[Pure primary carcinoid tumor of the testis. Apropos of a case]

The authors report a case of pure primary carcinoid tumour of the testis. This is a rare tumour which can only be diagnosed by histological examination of the resection specimen. They may be primary or metastatic, with radically different prognoses. The diagnosis of such lesions requires the search for the primary carcinoid tumour.

[A review of 72 renal artery stenoses in a series of 715 kidney transplantations in children]

In a series of 715 renal transplantations performed between 1973 and 1989, 72 cases of renal artery stenosis (RAS) in 69 children (9.7%) were managed at Hôpital Necker Enfants Malades. Forty cases of RAS were treated exclusively by antihypertensive drugs. A good result was obtained in 82.5% of cases. Thirty three transluminal angioplasties (TLA) were performed in 23 children with 26 RAS. A good clinical result was obtained in 15 children with a total of 17 stenoses, corresponding to a success rate of 65%. Transluminal dilatation of anastomotic stenoses always failed. There were no cases of transplant thrombosis. Eleven RAS were operated, including 5 after failure of TLA. Eight patients (73%) obtained a clinical improvement. There were 2 postoperative thromboses. Antihypertensive treatment must be administered in every case. If medical treatment fails, and with the exception of anastomotic stenoses, TLA should be the first-line procedure, while surgery is reserved for failures of TLA and for anastomotic stenoses.

Association between bovine collagen dermal implants and a dermatomyositis or a polymyositis-like syndrome

OBJECTIVE

To determine whether an excess incidence of dermatomyositis or polymyositis or both exist in patients treated with injectable bovine collagen implants and to characterize the clinical picture.

DESIGN

Historical cohort study (July 1980 through June 1988).

PATIENTS

Patients were identified from personal experience or adverse reaction reports received by the manufacturer.

SETTING

An 8-year period in the United States during which approximately 345,000 patients received implants.

RESULTS

Eight patients with dermatomyositis and an additional patient with polymyositis were identified from approximately 345,000 patients receiving injectable bovine collagen implants from July 1980 through June 1988. The nine patients with dermatomyositis or polymyositis were diagnosed an average of 6.4 months (range, 0.7 to 24.9 months) after collagen implant or skin test exposure or both. Eight of the nine patients had a delayed-type hypersensitivity response at the test or treatment sites or both, and five of six patients tested were found to have increased serum antibodies to collagen. Compared with the general population, the incidence of dermatomyositis or polymyositis among collagen-treated patients was statistically increased (standardized incidence ratio, 5.05; 95% CI, 2.31 to 9.59; P < 0.0001). A similar analysis of the eight dermatomyositis case patients produced a standardized incidence ratio of 18.8 (CI, 8.1 to 37.0; P < 0.0001). Using a Monte Carlo simulation, an interval of 6.4 months or less from exposure to onset of disease was found to be an extremely rare event, occurring less than 72 times per one million simulation trials (CI, 57 to 91).

CONCLUSIONS

Because these data suggest that an immunologic response to bovine type I or type III collagen or both caused this dermatomyositis or polymyositis-like syndrome, the risks versus benefits for the cosmetic use of collagen implants should be reassessed.

[Epididymitis disclosing an idiopathic urethroseminal reflux in children]

Idiopathic urethroseminal reflux is exceptional in children. In both of our cases, it presented in the form of epididymitis and was confirmed by suprapubic cystography, which also eliminated an obstructive cause and any associated malformations. Long-term antiseptic treatment prevented recurrent infections.

Extracorporeal lithotripsy of ureteric calculi using the Dornier HM-3 lithotriptor

Over a 5-year period (November 1984-November 1989), we treated 356 patients with ureteric calculi; 170 were treated by extracorporeal shock wave lithotripsy (ESWL) on a Dornier HM-3 lithotriptor. The calculi (n = 176) were uniformly distributed along the length of the ureter: 44 were just below the pelviureteric junction, 59 were lumbo-iliac, 42 were in the upper bony pelvis and 32 in the lower bony pelvis. The mean diameter of the upper ureteric calculi was 10 mm and for the others it was 8 mm. Thirty-four patients with acute obstructive pyelonephritis required pre-ESWL drainage of the urine. X-ray localisation required intravenous urography during lithotripsy in 52 cases (30%). On plain X-ray the following day 170 stones (96%) were judged to have disintegrated. The 6 patients whose stones were not fragmented received further treatment (ureterotomy (4) and ureteroscopy (2)). Five patients required additional treatment because of pain or fever (catheterisation (3) and ureterotomy (2)) and 2 patients had a second lithotripsy owing to insufficient fragmentation. Four patients were lost to follow-up. In 153 patients (90%) the fragments were eliminated completely, 146 in the first month and the remainder before the sixth month. No serious sequelae were observed. In addition to the 5 patients who required supplementary treatment. 11 patients with pain or fever needed medical treatment. We recommend first intention in situ ESWL for all ureteric calculi.

