[Long-term results of the treatment of urinary incontinence with bulbar implantation of artificial urinary sphincter in men: a single-center experience]

OBJECTIVE

To report the functional results and morbidity after implantation of bulbar artificial urinary sphincter (AUS) in incontinent men with at least 5 years of follow-up.

PATIENTS AND METHODS

The files of patients treated between 1984 and 2003 by setting up a SAU at bulbar location were reviewed. The following data were recorded: age, etiology of incontinence, intra-operative complications. To evaluate the results on continence, patients were seen at 1, 3, 6 and 12 months, and yearly thereafter.

RESULTS

Overall, 159 men implanted with an AUS were included. The median age was 68.4 years and the median follow-up was 69 months. The etiology of incontinence was a prostate surgery in 83% of cases. The five-year rates of continence and satisfaction were 74.2% (n=118) and 92% (n=140), respectively. The five-year rates of infections and erosions were 4.4% and 9.4%, respectively. In case of previous radiotherapy, the rate of erosion at 5 years was 22.2%. The rate of atrophy and urethral mechanical failure at 5 years was 7.5% and 23.6%, respectively. The rate of reoperation at 5 years was 41.5%.

CONCLUSION

Our results confirm that the AUS is still the standard treatment for male with urinary incontinence due to intrinsic sphincter deficiency. Minimally invasive therapies are being developed that could overcome the mechanical failures and offer an alternative in case of primary or even secondary failure of the AUS.

[Technical aspects of laparoscopic robot-assisted pyeloplasty]

From 2000, the robot-assisted laparoscopic approach has been developed for the management of ureteropelvic junction obstruction (UJO) with equivalent outcomes to conventional laparoscopic access regarding functional results. This system has simplified the suturing and has improved the precision of operative technique. The main surgical steps of the transperitoneal laparoscopic robot-assisted pyeloplasty are as follows: four or five port arrangement; initial dissection and early identification of the ureteropelvic junction; renal pelvis section; transection of the ureter and preparation of a spatula; continuous posterior suture; confection of a handle racket suture; placement of a double J stent; ending of the anastomosis. Outcomes after robotic and pure laparoscopic pyeloplasties are equivalent nowadays. Despite the financial cost, it seems easier and technically feasible and accessible for surgeons accustomed to the laparoscopic techniques and even beginners to learn the robotic technique if the system is available in their institution with success rate (radiologic and clinical) almost similar with those obtain with open techniques.

Association of plasma amyloid beta with risk of dementia: the prospective Three-City Study

OBJECTIVE

Several lines of evidence indicate that a decrease in the CSF concentration of amyloid beta(42) (Abeta(42)) is a potential biomarker for incident Alzheimer disease. In contrast, studies on plasma Abeta(1-40) and Abeta(1-42) peptide levels have yielded contradictory results. Here, we explored the links between incident dementia and plasma Abeta(1-40) and Abeta(1-42) peptide concentrations in the prospective, population-based Three-City (3C) Study. We also assessed the association between plasma concentrations of truncated Abeta (Abeta(n-40) and Abeta(n-42)) and the risk of dementia.

METHODS

During a subsequent 4-year follow-up period, 257 individuals presented incident dementia from 8,414 participants, and a subcohort of 1,185 individuals without dementia was drawn as a control cohort. Plasma levels of Abeta(1-40), Abeta(1-42), Abeta(n-40), and Abeta(n-42) were measured using an xMAP-based assay technology. The association between plasma Abeta peptide levels and the risk of dementia was assessed using Cox proportional hazard models.

RESULTS

Of the various Abeta variables analyzed, the Abeta(1-42)/Abeta(1-40) and Abeta(n-42)/Abeta(n-40) ratios presented the strongest association with the risk of dementia: people with a high Abeta(1-42)/Abeta(1-40) or Abeta(n-42)/Abeta(n-40) ratio had a lower risk of developing dementia. These associations were restricted to individuals diagnosed at 2 years of follow-up and the Abeta(n-42)/Abeta(n-40) ratio was mainly associated with the risk of mixed/vascular dementia.

CONCLUSION

Plasma Abeta peptide concentrations and Abeta(1-42)/Abeta(1-40) and Abeta(n-42)/Abeta(n-40) ratios may be useful markers to indicate individuals susceptible to short-term risk of dementia.

Systematic microbiological tests in kidney transplantation and their value in predicting posttransplantation infection

BACKGROUND

Immunosuppressive therapy has many side effects among which is an increased infectious risk for the recipient. Transmission of pathogens from the graft to the recipient has not been well evaluated; there are no guidelines regarding the need for microbiological tests on the graft prior to transplantation. We routinely performed such tests to evaluate the risk and determine whether a patient should receive preemptive antibiotic therapy after transplantation. We herein have reported our preliminary results.

