[Urinary tract infections in adults: Comparison of the French and the European guidelines]

INTRODUCTION

Acute urinary tract infections (UTIs) in adult are now a major public health issue in terms of morbidity, mortality and in terms of costs for society. The latest French guidelines and the European Association of Urology guidelines differ in some points. The aim of this article is to compare the guidelines of these two societies in order to highlight their differences but also their common points in the management of UTIs.

METHODS

A comparative analysis of the latest French and European guidelines was carried out. The authors defined the following sub-sections: terminology, pyelonephritis, male UTIs, pregnancy urinary tract infections and cystitis.

RESULTS AND CONCLUSION

The guidelines of these two societies are not very different in terms of diagnostic and therapeutic management. The major differences are in the duration of antibiotic therapies, where French guidelines continue to recommend long term treatments where EAU sometimes recommends only 5 days of antibiotics, as in the case of simple acute pyelonephritis.

LEVEL OF EVIDENCE

3.

[Recommendations of the Infectious Disease Committee of the French Association of Urology. Diagnosis, treatment and monitoring candiduria]

The candiduria are frequently encountered in urology. We present the recommendations of the Infectious Diseases Committee of the French Association of Urology for diagnosis, treatment and monitoring of urinary tract infections. C. albicans is the most frequently isolated species, representing 60% of the isolates. Immunosuppression, diabetes mellitus, age extremes of life, the presence of catheters or procedures on the urinary tract are risk factors for Candida urinary tract infection. The candiduria is usually asymptomatic and does not need treatment. Only 4-14% of patients with candiduria have symptoms of urinary infection. It is necessary before choosing candiduria isolated on a first urinalysis to eliminate contamination by conducting a second harvest. In patients surveyed, the removal of the material allows the resolution of the candiduria nearly half the time and represents the first step of management. Oral fluconazole is the recommended treatment for cystitis (400 mg on day 1 and 200 mg daily for 7 to 14 days). In cases of pyelonephritis without associated candidemia, the first-line therapy is fluconazole (3-6 mg/kg/day) for 14 days or amphotericin B at a dose of 0.5 to 0.7 mg/kg/day with or not associated to flucytosine when potentially resistant strain (C. glabrata).

[Acute prostatitis]

A urinary infection in a febrile man is classiquely defined as a prostatitis. Investigation exams look for complicating factors or post voiding residual which should be drained. Antibiotic treatment should begin with a fluroquinolone or cephalosporin gr 3 for 3 to 6 weeks.

Le reflux urétro-vaginal permictionnel

Reflux into vagina during micturition is a rare phenomenon in adults. We report a case of a 22-old-year woman who presented with intravaginal influx of urine. This case illustrates the anatomic basis, diagnostic examinations and clinical and bacteriological implications of this phenomenon.

[Abbé-Mustardé's flap with lower lid transposition: three clinical cases]

The ideal solution first recommended is the use of Abbé-Mustardé's flap with lower lid transposition to rebuild the total loss of the upper eyelid. Every step of the surgical technique has been detailed to improve the result and keep the drawbacks under control. After having read articles on this subject, we describe three clinical cases, which enable us to compare with others surgical techniques that cannot rebuild all the levels of the eyelids and the edge of the eyelashes.

Adénocarcinomes de l’ethmoïde : expérience nantaise (80 cas)

OBJECTIVE

To present results of a retrospective analysis of eighty cases of ethmoid adenocarcinoma. Carcinologic and surgical results of anterior skull base resection via the transfacial approach are presented.

METHODS

Tumors were classified as 5% T1, 23% T2, 31% T3, 21% T4a and 20% T4b. Thirty-four patients were treated via a paralateronasal approach without skull base resection. Anterior skull bas resections were performed via the transfacial approach for 26 patients and by combined neurosurgical approach for 21.

RESULTS

Mean follow-up was 4.8 years. Survival rate was 63.4% at 5 years and 57.9% at 8 years. Forty-two patients were alive and disease-free at last follow-up. Three patients were alive with recurrence. The rate of local recurrence was 38.8%. Complications occurred in 20% of the patients who had a transfacial approach. Complications appeared to be less frequent than with the combined approach.

CONCLUSION

Prognosis is related to local control and could be improved by using skull base resection more systematically. In our experience this can be managed by a transfacial approach with similar carcinological results and less complications than the combined approach.