[Posterior urethral valves in newborns and infants. Treatment and clinical course]

Severe forms of posterior urethral valve are essentially seen in neonates and infants. In 6 neonates under the age of 3 months, the predominant presenting features were a deterioration in the general status and renal failure. Transurethral section of the valves, after urinary drainage for an average of one month, restored patency of the lower urinary tract in every case. All children have persistent renal failure, which is moderate or severe in 4 cases. In 6 infants between the ages of 3 and 11 months, the clinical presentation was dominated by signs of infection. Section of the valve was able to be performed earlier, with subsequent urethral stricture in one case. Five infants, initially presenting with renal failure, have persistent moderate renal failure. The degree of obstruction accounts for the severity of the uropathy and its early clinical presentation. The renal prognosis is poor and related to the uretero-renal consequences of the valve as well as associated renal dysplasia.

[Cutaneous trans-jejunal ureterostomy: an original technique used in 29 patients]

The authors report an original technique of transintestinal cutaneous diversion using the jejunum A 10 to 15 cm segment of jejunum is raised from the second loop and is attached to the skin transperitoneally. The stoma lies below the ureterojejunal anastomosis and the two ureters, sutured according to Wallace's technique, are implanted end-to-end into the proximal and extraperitonealised end at the height of the sacral promontory. 29 patients have been treated by this technique for various indications: 21 bladder tumors, 5 neurogenic bladders, 1 bladder exstrophy, 1 cervical cancer, 1 prostatic cancer. 15 patients (52%) had previously received pelvic irradiation. The mean follow-up was 47 months (2-192 months) and the mortality was zero. 4 patients (13.8% developed early complications: 2 cases of urinary tract obstruction and 2 intestinal obstructions requiring 3 operations. 6 patients developed 7 minor late complications (24.1%): 2 cases of pyelonephritis, 4 cases of renal stones, only one of which required an operation, and 1 case of prolapsed stoma. None of the patients developed any alteration in renal function or dilatation of the upper urinary tract after the operation. The addition of sodium bicarbonate was found to be useless, as none of the patients developed any metabolic disorders. Transjejunal cutaneous ureterostomy achieves excellent drainage by means of a short graft with a stoma situated below the level of the ureteric implantation, as reflected by the absence of any long-term deterioration in renal function despite full lumen ureterojejunal implantation without an antireflux device. This technique is simple to perform and is indicated in all situations, particularly after pelvic irradiation. It is associated with low morbidity, no mortality and ensures an excellent long-term result.

[Isolated and unilateral malacoplakia of the upper urinary tract. Apropos of a case]

Malakoplakia, strictly unilateral and localised to the upper urinary tract, is a rare presentation of this uncommon inflammatory disease. In this 53 year old woman, the disease presented in the form of a tumour of the left upper urinary tract. Radical nephroureterectomy was performed and histological examination of the resection specimen revealed the diagnosis.

Tumors of the upper urinary tract: 10 years of experience

We reviewed 108 patients with upper urinary tract tumors who underwent surgical treatment during a 10-year period (87 men and 21 women with a mean age of 63.5 years). Of the tumors 97% were unilateral and only 3 patients had bilateral tumors. Two-thirds of the patients had a single tumor focus and a third had 2 or more tumor foci. Additionally, there were 31 patients (28.7%) with previous and/or simultaneous bladder tumors. Nephroureterectomy was performed in 92 cases, nephrectomy in 6 and a conservative operation in 13. In 65 cases lymphadenectomy was added. The survival rates at 5 and 10 years were 67 and 65%, respectively. Of the patients 90% with cancer-related deaths had high grade tumors. Of the 15 patients with positive lymph nodes 87% died of metastasis compared to 8% of the 50 patients with negative lymph nodes. Nine patients (8.7%) had relapse in the upper urinary tract, 6 (5.8%) in the ipsilateral ureter and 3 (2.9%) in the contralateral ureter. Of these 3 patients 2 had recurrent multifocal bladder tumors. For patients who present with an upper urinary tract tumor the risk of a bladder cancer was approximately 9% and that of a contralateral urothelial tumor was 1%.