MATERIALS AND METHODS

We reviewed 150 consecutive renal transplantations from cadaveric heart-beating donors. Microbiological tests were systematically performed not only on the preservation solution, but also on graft artery, vein, ureter, and perirenal fat. We reviewed the recipient's medical history for clinically significant infectious episodes in the first month after transplantation.

RESULTS

Thirty-one percent of all microbiological tests were positive with 23 patients showing multiple positive tests, 74% of which were concordant. We documented 3 cases of direct graft-to-recipient pathogen transmission, all of which presented with 3 positive concordant tests. Graft culture prior to transplantation is often positive, but in more than half of the cases positive tests are either isolated or discordant. We only treated patients with concordant test results; no adverse consequence was observed among the untreated patients. Transmission occurred only in patients with at least 3 concordant tests.

CONCLUSIONS

Multiple microbiological tests on the graft prior to transplantation seemed useful to determine which patients would benefit from preemptive antibiotic therapy. Further studies may help to define which microbiological tests are the most important.

[Oncologic and functional outcomes after radical prostatectomy in T3 prostate cancer]

According to current literature, the gold standard treatment for T3 prostate cancer is the combination of radiotherapy and extended hormonotherapy. Clinical staging based on digital rectal examination seems useless nowadays, since 20% of T3 prostate cancer is overevaluated during physical examination. Prostatic MRI is extensively needed to evaluate extraprostatic extension during preoperative work-up. EAU guidelines recommend radical prostatecomy only in selected patients: less than or equal to cT3a, PSA less than 20 ng/ml and biopsy Gleason score less than or equal to 8. Carcinologic control obtained after radical prostatectomy is variable from one series to another, with biochemical free survival rate at 5, 10 and 15 years that range from 45 to 62%, 43 to 51%, and 38 to 49%. Specific survival rates at 5, 10 and 15 years are, respectively, of 84 to 98%, 85 to 91% and 76 to 84%. Surgical margins rate differ from 22 up to 61% corresponding to several operative techniques and surgeon's own experience. Regarding urinary continence, functional outcomes are in line with those of prostatectomy for localized prostate cancer. Considering erectile dysfunction, rates are linked with the type of surgery, which can be extensive or not. There is no impact on overall or specific survival of neoadjuvant treatments. One current question remains the efficacy of early adjuvant treatment after prostatectomy, especially adjuvant irradiation. Radical prostatectomy can be considered in selected cases as a viable alternative first-line treatment option. However, patients have to be warned that they may undergo complementary treatments during the postoperative course of the disease.

Alzheimer disease with cerebrovascular disease and vascular dementia: clinical features and course compared with Alzheimer disease

OBJECTIVE

Vascular dementia (VaD) and Alzheimer disease with cerebrovascular disease (AD+CVD) are the leading causes of dementia after Alzheimer disease alone (AD). Little is known about the progression of either VaD or AD+CVD. The aim of this study was to compare demographic features, cognitive decline and survival of patients with VaD, AD+CVD and AD alone attending a memory clinic.

METHODS

This study included 970 patients who were followed at the Lille-Bailleul memory clinic, France. Cognitive functions were measured with the Mini Mental State Examination (MMSE) and the Dementia Rating Scale (DRS). Survival rate was analysed with a left-truncated Cox model. Analyses were adjusted for age, sex, education, hypertension, diabetes and baseline MMSE and DRS.

RESULTS

Of 970 patients, 141 had VaD, 663 AD alone and 166 AD+CVD. The latter were significantly older than AD or VaD patients at onset (71 (SD 7) vs 69 (9) and 68 (9) years, p = 0.01) and at first visit (75 (6) vs 73 (8) and 72 (8) years, p = 0.0002). Baseline MMSE and DRS evaluations were highest for VaD compared with AD alone or AD+CVD patients (p<0.006). Cognitive decline during follow-up was slowest for VaD, intermediate for AD+CVD and fastest for AD alone (p = 0.03). After adjustment, compared with AD patients, mortality risk was similar for those with VaD (relative mortality risk (RR) = 0.7 (0.5 to 1.1)) and tended to be lower for AD+CVD (RR = 0.7 (0.5 to 1.0)). The shorter the delay between first symptoms and first visit, the longer patients survived.

CONCLUSION

This clinical cohort study shows that patients with VaD, AD+CVD and AD present different characteristics at baseline and during follow-up, and underlines the need to distinguish between them.

[Nephron sparing surgery for renal tumors on a solitary kidney: oncological outcomes and long-term functional evolution]

OBJECTIVE

Nephron sparing surgery raises the challenge of avoiding chronic haemodialysis for patients having malignancies on a solitary kidney. The aim of this study was to estimate the long term renal function, survival and risk of recurrence of patients undergoing elective nephron sparing surgery for renal cancer on a solitary kidney.

