the seminal duct with homolateral renal agenesis: contribution of ultrasonography]

Based on an incidental case of ectopic ureteric orifice in the seminal tract associated with homolateral renal agenesis, the authors demonstrate the value of ultrasonography, particular transrectal, both for diagnosis and follow-up. Digital rectal examination is the key to the diagnosis, combined with ultrasonography and urography. The indications for surgery depend on the clinical symptoms and signs.

[Correlation between chemical composition, density, and results of extracorporal lithotripsy in renal and ureteral lumbar calculi]

Based on a series of 388 patients with a total of 466 renal and lumbar ureteric stones (414 kidneys) treated between 1987 and 1990 by extracorporeal shock wave lithotripsy (ESWL) using the SONOLITH 3000* apparatus, the authors analyse the indications and results criteria for ESWL. The success criteria adopted excluded any residual fragment and considered patients lost to follow-up as failures. The success rate varied between 48.3% and 73.8% when residual fragments less than 5 mm were included and when drop-outs were excluded. A correlation was established between the radiographic appearance of the stone (dense, smooth, spiculated), its predominant spectrophometric nature and the results of ESWL: low density, spiculated Weddellite (WD) stones gave good results and very dense, smooth Whewellite (WW) stones gave less favourable results. The authors propose a refinement of the indications for ESWL in order to improve the results. Predominantly WW stones may be suitable for primary percutaneous nephrolithotomy.

[Silica urinary calculi. Report of a case]

The authors report a case of anuria due to bilateral ureteric obstruction by silica stones in a patient taking magnesium trisilicate for many years. A review of the literature concerning silica stones is presented. The diagnosis should be suggested by the clinical history and confirmed by stone analysis. The treatment of silica stones is not specific, but must be associated with withdrawal of the drug responsible.

Immunization with immune complexes: characterization of monoclonal antibodies against a TSH-antibody complex

Monoclonal antibodies (MAb) to human thyrotropin (hTSH) were prepared by immunization of mice and rats according to different procedures. We have previously demonstrated that a specific antigenic region on the surface of the hTSH molecule was highly immunogenic; in order to produce specific MAb to weakly immunogenic regions of hTSH, we immunized mice and rats with a complex composed of hTSH and an anti-beta hTSH MAb 27 directed against the highly immunogenic region. Monoclonal antibodies elicited by this immunization procedure were highly specific and a high percentage was found complementary to the MAb 27 used in the immunogen. We did not search for anti-MAb 27 antibodies, however one hybridoma produced antibody that preferentially reacted with the immune complex. This antibody, called 515, is an IgG1 that binds the complex with 100-fold greater affinity than it does to the anti-beta hTSH MAb 27 alone. This enhancement was also observed with the Fab fragment of the MAb suggesting that the epitope recognized by this anti-complex MAb is displayed in a very different way when hTSH is bound to the first MAb.

Monoclonal antibody mapping of the antigenic surface of human thyrotropin and its subunits

Although the amino acid sequence of the alpha- and beta-subunits of glycoprotein hormones in various species has been deciphered, data on their tertiary structure are not abundant. This impedes correlation between structure and function. The availability of monoclonal antibodies to human TSH (hTSH) offers the opportunity to enumerate the antigenic determinants present on the surface of hTSH and its subunits and to examine their spatial relationships. Twenty-eight monoclonal antibodies to hTSH were obtained from several fusions, and screens carried out separately in the laboratories involved in this study. Affinities for hTSH ranged from 10(8)-10(11) M-1. Cross-reactivity with bovine TSH (bTSH), human gonadotropins (hLH, hFSH, and hCG), and the alpha- and beta-subunits of hTSH distinguished 10 groups of monoclonal antibodies (mAb) according to their main cross-reactions: 1) hTSH alpha, hLH, hFSH, and hCG; 2) hTSH alpha, bTSH, hLH, hFSH, and hCG; 3) hFSH; 4) bTSH and hFSH; 5) bTSH, hLH, and hFSH; 6) bTSH, hLH, hFSH, and hCG; 7) hTSH beta; 8) hTSH beta and bTSH; 9) hTSH beta and hFSH; and 10) hTSH beta, hLH, hFSH, and hCG. mAb were incorporated into 2-site binding assays to probe hTSH by a 28 X 28 matrix, the free alpha-subunit by a 4 X 4 matrix, and the free beta-subunit by a 18 X 18 matrix. Regarding intact hTSH, 12 different clusters of mAb were distinguished and interpreted as reflecting 12 distinct antigenic regions on the surface of the hTSH molecule. Two of them were localized on the alpha-subunit, and 6 on the beta-subunit; 4 were only expressed by the holo-hormone and, thus were designated conformational antigenic regions (alpha beta). Surface mapping of the free alpha- and beta-subunits was virtually identical to that observed with the holo-hormone. Modification of the operative conditions of mAb reacting only with holo-hTSH shows that they recognize the alpha-subunit, but not the beta-subunit of hTSH. These results indicate that 1) hTSH beta presents epitopes that are evolutionary conserved; 2) hTSH alpha presents several epitopes that are species specific and 2 that are not hormone specific; 3) dissociation of hTSH does not modify the antigenic surface expressed by both subunits when they are associated; and 4) some of the conformational determinants expressed only by holo-hTSH are more likely derived from the alpha-subunit than from the beta-subunit.

Characterization of monoclonal antibodies against human thyrotropin and use in an immunoradiometric assay and immunohistochemistry

Monoclonal antibodies were prepared against human thyrotropin. 13 different antibodies were characterized. Ten antibodies were of the IgG1 subclass. The affinities of the antibodies were in the range 10(9)-10(11) mol-1 X l. Four of them were specific for hTSH and did not react with hLH, hFSH, hCG or alpha hCG. Four reacted with these hormones and recognized the alpha subunit of hCG. One cross-reacted only with hFSH. The remaining four antibodies recognized the holo-hTSH only, and thus were designated as anti-conformational determinants. Monoclonal antibodies reacting with different antigenic determinants on the hTSH molecule defined seven clusters. Two of them were used to develop a simplified two-site sandwich radioimmunoassay in which one monoclonal antibody was immobilized on tubes (anti-beta TSH) and another (anti-alpha) labelled with 125I. This assay was highly specific and demonstrated a sensitivity level of 0.1 microIU/ml. Two monoclonal antibodies were used in immunohistochemistry and their quality and specificity was assessed in the detection of hTSH immunoreactivity in human pituitary biological sections.