[Prostatic specific antigen (PSA). Interpretation of results as a function of the assay method]

The authors compare the two PSA assay methods most widely used in France. The first method (RIA Baxter) uses an isotope marker (Iodine 125), the other (EIA Biotrol) uses an enzymatic marker (alkaline phosphatase). PSA was assayed by means of these two techniques in 2 groups of patients: one group of 49 men considered to be free of any prostatic disease, recruited from blood donors; another group of 87 male patients in whom a PSA assay was performed prospectively at the first urology outpatients visit. The two PSA assay techniques gave different results, but the values obtained by these two methods were not discordant. It is therefore possible to define a coefficient of proportionality of 1.47 regardless of the PSA concentration or the urological disease considered (EIA Biotrol x 1.47 = RIA Baxter).

[Do posterior urethral valves alter the results of renal transplantation in children?]

The authors conducted a retrospective study based on a series of 715 renal transplantations in children performed between January 1973 and December 1989 at the Hôpital Necker-Enfants Malades in order to determine whether the long-term result of renal transplantation was as good in children with posterior urethral valves (PUV) as in children with a normal lower urinary tract. Group 1 consisted of 50 renal transplantations performed in 41 children in whom the primary urological disease was PUV. The bladder was able to be used without modification in 36 cases and had to be enlarged in 5 cases. A permanent cutaneous urinary diversion was not required in any of these transplanted patients. Group 2 consisted of 665 renal transplantations performed in children without PUV. There was no significant difference between the two groups in terms of the distribution of cadaver kidney and living related donor transplantations. Immunosuppressive treatment consisted of various combinations of prednisone, azathioprine, ALS for the earlier patients in the series, OKT 3 and cyclosporin for the more recent patients. In group 1, we observed a urological complication rate of 20% and a vascular complication rate of 14%, while, in group 2, the urological complication rate was 16.9% and the vascular complication rate was 9.5%. The actuarial 5-year and 10-year graft survival rates were 63% and 49% in group 1 and 63% and 49% in group 2, respectively. The actuarial graft survival rates were therefore identical in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Urethral stricture in children. Long term results of surgical treatments]

Thirty-six urethral strictures were treated between 1977 and 1984. Three strictures were considered to be congenital, eleven were traumatic and twenty-two were iatrogenic. The authors performed twenty five internal urethrotomies, twelve resection-sutures of the urethra and eleven urethroplasties including eight patch grafts with a pedicle derived from scrotal or penile skin, a tubed pedicle scrotal skin flap, one Jurascek urethroplasty and one Leveuf urethroplasty. Internal urethrotomy only gave 50% of good results and is now reserved for short strictures less than one centimetre in length. Resection-suture is an excellent operation which should be reserved for strictures less than two centimetres in length: it gave 84% of good results. One of the various types of pedicle cutaneous urethroplasty is certainly the best operation for long strictures: it gave more than 90% of good results in the present series.

A multicenter, double-blind, placebo-controlled trial of the efficacy of prazosin in the treatment of dysuria associated with benign prostatic hypertrophy

An 8-center, double-blind, placebo-controlled trial of 39 patients with benign prostatic hypertrophy was conducted to assess the effects of prazosin HCl treatment on functional urologic variables after a treatment period of 4 weeks. The randomized groups were comparable for demographic variables and symptoms, except for the mean residual urinary volume, which was significantly higher in the prazosin HCl group. Prazosin HCl elicited statistically significant improvements in the mean prostatic urethral pressure and prostate area (Mann-Whitney U test: p = 0.001 for both variables as compared with the placebo group). Functional bladder capacity also improved significantly in the group receiving the test drug (Mann-Whitney U test: p = 0.05, as compared with the placebo group). Clinical improvements were also observed in the mean maximum urinary flow, decreased nocturia frequency, and residual urinary volume. Patient preference significantly favored the prazosin HCl treatment (Mann-Whitney U test: p = 0.001). Seven patients on prazosin HCl and 5 receiving placebo reported one or more side effects during the trial phase; these were mild to moderate and disappeared or were tolerated. No statistically significant effects on blood pressure or heart rate were observed.