MATERIAL AND METHODS

Between January 1975 and December 2002, 37 elective nephron sparing surgery of kidney tumors were performed on 33 patients with a solitary kidney. Surgery was performed without interruption of blood flow. Pre- and postoperative renal function were compared by using a non parametric test of Kruskal and Wallis. Survival rates were estimated by the Kaplan Meier method and the prognostic factors were defined on a multivariate analysis using a Cox model.

RESULTS

Mean tumoral diameter was 4.6 cm [1.5-10]. The median follow-up was of 83 months. Three patients died in the postoperative period. The postoperative creatinine clairance was significantly lower than the preoperative value (p=0.01), but without significant variation of the renal dysfunction rate (p=0.18) and without significant decrease during the follow-up. No patient required chronic haemodialysis. Overall and disease-free survival rates at five and 10 years was 69 and 56.2%, and 55.8 and 27%, respectively. Multivariate analysis retained tumor size, Fuhrman grade and antecedent of controlateral cancer as independent prognostic factors in overall survival.

CONCLUSION

In our experience, even in the presence of bad prognostic factors, nephron sparing surgery allows a relative savings of the long term renal function. Taking in account the poor life expectancy of people around 60 being put on haemodialysis, all attempt should be made to perform nephron sparing surgery in patients having a cancer on a solitary kidney.

[Results of nephron-sparing surgery for renal cell carcinoma of more than 4 cm in diameter]

To date, radical nephrectomy (RN) remains the gold standard treatment for renal cell carcinoma (RCC) larger than 4 cm. However, from the early 1990's, improvements in surgical techniques have lead to the development of nephron-sparing surgery (NSS) for small renal tumours of less than 4 cm in diameter. This surgical procedure avoids nephronic waste with an acceptable morbidity and similar oncological outcomes compared to radical surgery. Recent large published series did not show any difference between NSS and RN in terms of oncological safety. Specific and disease-free five-year survival rates (82% to 97.3% and 81% to 97.3%, respectively) have confirmed the safety of NSS. Regarding laparoscopic NSS, the technique is still under evaluation and only mid-term outcomes are available so far. However, these studies are still limited and longer follow-up is needed before any definitive statement can be made. Current guidelines recommend NSS only in case of RCC of less than 4 cm in diameter in elective indications. In daily practice however, surgical teams are pushing back the limit above the threshold of 4 cm. More and more surgeons are either considering anatomical location or technical expected difficulties rather than just the tumour size. NSS leads to higher risk of bleeding, especially in case of tumours larger than 4 cm. Therefore, it is absolutely necessary to investigate thoroughly the vascularization of the tumour to avoid such complications with exhaustive and accurate preoperative imaging.

Quality cesarean delivery in Ouagadougou, Burkina Faso: a comprehensive approach

OBJECTIVE

To assess the effects of a comprehensive intervention (staff training, equipment, internal clinical audits, cost sharing system, patients-providers meetings) in improving cesarean delivery access and quality in an urban district of Burkina Faso.

METHODS

We conducted a before-after study in the health district sector 30 in Ouagadougou between 2003 and 2006. We measured cesarean delivery quality (accessibility, diagnosis, procedure, postoperative follow-up) and maternal and neonatal health in 1371 sections.

RESULTS

The number of cesarean deliveries performed increased each year, from 42 in 2003 to 630 in 2006. This increase happened without increase in maternal and perinatal post-cesarean mortality (respectively 1.1% and 3.6% in 2006). The cesarean delivery rate for women of the district increased from 1.9% to 3.3% of expected births between 2003 and 2005.

CONCLUSION

To improve access to quality cesarean delivery, we have shown that it was necessary to have a systemic approach combining technical, operational, sociocultural, and political factors.

BCL-2 counteracts Doppel-induced apoptosis of prion-protein-deficient Purkinje cells in the Ngsk Prnp(0/0) mouse

The pro-apoptotic factor BAX has recently been shown to contribute to Purkinje cell (PC) apoptosis induced by the neurotoxic prion-like protein Doppel (Dpl) in the prion-protein-deficient Ngsk Prnp(0/0) (NP(0/0)) mouse. In view of cellular prion protein (PrP(c)) ability to counteract Dpl neurotoxicity and favor neuronal survival like BCL-2, we investigated the effects of the anti-apoptotic factor BCL-2 on Dpl neurotoxicity by studying the progression of PC death in aging NP(0/0)-Hu-bcl-2 double mutant mice overexpressing human BCL-2 (Hu-bcl-2). Quantitative analysis showed that significantly more PCs survived in NP(0/0)-Hu-bcl-2 double mutants compared with the NP(0/0) mutants. However, number of PCs remained inferior to wild-type levels and to the increased number of PCs observed in Hu-bcl-2 mutants. In the NP(0/0) mutants, Dpl-induced PC death occurred preferentially in the aldolase C-negative parasagittal compartments of the cerebellar cortex. Activation of glial cells exclusively in these compartments, which was abolished by the expression of Hu-bcl-2 in the double mutants, suggested that chronic inflammation is an indirect consequence of Dpl-induced PC death. This partial rescue of NP(0/0) PCs by Hu-bcl-2 expression was similar to that observed in NP(0/0):Bax(-/-) double mutants with bax deletion. Taken together, these data strongly support the involvement of BCL-2 family-dependent apoptotic pathways in Dpl neurotoxicity. The capacity of BCL-2 to compensate PrP(c) deficiency by rescuing PCs from Dpl-induced death suggests that the BCL-2-like property of PrP(c) may impair Dpl-like neurotoxic pathways in wild-type neurons.

