Prolapsus et colpocèle antérieure. Double promontofixation cœlioscopique. Technique

Genito-urinary prolapse is a common disease that requires a global approach which includes all the compartments. Sacrocolpopexy with anterior and posterior mesh allows long-lasting anatomical restoration with a preservation of the sexual function. The laparoscopic approach is a modern and efficient answer for this functional surgery.

[Spontaneous intraperitoneal rupture of the ureter]

An unusual case of spontaneous intraperitoneal rupture of the ureter was observed in adult with acute renal pain. Diagnosis was best established with CT rather than intravenous urography. CT demonstrated ureteral leakage with the contrast medium extravasating into the peritoneal cavity. The patient was initially managed successfully by endourology. Secondary stenosis of the ureter required surgery for partial resection of the distal ureter.

[Review on the use of CO2 in laparoscopy surgery]

Laparoscopic surgery is one of the treatment modalities available to urologists, who must be familiar with the concepts of the physiology of CO2 and its clinical consequences. CO2 is absorbed during insufflation, leading to hypercapnia, reaching a steady-state from the 20th minute. The insufflation pressure must be between 10 and 14 mmHg. Intraoperative surveillance is based on oxygen saturation (pulse oximeter) and capnography, which measures the CO2 concentration of expired air. The causes of hypercapnia must be prevented: untimely recovery, retroperitoneal dissection, excessive intra-abdominal pressure. If hypercapnia occurs, the patient must be exsufflated and the operation should be resumed after a certain interval. The specific complications of laparoscopy (gas embolism, arrhythmias, pneumothorax) can be avoided by respecting the rules of security and by maintaining surveillance during recovery. The pain due to diaphragmatic peritoneal irritation can also be decreased by complete exsufflation.

[Surgical treatment of genito-urinary prolapse by abdominal approach with promotofixation and setting of an anterior subvesical prosthesis combined with retropubic colpopexia: anatomical and functional results in 104 patients]

A homogeneous series of 104 patients with genito-urinary prolapse or urinary incontinence is reported. Surgical treatment combined promotofixation with (n = 45) or without (n = 59) subtotal hysterectomy, retropubic colpopexia and in certain cases posterior colpoperineorraphia with myorraphia of the levator ani (n = 28). Anatomic results were excellent for bladder and uterine ptosis. Moderate results were obtained for rectoceles and procedures involving the posterior perineum. A rectovaginal prosthesis or complete repair of the rectovaginal wall appeared to be required to improve results for rectoceles. Urine function was good for urinary incontinence: 91% success. Results depended on the pressure of the uretral closure. A complete urodynamic work-up is required prior to surgery in case of sphincter failure. Poor results were also related to excessive posterior traction which can open the cervico-uretral angle. Treatment of genito-urinary prolapse with promotofixation in combination with retropubic colpopexia is a reliable reproducible technique which gives excellent long-term results if excessive promontory traction is avoided and if, in certain cases, the rectovaginal wall is repaired or a prosthesis implanted when maximum uretral closure pressure is weak.

[Survival of patients with infiltrating tumors of the bladder treated with cystectomy]

We reviewed the results of infiltrating bladder cancer treated by radical cystectomy to evaluate survival. Between January 1989 and December 1992, a total of 58 consecutive cystectomies or anterior pelvectomies performed on 48 men and 10 women (mean age 63.2 years) in our department were retrospectively evaluated. Four patients were lost to follow-up and the mean follow-up was 72 months. Pathologic staging was as follows: stage pT0,A,1: 13.5%, stage pT2: 17.5%, stage pT3a: 12%, stage pT3b: 36%, stage pT4: 21%. The year probability of the overall survival was 60% for p T2-p T3a patients, 15% for pT3b patients, and 9% for pT4 patients, respectively. Overall, 53.5% of patients died of cancer, 7.5% of intercurrent disease, and 39% were alive. The cancer related death rate was 12% for pT2-pT3a patients, and 82% for pT3b-pT4 patients. The 5- year probability of specific survival was 80% for pT2-pT3a patients, 15% for pT3b patients, and 9% for pT4 patients, respectively. Infiltrating bladder cancer still has a high mortality rate. Radical cystectomy may be considered to be a curative procedure for stages pT2 and pT3a. Adjuvant chemotherapy and/or radiotherapy seem necessary at stages pT3b and pT4. Preoperative criteria need to be better defined to reduce understaging.

[Endoscopic surveillance of superficial papillary tumors of the bladder]

All cases of superficial bladder tumor treated in 1991 at the urology department of La Pitié hospital were reviewed to study the course of superficial bladder tumors with regard to the risk of muscle infiltration and the value of endoscopic follow-up. In 1991, 73 patients (63 men and 10 women) with a mean age of 64 years had TUR for superficial bladder tumor. Patients had repeated cystoscopy at 3 and 6 months and then on a yearly basis for 5 years. Fourty-eight patients had TIS tumors, and 19 patients had T1 tumors. Five patients were lost to follow-up. Sixty-eight patients were followed for 5 years. Of 48 patients with stage TIS tumors, 39 (81.5%) did not show any deterioration at histological examination, eight patients (16.5%) had infiltration of the lamina propria by tumor (pT1) and the tumor invaded muscle in one patient (2%). Of the 19 patients with stage T1 tumors at the first TUR eight (47%) had no pathologic deterioration, but nine (53%) developed muscle invasion (pT2). Two patients were lost to follow-up. Invasion of the lamina propria present at diagnosis or during the subsequent course is considered to be an indicator of high risk of progression to muscle invasive disease (over 50% of cases). The prognostic accuracy of both the grade and stage needs to be enhanced using molecular markers.