Suction lipoplasty: biohazardous aerosols and exhaust mist--the clouded issue

With the increased popularity of suction lipoplasty procedures, attention has been focused on their safety. One significant concern involves the rotary vane aspirators used to provide the suction required for the procedure. A series of experiments was carried out to determine whether aerosols are produced during the use of a rotary vane aspirator, since aerosols are known to be hazardous under appropriate conditions. Using a viable strain of Pseudomonas aeruginosa, we challenged the system through the suction port, and the exhaust from the aspirator was then cultured in a particle sampler. Results indicate that viable pathogens are released from the exhaust in physiologically significant particles capable of penetrating to the level of the alveolus in the normal human lung. These infectious particles were produced for 3 hours after the initial challenge. When an appropriate filtration device was attached to the aspirator outflow, the aspirator pump and environment were protected. In the absence of an appropriate filtration device, the aerosolized particles may constitute a hazard to patients or medical workers in the vicinity of the aspirator.

Genital tract reconstruction in a patient with congenital absence of the vagina and hypoplasia of the cervix

A 15-year-old female presented with congenital absence of the vagina and a blind ending hypoplastic cervix. The uterine cavity appeared normal by ultrasound examination, and the patient experienced molimina. Cognizant of risks and failures of described attempts at correction, reconstruction was performed using a series of stents covered with skin grafts. At 21 months postoperatively, the patient now has a functioning vagina and menstruates regularly. The desire to avoid a hysterectomy coupled with new alternatives in the management of the infertile patient resulted in the approach described.

Prostatic and membranous urethrorectal fistulas: a new technique of surgical closure

We report on a quick, safe and simple procedure, the anterior perineal trans-anorectal approach, which was used successfully to treat 2 difficult cases of prostatorectal and membranous urethrorectal fistulas. This method was devised after a review of all techniques to treat these fistulas, which are known to be difficult. Our 2 cases, like others, demonstrate the harmlessness of anterior section of the anal sphincter, provided the sphincter is repaired correctly. This approach should be used in patients with urethroprostatorectal pathological conditions for whom a perineal access is contemplated.

[Mortality and morbidity after total cystectomy for cancer]

The authors review mortality and morbidity in 100 consecutive patients who during a six year period underwent total cystectomy for carcinoma of the bladder. The postoperative mortality was 15 (15%), essentially as a result of septic and respiratory complications. In relation to the type of diversion: 6 deaths in 46 cases of cutaneous ureterostomy, 4 deaths amongst 19 cases of trans-intestinal cutaneous ureterostomy, 3 deaths amongst 24 cases of uretero-colic implantation and 2 deaths amongst 11 cases of replacement enterocystoplasty . Amongst factors involved in the cause of postoperative mortality, three appeared to be of essential importance: a very high anaesthetic class (class IV), defective drainage of dissected areas, sources of deep abscesses , and use of the intestine in the method of completing total cystectomy. In the last 40 cases, the use of cutaneous ureterostomy in 82.5% of cases and careful attention to drainage of the operative site led to a reduction in mortality to 5% (2/40) whilst in the first 60 cystectomies of the series, 68.3% of which were completed by ureterocolic implantation, mortality was 21.7% (13/60). Early and late complications were also much more frequent in diversion procedures using the intestine than after direct cutaneous ureterostomy. But after replacement enterocystoplasty , late complications were virtually nonexistent. The authors indicate the following guidelines as conclusions: - in patients who accept a cutaneous implant, direct cutaneous ureterostomy is the best bypass procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prognostic value of extraembryonic components in testicular dysgerminoma (seminoma excluded)]

In 32 cases of non-seminoma germinal tumours of the testis, correlations were established between the presence in situ of beta HCG and alpha foetoprotein, as demonstrated by the PAP immuno-peroxidase technique, the results of serum radioimmunological assays and the clinical course of the disease. It appeared that beta HCG-secreting mononucleate cells were present side by side with multinucleate syncytiotrophoblastic cells and that the immunohistological technique gave "earlier" results than the radioimmunological assays. The demonstration by this technique, in stage II dysgerminomas, of a cryptocellular trophoblastic carcinoma with beta HCG-secreting mononucleate cells indicates a highly malignant germinal tumour.