The difficulty of questioning clinical practice: experience of facility-based case reviews in Ouagadougou, Burkina Faso

OBJECTIVE

To describe the implementation of facility-based case reviews (medical audits) in a maternity unit and their effect on the staff involved.

DESIGN

Cross-sectional descriptive study.

SETTING

A 26-bed obstetric unit in a district hospital in Ouagadougou, Burkina Faso.

SAMPLE

Sixteen audit sessions conducted between February 2004 and June 2005. Thirty-five staff members were interviewed.

METHODS

An analysis of all the tools used in the management of the audit was performed: attendance lists, case summary cards and register of recommendations. The perceptions of the staff about the audits were collected through a questionnaire administrated by an external investigator from 10 June 2005 to 16 June 2005.

MAIN OUTCOME MEASURES

Session participation, types of problems identified, recommendations proposed and implemented and staff reaction to the audits.

RESULTS

Only 7 midwives from a total of 15 regularly attended the sessions. Eighty-two percent of the recommendations made during the audits have been implemented, but sometimes after a delay of several months. Interviewed personnel had a good understanding of the audit goals and viewed audit as a factor in changing their practice. However, midwives highlighted problems of bad interpersonal communication and lack of anonymity during the audit sessions, and pointed out the difficulty of practising self-criticism.

CONCLUSIONS

A lack of staff commitment and the resistance of maternity personnel to being evaluated by their peers or service users are reducing acceptance of routine audits. The World Health Organization must take all these factors into account when promoting the institutionalisation of medical audits in obstetrics.

Cognitive decline and survival in Alzheimer's disease according to education level

OBJECTIVE

We tested the hypothesis that a higher education level is associated with faster cognitive decline and lower survival in a cohort of 670 Alzheimer's disease patients, followed for 3.5 years at the Lille-Bailleul memory centre.

METHODS

The patients were categorized in 3 groups according to educational levels: low (<or=8 years), intermediate (9-12 years) and high (>12 years). Cognitive function was measured with the Mini Mental State Examination (MMSE) and the Mattis Dementia Rating Scale (DRS). Survival was analyzed with a Cox model. Analyses were adjusted for age, sex, cholinesterase inhibitor treatment, diabetes, hypertension, visible vascular lesions on MRI, baseline DRS and MMSE.

RESULTS

The adjusted mixed random model showed that MMSE declined faster for patients with high and intermediate educational levels compared with those with a low educational level (p < 0.0001). The mean annually adjusted DRS decline was highest for the groups with the most education (p = 0.05). The mortality risk was not higher in the better-educated groups (high vs. low: RR = 0.84; 95% CI = 0.35-1.99, intermediate vs. low: RR = 0.82; 95% CI = 0.41-1.63).

CONCLUSION

In our cohort, highly educated patients had a faster cognitive decline than less educated patients but similar mortality rates. Our findings support the cognitive reserve hypothesis.

Prognostic value of MET, RON and histoprognostic factors for urothelial carcinoma in the upper urinary tract

PURPOSE

RON (recepteur d'origine Nantais) (Santa Cruz Technology, Santa Cruz, California) and c-met (Dako, Glostrup, Denmark) are members of the c-met proto-oncogene family. c-met encodes a receptor tyrosine kinase and has a role in oncogenesis. RON has a role in cell transformation and epithelial tumorigenesis. Over expression of the 2 genes has been demonstrated in human bladder cancer. We explored whether over expression of the 2 proteins has a role in the tumorigenesis and defined histoprognostic factors of poor clinical outcomes in patients with these tumors.

MATERIALS AND METHODS

We reviewed the records of 42 patients with upper urinary tract urothelial carcinoma. A total of 24 tumors were localized in the renal pelvis and 18 were in the ureter. Immunohistochemical staining for RON and c-met was performed using tissue microarrays.