[Trophoblastic cryptocarcinoma with mononucleate cells, secreting beta chorionic gonadotropic hormones in seminoma. Prognostic value]

In 18 cases of seminoma of the testis correlations were established between beta HCG secretion, as demonstrated by the PAP immunoperoxidase technique, serum radioimmunological assays and clinical course of the disease. Mononucleate beta HCG-producing cells were found side by side with multinucleate syncytiotrophoblastic cells. This information was obtained earlier with the immunohistochemical technique than with radioimmunological assays. The immunoperoxidase technique makes it possible to detect mononucleate beta HCG-positive cell cryptocarcinomas which, when present in stage II seminomas, constitute a very dangerous dysgerminal tumour.

[Role of radiotherapy in the treatment of bladder cancer. Comments apropos of 178 cases]

In the light of their experience involving 178 patients suffering from carcinoma of the bladder and a study of the literature, the authors attempt to determine the role of radiotherapy in the treatment of carcinoma of the bladder. A number of points emerge: --the possibility of stopping the progression of a recurrent multifocal superficial malignant tumour by 2 flashes of 6.5 Gy; --the efficacy of curative doses of radiotherapy associated with transurethral resection of the tumour in 20% of cases. These figures rise to 50% in anaplastic carcinomas. 20% efficacy of radiotherapy alone without surgery is a high figure. It tends to restore the radiotherapy sensitivity test suggested by R. Couvelaire to its true value; --when combined with excision surgery (partial cystectomy or total prostato-cystectomy), high doses of radiation do not give a better result than limited radiation. In view of the gravity of radiotherapy complications which may occur in up to 20% of cases where high doses of radiation have been administered, the authors would be inclined to limit radiotherapy when treatment of the tumour must be mixed, with surgery. A preoperative flash of 6.5 Gy followed by postoperative radiotherapy up to a total of 45 Gy when partial cystectomy is used. When a decision is made to perform cutaneous implantation of the ureters, the technique should consist of concentrated radiotherapy of 20 Gy in one week followed by excision by total prostato-cystectomy the next week. When urinary bypass is to involve uretero-colonic implantation or bladder replacement, flash radiotherapy of 6.5 Gy once or twice. No additional postoperative radiotherapy. Sandwich radiotherapy is too dangerous.

Simultaneous posterior and anterior interosseous nerve syndromes

A patient with simultaneous posterior and anterior interosseous nerve syndromes is presented. During induction of anesthesia, the paralyzed muscles exhibited denervation sensitivity to succinylcholine. Following exploration and repair of a posterior interosseous nerve defect, full function returned in the dorsal muscles as well as the flexor pollicis longus and pronator quadratus muscles.

[Extravesical openings of ectopic ureters: diagnostic problems (author's transl)]

The authors have reviewed 80 cases of ectopic ureter in 74 patients (62 women and 12 men). In most cases the abnormality involved the upper part of a double ureter system, and the extravesical openings were not only ectopic (located within or, most commonly, below the vesical sphincter in women), but also malformed with stenosis and/or reflux. The kidneys drained were damaged by dysplasia and/or interstitial nephritis. The presenting symptoms were fever, abdominal pain and disorders of micturition; incontinence, exclusively found in women, took only second rank. The purulent urine discharged could pass for leucorrhoea. Diagnosis was made by intravenous urography and by clinical or endoscopic finding of the ectopic opening.

Augmentation mammaplasty: a review of 18 years

We have reviewed the experience of our clinic since 1962, when the first augmentation mammaplasty using a silicone implant was performed. All-inclusive, this review of 1,567 patients has taken us through a metamorphosis of improved prostheses and refined surgical and postoperative techniques that have resulted in a significantly lower incidence of breast firmness. Since the purpose of all aesthetic surgery is to improve the quality of life of the patient through an enhancement of her or his own self-image, the results of present-day augmentation mammaplasty with the Silastic gel prosthesis indicate that this surgery is worthwhile and should be continued. It is anticipated that further improvement in results will be noted when the problem of subclinical infection is resolved.

[Triamterene induced nephrolithiasis (author's transl)]

Various studies have demonstrated a relationship between nephrolithiasis and the ingestion of certain drugs. We are particularly interested in the effects of triamterene. Five published case studies on patients of both sexes between 43 and 60 years of age have proven that a regular consumption of normal doses of triamterene has a direct effect upon the formation of renal stones. The stones analysed by infra-red spectrophotometry during the above observations contained from 20 to 100% of triamterene and it's metabolite hydroxytriamterene, following a daily consumption of 150 to 350 mg during a period of 6 to 38 months. It has been confirmed that triamterene and it's metabolite hydroxytriamterene are very poorly soluble and super-saturate the urine for a brief period following the ingestion of the drug. Triamterene might also intervene in the initial phenomena of nucleation. It is therefore recommended that triamterene be used with caution in those patients presenting a history of nephrolithiasis. The existence of drug induced nephrolithiasis reinforces the importance of the technique of renal stone analysis, and the necessity of a systematic study of all renal stones found. This will allow us to develop the study of the correlations between the different episodes of renal stone disease, the nature of the treatment undertaken and the systematic analysis, layer by layer, of the stone.

[Assessment of the renal consequences as related to operative technique in surgery for 190 staghorn or calyceal calculi. Comparative value of renal scintigraphy and intravenous urography (author's transl)]

The authors have studied 86 patients with staghorn calculi who underwent preoperative quantitative renal scintigraphy. 50 of them (63 kidneys) had one or two follow-up scans between 1 and 9 years after the operation. These scintigraphic data were compared with those of I.V.U. These 50 patients had undergone surgery on 60 kidneys (12 pyelotomies only, 26 pyelotomies associated with limited nephrotomies, 18 extended nephrotomies and finally 4 bi-value nephrotomies). In 46 of these patients, the urine became definitively sterile and there was no recurrence of lithiasis in any of them. These quite exceptional conditions were such that it is possible to bear in mind only the operative technique in assessing the possible harmful consequences of each type of operation. The authors clearly show that the threat to function of the kidney which has been operated upon is more threatened when there has been a nephrotomy and when such a nephrotomy has been more extensive. A limited nephrotomy is associated with a mean loss of (% of renal function. Extended nephrotomies or more than 3 cm result in a loss of function of approximately 22%. Large bi-value nephrotomies result in a 36% loss of function. Simultaneous study of scintigraphic scans and I.V.U. revealed that a loss of 1 cm in height of the renal parenchyma corresponds to a functional loss of 10% as determined by scintigraphy. Of basic importance is the fact that the impairment caused by nephrotomies remains stable and does not worsen with the passage of time.

[Management of cancers of the testis. Results in 61 cases and current trends (author's transl)]

Progress in the management of dysembryoma and choriocarcinoma of the testis has been achieved by more effective chemotherapy (particularly since CDDP was introduced) and by precise timing of surgery, occasional radiotherapy and chemotherapy. In their study, the authors have divided the 61 cancers treated into three stages, depending on whether the lesions were limited to the testis (7 patients with choriocarcinoma and 4 with dysembryoma), had invaded the lymphnodes (16 patients with choriocarcinoma and 9 with dysembryoma) or were disseminated (15 patients with choriocarcinoma and 10 with dysembryoma). The prospects of cure are about 90% for stage 1,75% for stage II and 50% for stage III.

[Therapeutic trials in inoperable carcinoma of the bladder (author's transl)]

The authors report the preliminary results of attempts at treatment using radiotherapy and chemotherapy for inoperable carcinoma of the bladder. Chemotherapy alone (cis diamine dichloropalatinum : CDDP) used twice for metastases gave 1 regression of more than 50 % and 1 failure, used twice for non-irradiated pelvic tumours gave 1 regression of more than 50 % and finally was associated with no improvement in 7 patients already irradiated. Chemotherapy (CDDP) associated with a series of flash doses of radiotherapy was used in 6 cases and gave one regression of more than 50 % and one of less than 50 %. Bleomycin in continuous infusion associated with flash radiotherapy was used in 3 cases and gave a regression of more than 50 % of pelvic tumours in two. These poor though not completely nil results have lead the authors to develop a cooperative treatment programme involving the urologist, radiotherapist and chemotherapist.

[The treatment of stress incontinence in women by aponeurotic "supporting" of the neck of the bladder. A new improved technique (author's transl)]