RESULTS

Patient age was 46 to 100 years (mean 70.6). Of the patients 23 (54%) died of disease. Over expression of c-met was associated with a higher risk of embolism (p = 0.0002), while over expression of RON was not significantly associated with emboli (p = 0.5). Univariate analysis showed that relapse was significantly associated with ureteral localization (p = 0.02), vascular invasion (p = 0.003), and high grade (p = 0.04) and high stage (0.02) urothelial carcinoma. The association with vascular invasion, and high grade and high stage urothelial carcinoma was also statistically significant (p <0.0001). Notably superficial tumors showed an important relapse rate (p = 0.003).

CONCLUSIONS

Independent prognostic factors of relapse in upper urinary tract urothelial carcinoma are ureteral localization, vascular invasion, high grade and high stage. c-met seems to influence the development of vascular invasion via an unknown mechanism. Nevertheless, to our knowledge an association between c-met over expression and aggressive clinical behavior in upper urinary tract carcinomas has not been previously reported.

Evidence for the association of the S100beta gene with low cognitive performance and dementia in the elderly

Variations in the S100beta gene may be instrumental in producing a continuum from mild cognitive decline to overt dementia. After screening 25 single nucleotide polymorphisms (SNPs) in S100beta, we observed association of the rs2300403 intron 2 SNP with poorer cognitive function in three independent populations. Moreover, we detected a significant association of this SNP with increased risk of developing dementia or Alzheimer's disease (AD) in six independent populations, especially in women and in the oldest. Furthermore, we characterised a new primate-specific exon within intron 2 (the corresponding mRNA isoform was called S100beta2). S100beta2 expression was increased in AD brain compared with controls, and the rs2300403 SNP was associated with elevated levels of S100beta2 mRNA in AD brains, especially in women. Therefore, this genetic variant in S100beta increases the risk of low cognitive performance and dementia, possibly by favouring a splicing event increasing S100beta2 isoform expression in the brain.

A novel technique to achieve cutaneous continent urinary diversion in spinal cord-injured patients unable to catheterize through native urethra

STUDY DESIGN

Description of a technique and prospective follow-up study.

OBJECTIVES

To present and assess a perioperative strategy associated with a single-procedure surgical technique for continent cutaneous diversion in spinal cord injury (SCI) patients requiring self-catheterization and unable to do it through the native urethra.

SETTING

University hospital, Paris, France.

METHODS

We considered SCI patients suffering from urinary incontinence related to neurogenic detrusor overactivity and/or poor bladder emptying for more than 1 year and inability to perform self-catheterization through the native urethra. These patients including quadriplegics underwent selection for surgery by occupational therapists and neurorehabs to assess the ability to self catheterize through an abdominal stoma and to determine the optimal site to place the stoma. The surgical technique included a single procedure: aponevrotic sling in women requiring stress continence reinforcement, supratrigonal cystectomy, preserved detrusor wall flap (original description), enterocystoplasty, a catheterizable tube using either the Mitrofanoff or Young-Monti principle and Politano-Leadbetter anti-reflux technique. A prospective follow-up study of consecutive patients reviewed initial condition, indication, surgical technique, complications, continence, catheterizing difficulties, functional bladder capacity and serum creatinine.

RESULTS

Thirteen consecutive patients were selected for surgery. Median follow-up was 44 months. Stoma location was variable from one patient to another. All patients had a catheterizable continent stoma at last follow-up. Kidney function was preserved.

CONCLUSION

Given these results, a multidisciplinary approach including neuro-rehabilitation practitioners and urologists performing appropriate technical solutions in highly selected SCI patients unable to catheterize native urethra provides upper urinary tract protection and continence after a single procedure.

Reducing financial barriers to emergency obstetric care: experience of cost-sharing mechanism in a district hospital in Burkina Faso

OBJECTIVE

To describe the implementation of a cost-sharing system for emergency obstetric care in an urban health district of Ouagadougou, Burkina Faso and analyse its results after 1 year of activity.

METHODS

Service availability and use, service quality, knowledge of the cost-sharing system in the community and financial viability of the system were measured before and after the system was implemented. Different sources of data were used: community survey, anthropological study, routine data from hospital files and registers and specific data collected on major obstetric interventions (MOI) in all the hospitals utilized by the district population. Direct costs of MOI were collected for each patient through an individual form and monitored during the year 2005. Rates of MOI for absolute maternal indications (AMI) were calculated for the period 2003-2005.

RESULTS

The direct cost of a MOI was on average 136US$, including referral cost. Through the cost-sharing system this amount was shared between families (46US$), health centres (15US$), Ministry of Health (38US$) and local authority (37US$). The scheme was started in January 2005. The rate of cost recovery was 91.3% and the balance at the end of 2005 was slightly positive (4.7% of the total contribution). The number of emergency referrals by health centres increased from 84 in 2004 to 683 in 2005. MOI per 100 expected births increased from 1.95% in 2003 to 3.56% in 2005 and MOI for AMI increased from 0.75% to 1.42%.