The authors describe a number of new technical details concerning surgery for stress incontinence in the woman using a sub-cervical strip. This involves the taking of a free aponeurotic strip from the upper lip of a Pfannensteil incision (which eliminates all possibility of incisional hernia), extensive pre-vesico-cervico-urethral dissection which is particularly important during reoperation (which allows the neck to rise up into its "normal" position in a patient placed in the Trendelenburg position), preparation of the sub- and latero-cervical course via a vaginal approach (avoiding tearing of the bladder and malposition of the strip), accurate placing along a straight line of the two "legs" of the U-shape given to the strip under visual control, without any tension (which avoids dysuria and should be adequate to ensure continence during stress) and finally attachments of the free ends of the aponeurotic strip to the medial end of the ligaments of Cooper using non-absorbable sutures (which leaves the strip at the desired length). Results : nine patients who had never undergone previous surgery, with nine cures ; ten patients operated upon after the failure of previous surgery for stress incontinence (8 successes and 2 failures including one reoperation with success using the same technique) ; finally, five patients operated upon for stress incontinence occurring after pelvic surgery of another type : 3 successes and 2 imperfect results. The authors briefly mention the 21 failures seen in a series of 26 cases of uplifting of the neck using a strip of skin and the 18 failures in a series of 30 reoperations for the treatment of stress incontinence in which there was no cervico-urethrolysis prior to passage of the strip.

[Carcinoma of the kidney. Trial of chemotherapy. 97 patients (author's transl)]

Chemotherapy for carcinoma of the kidney using the sequence VM 26 (or vincristine), CCNU gave 12 per cent of objective results (complete remission or regression of more than 50 per cent in metastatic tumours and did not alter the actuarial survival curve of these patients. The same type of chemotherapy given on a routine basis and early did not alter the actuarial curves of the first remission after nephrectomy for carcinoma of the kidney at Robson stage III or II. Early chemotherapy would thus not appear to be justified before trials in cases of metastatic carcinoma have led to the discovery of a more effective form.

[Cutaneous urine shunts in adults (author's transl)]

The authors review 123 cases of cutaneous urine shunts in adults. - 93 cutaneous ureterostomies in 63 patients (58 malignant and 5 tuberculous lesions). There were 5 postoperative deaths (8%) and in the 36 operated cases followed-up for varying periods there was 1 death only from progressive renal insufficiency (2.7%), 10 minor incidents (27.8%) and 2 cases with kidney stones (5.5%). Not one of these patients had to be operated on again - 3 cutaneous uretero-ureterostomies with 2 excellent results and necrosis of the foot of the Y in the other case. - 45 transintestinal cutaneous ureterostomies (38 ileal loops and 7 colon grafts) for fistula of the lower urinary tract (2 cases), malignant tumors (35 cases), tuberculosis (1 case), bladder extrophia (1 case), neurological bladder (6 cases). There were 4 early postoperative deaths (8.9%) and 5 severe complications (2 eviscerations, 2 occlusions, 1 digestive tract hemorrhage). Of the 37 operated cases followed-up for varying periods, 5 (13.5%) had diminished renal function, 23 (62%) had late complications requiring further operations in 17 cases (45.9%). These complications were 7 cases of stenosis of the ureter, 1 case of fistual of the ureter, 1 ileal fistula, 4 cases of stenosis of the graft opening, 3 prolapses of the graft, 1 skin lesion, 5 kidney stones and 1 case in which reflux was poorly tolerated. - 12 transprosthetic cutaneous ureterostomies with only 2 good results. No cutaneous shunt operation is exempt from complication. Transprosthetic cutaneous ureterostomies are probably the least affected. Direct cutaneous ureterostomies are statistically better tolerated than transintestinal cutaneous ureterostomies, which appear to have the major inconvenience of deteriorating at a later stage, requiring repeated further operations.

[Course of superficial malignant tumors of the bladder. Apropos of 135 cases]

After recalling the difficulty of comparing the various series published in the literature. in the absence of common histological criteria. the authors review the records of patients with a class III or IV carcinoma of the bladder. strictly confined to the musoca, whether or not the basal membrane was damaged (stage O or A), with the exclusion of all cases with histological invasion of the muscularis and any other clinical or radiological signs of deep infiltration: 135 records with a follow-up of at least 6 months. This study led to the following findings: - One third of the tumours progressed to deep infiltration and/or metastases. - This unfavourable course occurred. in almost 3/4 of cases. during the 2 years following the clinical presentation of the tumour. - Such a grave course may develop for tumours not affecting the basal membrane without it having always been possible to define the stage of infiltration of the chorion. - A metastasis may develop while the tumour remains superificial. - 5 out of these 135 patients developed 2 or more extra-urological carcinomas. - Two thirds of these superifical tumours did not invade the muscularis during the period of observation which in 41 cases exceeded 6 years. - The difficulty lies in detecting which superificial malignant tumours of the bladder will not recur. which will recur superficially (where preservation of the bladder is automatic) and which will recur with infiltration and/or metastases. where an aggressive therapeutic attitude should be adopted before any infiltration or diffusion of the tumour manifests itself. - Tumours which did not recur were unifocal. - All multifocal tumours treated conservatively recurred.