CONCLUSIONS

The dramatic increase in MOI suggests that the cost-sharing scheme decreased financial and geographical barriers to emergency obstetric care. Other positive effects on quality of care were documented but the sustainability of such a system remains uncertain in the dynamic context of Burkina Faso (decentralization).

BAX contributes to Doppel-induced apoptosis of prion-protein-deficient Purkinje cells

Research efforts to deduce the function of the prion protein (PrPc) in knock-out mouse mutants have revealed that large deletions in the PrPc genome result in the ectopic neuronal expression of the prion-like protein Doppel (Dpl). In our analysis of one such line of mutant mice, Ngsk Prnp0/0 (NP0/0), we demonstrate that the ectopic expression of Dpl in brain neurons induces significant levels of cerebellar Purkinje cell (PC) death as early as six months after birth. To investigate the involvement of the mitochondrial proapoptotic factor BAX in the Dpl-induced apoptosis of PCs, we have analyzed the progression of PC death in aging NP0/0:Bax-/- double knockout mutants. Quantitative analysis of cell numbers showed that significantly more PCs survived in NP0/0:Bax-/- double mutants than in the NP0/0:Bax+/+ mutants. However, PC numbers were not restored to wildtype levels or to the increased number of PCs observed in Bax-/- mutants. The partial rescue of NP0/0 PCs suggests that the ectopic expression of Dpl induces both BAX-dependent and BAX-independent pathways of cell death. The activation of glial cells that is shown to be associated topographically with Dpl-induced PC death in the NP0/0:Bax+/+ mutants is abolished by the loss of Bax expression in the double mutant mice, suggesting that chronic inflammation is an indirect consequence of Dpl-induced PC death.

Computer-assisted access to the kidney

OBJECTIVES

The aim of this paper is to introduce the principles of computer-assisted access to the kidney. The system provides the surgeon with a pre-operative 3D planning on computed tomography (CT) images. After a rigid registration with space-localized ultrasound (US) data, preoperative planning can be transferred to the intra-operative conditions and an intuitive man-machine interface allows the user to perform a puncture.

MATERIAL AND METHODS

Both CT and US images of informed normal volunteer were obtained to perform calculation on the accuracy of registration and punctures were carried out on a kidney phantom to measure the precision of the whole of the system.

RESULTS

We carried out millimetric registrations on real data and guidance experiments on a kidney phantom showed encouraging results of 4.7 mm between planned and reached targets. We noticed that the most significant error was related to the needle deflection during the puncture.

CONCLUSION

Preliminary results are encouraging. Further work will be undertaken to improve efficiency and accuracy, and to take breathing into account.

Outcome after treatment of detrusor–sphincter dyssynergia by temporary stent

OBJECTIVES

To evaluate follow-up treatments used after treatment of detrusor-sphincter dyssynergia (DSD) by a temporary urethral sphincter stent.

MATERIALS AND METHODS

Between February 1994 and June 2003, 147 men with a mean age of 41.3+/-14.4 years were treated by temporary urethral stent inserted across the external sphincter for DSD. The underlying neurologic disease was quadriplegia in 85 cases, multiple sclerosis in 24 cases and paraplegia in 21 cases. A Nissenkorn (Bard) stent was used in 130 cases and a Diabolo (Porgès) stent was used in 17 cases. All patients were either unable to or they refused to perform intermittent self-catheterization. DSD was demonstrated by urodynamic studies in every case.

RESULTS

The mean duration of temporary stenting was 10.15+/-16.07 months. After temporary stenting, 92 patients were treated by permanent stent (Ultraflex, Boston Scientifics), 7 started intermittent self-catheterization, 12 had repeated changes of the temporary stent, 4 had an indwelling catheter, 3 underwent cystectomy with non-continent diversion, 2 were treated by endoscopic sphincterotomy, 1 was treated by bladder neck incision, 1 was treated by neuromodulation and 1 was treated by cystostomy. Fifteen patients were lost to follow-up. Two patients died during follow-up (not related to DSD).

CONCLUSION

After treatment of DSD by a temporary urethral sphincter stent, 70.7% of patients subsequently require a permanent urethral sphincter stent. This period allows selection of patients unlikely to benefit from permanent urethral sphincter stent.

Chapitre C-2 E - Chirurgie prothétique de l’incontinence urinaire d’effort par insuffisance sphinctérienne neurologique

Neurogenic sphincter incompetence, in the absence of detrusor dysfunction, results in stress urinary incontinence. Management is exclusively surgical. The available artificial sphincters ensure continence, provided intermittent self-catheterization is performed when necessary for neurogenic bladder. Artificial urinary sphincter is the reference treatment, historically and based on published cohort studies. However, it is associated with a higher morbidity in this population than in the non-neurological population. Although the surgical implantation technique is not modified in females as a result of the neurological disorder it is modified in males, as periprostatic implantation may be necessary, requiring specific training in this technique and rigorous patient selection. Other more recent prosthetic treatments are being developed, but are still at the stage of evaluation: periurethral fascia sling, periurethral injections and periurethral balloon implantation. These techniques eliminate the need to manipulate a pump to open the sphincter for self-catheterization. They appear to be promising, but their long-term results are unknown. In conclusion, operative indications for SUI due to neurogenic sphincter incompetence must be based on a multidisciplinary diagnostic assessment and explicit patient information.