[Carcinoma of the kidney in the adult: results of current treatment. 120 cases (author's transl)]

Extended radical nephrectomy with truly primary ligation of the renal pedicle and lymph node dissection ensures an overall 5 year survival of 65% in patients treated surgically at all stages combined together. At stages I and II, the 5 year survival in 84%. At stage III, venous and/or local lymph node involvement reduces the 5 year survival rate to 53%.

[What is the value of segmental urethrectomy for urethral stenosis in males?]

The authors analyze the results obtained in a homogenous series of 49 patients with urethral stenosis treated by segmental resection of the urethra and end-to-end urethro-urethral suture, with the following conclusions:--Segmental urethrectomy is indicated only for short lengths of stenosis, which do not require the sacrifice of more than 4 cm.--Excellent results were obtained in 41 out of 49 cases (84%).--Good results remain stable, as they were still present in 33 of these 41 successful cases after periods varying from 14 months to 7 years (average: 3 years and 2 months).--Good results have a good chance of remaining as out of the 8 failures only 2 were due to secondary deterioration after a satisfactory initial result. Traumatic and congenital stenoses give the best results as suture of the two healthy sections of the urethra can be performed. Nine successful results were obtained in 10 cases of iatrogenic stenosis after in-dwelling urethral sounds or endoscopic procedures. Twelve cases were successful out of 16 traumatic stenoses of the membranous urethra following pelvic fractures. Two cases of traumatic stenosis of the perineal urethra were both treated with success, as were fourteen out of 15 so-called "congenital" urethral stenoses in which there was no history of trauma or infection. As far as the procedure used is concerned, a successful outcome depends upon the degree of mobilization of the urethral ends, which should be large in order to be able to suture without tension.--The factors causing failure include: absence of excision of post-traumatic callus, insufficient hemostasis, insufficiently prolonged modelling of the suture, favourable for the formation of synechia and, more particularly, a poor condition of the urethra: sclerosed inflammatory stenoses and untreated associated prostatitis.--Sexual impotence is found, temporarily, in all patients operated upon for urethral stenosis, but virility returns in all cases within variable periods of up to two years.

[Congenital valves and diaphragms of the urethra in adult men. A series of 16 observations (author's transl)]

The authors studied 16 adult men with congenital valves and diaphragms in the urethra, and stress that: --their frequency is greater than is commonly stated; --they have serious effects on the upper urinary tract; --they are often difficult to diagnose radiologically; --they are responsible for some cases of difficulty in ejaculation which are wrongly considered to be cases of lack of ejaculation; --endoscopy play a fundamental role in their diagnosis and treatment, --excellent results are obtained with endoscopic treatment.

[Results of radical surgery for renal cancer in adults]

For thirteen years, between 1963 and 1976, 120/139 patients with renal cancer were operated. 45 were stage I, 20 were stage II, 45 were stage III and 12 were stage IV (Robson's classification). Of the 45 stage III cancers, 13 had lymphatic invasion and 37 had venous invasion ranging from microscopic stages to invasion of the inferior vena cava. Treatment included: preoperative teleirradiation with cobalt most often a single dose of 500 rads on the day before the operation. Wide excision with primary ligation of the vascular pedicle and node dissection via a lumbar abdominal transperitoneal route remaining the minimum strictly necessary. Sequential monthly chemotherapy over two years of Vincristine and CCNU (chloroethyl cyclo hexylnitroso urea). Postoperative mortality was considerable (14%) but involved patients with advanced cancers, poor general condition (o% stage I, 10% stage II, 22% stage III and 40% stage IV). The long range survival remains excellent in spite of the postoperative losses: 65 p. cent 5 years all stages. However, stage determines the prognosis: 85 p. cent 5 year survival stage I and II and 53 p. cent 5 year survival stage III. Severe affection of the general state of the patient carries a very poor prognosis. Fever does not indicate a worse value except in stage III tumors. In stages I and II it can have value in the paraneoplastic syndrome (terme non familier). The authors, uncertain of the efficacity of preoperative radiotherapy and postoperative chemotherapy, concluded that wide excision with node dissection is the proper fundamental treatment of renal cancer in the adult.