Chapitre H - Les conséquences neuro-urologiques de la chirurgie de l’incontinence urinaire d’effort et de la statique pelvienne

It is difficult to prove the neurourological origin of a voiding disorder, pain or postoperative functional disorders after stress urinary incontinence and pelvic repair surgery and their incidence is difficult to evaluate. The purpose of this chapter is to review the data of the literature concerning complications of this type of surgery, possibly related to a neurological injury, regardless of the site. The most frequently encountered postoperative problem is acute urinary retention. Prevention of acute urinary retention must be based on preoperative assessment looking for risk factors and the quality of postoperative resumption of voiding after removal of the bladder catheter Medium-term and long-term de novo dysuria and/or urgency must be analysed according to a neurourological approach, looking for obstruction (that must be removed) and complications related to the implanted prosthetic material or to the operative technique. The most difficult symptom to assess is postoperative pelvic pain "induced" by surgery. It can be accentuated by a previously undiagnosed concomitant spinal or regional lesion (hip) and the diagnostic assessment must be based on a multidisciplinary approach. This review emphasizes the low level of proof of data of the literature in this field and supports the impression that prospective data from homogeneous cohorts must be recorded in registries, for example, despite the difficulty of long-term evaluation (> 5 years). In the future, patients in whom prosthetic material is implanted should probably be encouraged to more readily cooperate in this field to ensure continuing improvement of the quality of surgical care.

Chapitre B-3 B - Hypertrophie Bénigne de la Prostate et neuro-urologie

Benign prostatic hyperplasia, which is usually treated conservatively (except in the presence of complications) in non-neurological patients, needs to be managed even more cautiously in patients with neurogenic bladder. The treatment decision must include analysis of the previous voiding mode. The development of detrusor-sphincter dyssynergia in an elderly man with a neurological disease must raise the suspicion of prostatic obstruction. The difficulty of establishing a diagnosis of obstruction, that cannot always be confirmed by clinical tools, urodynamic assessment or the search for renal complications, may lead to temporary prostatic stenting as a diagnostic procedure. Certain situations are more specifically encountered in patients with neurogenic bladder: spinal cord injury patients with reflex voiding, patients with stroke and its sequelae, ageing men and diabetic patients.

Aurora-A/STK-15 is a predictive factor for recurrent behaviour in non-invasive bladder carcinoma: a study of 128 cases of non-invasive neoplasms

Aurora-A, a member of serine/threonine kinase, is implied in mitosis and centrosome maturation. Increasing levels of Aurora-A have been shown to be present in several malignancies and especially in bladder cancer. No immunohistochemical marker has shown to be able to predict the clinical outcome of patients with superficial bladder cancer, except MIB-1, as a predictive marker of relapse and progression. The aim was to investigate the expression of Aurora-A and MIB-1 in tissue micro arrays of superficial bladder cancer representative of pTa papillary urothelial neoplasm with different degrees of aggressiveness (low malignant potential [PUNLMP], non-invasive papillary urothelial carcinoma low grade [NILGC], non-invasive papillary urothelial carcinoma high grade [NIHGC] and carcinoma in situ). We analysed predictive values of both markers, their specificity and sensitivity in tumor recurrence. Aurora-A was a sensitive marker to predict tumor recurrence especially for pTa (PUNLMP, NILGC; PUNLMP p<0.001, NILGC p<0.001) with statistical significant correlation between immunohistochemical staining and clinical outcome. MIB-1 expression displayed statistical difference p=0.002 in the PUNLMP group and p=0.03 in the NILGC group. Aurora-A is a more sensitive marker than MIB-1 to predict relapse in pTa bladder neoplasias. The combination of both markers seems to have a very powerful predictive value of recurrence (p<0.001).

An automatic system for the analysis of intercellular communication and early carcinogenesis

Some recent works on intercellular communication pointed out an impaired trafficking of Cx43 proteins in early carcinogenesis. In collaboration with biologists, we propose an automatic system for the analysis of spatial protein configurations within cells at early tumor stages. This system is an essential step towards the future development of a computer-aided diagnosis tool and the statistical validation of biological hypotheses about Cx43 expressions and configurations during tumorogenesis. The proposed system contains two dependent part: a segmentation part in which the cell structures of interest are automatically located on images and a characterization part in which some spatial features are computed for the classification of cells. Using immunofluorescent images of cells, the nucleus, cytoplasm and proteins structures within the cell are extracted. Then, some spatial features are computed to characterize spatial configurations of the proteins with regard to the nucleus and cytoplasm areas in the image. Last, the 3D cell images are classified into pathogenic or viable classes. The system has been quantitatively evaluated over 60 cell images acquired by a deconvolution high-resolution microscope and whose ground truth has been manually given by a biologist expert. As a perspective, a 3D spatial reasoning and visualization module is currently under development.

Use of the SCOT solution in kidney transplantation: preliminary report

SUBJECT

This article reports preliminary findings relating to the use of a new preservation solution, the Solution de Conservation des Organes et des Tissus (SCOT), in renal transplantation. This fourth-generation solution combines an extracellular-like composition with 20 kDa polyethylene-glycol, known for its cell-protection capacity and immunocamouflage properties.

METHODS

We have reported preliminary data obtained in 29 transplantations (25 cadaveric donors and 4 living related donors) between December 2004 and November 2005. The SCOT solution was used for both in situ flush and static preservation. We compared primary organ nonfunction and delayed graft function rates as well as blood creatinine levels in recipients of grafts processed with SCOT solution, versus University of Wisconsin solution (paired for age with the previous group) and with EuroCollins solution (historic data).

RESULTS

We observed delayed graft-function in 10% of the SCOT-processed group, 14% in the University of Wisconsin solution group, and 23% of the EuroCollins group. No case of primary organ nonfunction was reported. Creatinine levels in both SCOT and University of Wisconsin solution groups were similar. We did not observe any humoral or cellular graft rejection in the first 3 months after transplantation. In light of these preliminary results, the use of SCOT is safe for kidney preservation in the human setting. Further experience is warranted to assess the clinical consequences of its immunocamouflage properties as described in animal models.

Effects of the molecular weight of peg molecules (8, 20 and 35 KDA) on cell function and allograft survival prolongation in pancreatic islets transplantation

The normopotassic solution SCOT (Macopharma, France) used for the isolation of the islets of Langerhans may improve both graft function and survival. We believe that this is due to the immunoprotective properties of polyethyleneglycol (PEG) (20 kDa; 1.5 mM/L), which is contained in this solution. However, the optimal PEG chain length remains to be determined. Three extracellular type solutions (SCOT without PEG) containing various PEG-8 kDa, 20 kDa, or 35 kDa- at 1.5 mM/L were compared in vitro for viscosity and osmolarity as well as in vivo using a murine model of pancreatic islet allotransplantation. We compared the effects of the various solutions on functional cell recovery (primary nonfunction rate, PNF) and immunoprotection (allograft survival time). We showed that the viscosity of PEG 35 kDa solutions was too high for physiological use. PEG 20 kDa solution provided the best graft function (0% PNF, P < .05). PEG 8 kda and 20 kDa solutions significantly increased allograft survival time compared to the PEG 35 kDa solution (P < .05). Graft survival was similar with PEG 20 kDa and PEG 8 kDa solutions: 27.50 +/- 3.70 days versus 23.13 +/- 4.39 days (NS). However, the number of PNF with PEG 8 kDa solution (50%) was significantly higher (P < .01) than that with the PEG 20 kDa solution (0%). These preliminary results indicated that the optimal chain length at 1.5 mM/L of PEG is 20 kDa.

Effects of the molecular weight of peg molecules (8, 20 and 35 KDA) on cell function and allograft survival prolongation in pancreatic islets transplantation

The normopotassic solution SCOT (Macopharma, France) used for the isolation of the islets of Langerhans may improve both graft function and survival. We believe that this is due to the immunoprotective properties of polyethyleneglycol (PEG) (20 kDa; 1.5 mM/L), which is contained in this solution. However, the optimal PEG chain length remains to be determined. Three extracellular type solutions (SCOT without PEG) containing various PEG-8 kDa, 20 kDa, or 35 kDa- at 1.5 mM/L were compared in vitro for viscosity and osmolarity as well as in vivo using a murine model of pancreatic islet allotransplantation. We compared the effects of the various solutions on functional cell recovery (primary nonfunction rate, PNF) and immunoprotection (allograft survival time). We showed that the viscosity of PEG 35 kDa solutions was too high for physiological use. PEG 20 kDa solution provided the best graft function (0% PNF, P < .05). PEG 8 kda and 20 kDa solutions significantly increased allograft survival time compared to the PEG 35 kDa solution (P < .05). Graft survival was similar with PEG 20 kDa and PEG 8 kDa solutions: 27.50 +/- 3.70 days versus 23.13 +/- 4.39 days (NS). However, the number of PNF with PEG 8 kDa solution (50%) was significantly higher (P < .01) than that with the PEG 20 kDa solution (0%). These preliminary results indicated that the optimal chain length at 1.5 mM/L of PEG is 20 kDa.