[Clinical stage T3 prostate cancer: natural history, therapeutic choices and their results]

Clinical stage T3 prostate cancer is ambiguous both in terms of its definition and its place in the natural history of the disease, and there is no consensus concerning its treatment. In a review of the literature, 148 articles were selected and analysed from the Medline database over a 14-year period (1983-1997). Single-agent therapy: Radiotherapy and radical prostatectomy: it is unlikely that these treatments can cure clinical stage T3 prostatic cancer, except perhaps for a small minority of patients actually presenting with overstaged pT2 disease or certain forms of low-grade pT3. Neither treatment appears to have any advantage over the other-Endocrine therapy: it has been proposed as exclusive treatment at this stage. Few studies have been reported. However, many authors consider this choice to be legitimate, because one-half of patients already have lymph node involvement. Combination therapy: Radiotherapy and endocrine therapy: recent studies comparing exclusive external beram radiotherapy with endocrine therapy show an advantage in favour of combination therapy. Total prostatectomy and endocrine therapy: neoadjuvant endocrine therapy does not provide any advantage. Adjuvant endocrine therapy improves local control and progression-free survival. Adjuvant radiotherapy and radical prostatectomy provides no advantage for T3. The choice of treatment for stage T3, N0, M0 obviously depends on the patient's general state and life expectancy. If the option of a curative treatment in a young subject can be reasonably considered, combination therapy should be preferred.

[The intratesticular leiomyoma: an unusual location. Report of a case]

Intratesticular location of leiomyoma is unusual. A single case has been published in the literature. We report a case of what we consider to be an intratesticular leiomyoma, with a description of its pathology, a discussion of its differential diagnosis and histogenesis.

[Epidermoid carcinoma of the bladder]

Squamous carcinoma of the bladder is a rare tumour, little known in Western countries in contrast with the high incidence in the Middle East and East Africa. It has a sex-ratio of 1 and black populations appear to be preferentially affected. Several recent theories of carcinogenesis elucidate the pathophysiology of this tumour. Its risk factors essentially consist of urinary schistosomiasis and mechanical and chemical vesical irritant factors. The diagnosis of this cancer is often delayed, but can be facilitated by strict follow-up of high-risk patients. Prevention appears possible in these patients. Its prognosis, traditionally poor, essentially depends on tumour stage and grade. Treatment is surgical, essentially radical cystectomy, which has a real therapeutic efficacy. The respective roles of chemotherapy and radiotherapy are currently under evaluation.

Spontaneous rupture of orthotopic detubularized ileal bladder replacement: report of 5 cases

PURPOSE

We defined the mechanisms responsible for rupture of orthotopic, detubularized ileal bladder replacement.

MATERIALS AND METHODS

We reviewed retrospectively the records of 5 cases of ileal neobladder rupture treated at our center between 1985 and 1995.

RESULTS

The interval to perforation varied from 3 to 60 months after surgery. The perforation site was typically the upper part of the right limb of the reservoir. We observed an acute episode of bladder over distension immediately before perforation in 2 cases and a chronic state of neobladder over distension in the 3 remaining cases. Bacterial infection was associated in 4 cases. Intraperitoneal adhesions were an associated mechanism for rupture in only 1 case. We found chronic ischemic changes weakening the bladder wall to be an additional factor for rupture in the 3 cases associated with chronic over distension.

CONCLUSIONS

Acute or chronic over distension of the neobladder is the main factor for spontaneous rupture of orthotopic detubularized ileal bladder replacement. Chronic ischemic changes of the bladder wall, possibly facilitated by detubularization and the variability of the mesenteric circulation, are additional factors that lead to perforation.

[Can the combination of bladder ultrasonography and urinary cytodiagnosis replace cystoscopy in the diagnosis and follow-up of tumors of the bladder?]

OBJECTIVES

Cystoscopy is currently the reference examination for the diagnosis and surveillance of bladder tumours (BT). However, this examination remains unpleasant for the patient, despite the development of flexible cystoscopes. Among the many diagnostic methods performed in combination with cystoscopy, the authors decided to evaluate the performances of the combination of ultrasonography+urine cytology in the diagnosis and follow-up of bladder tumours.

METHODS

This prospective study included 124 cases in the context of postoperative surveillance of BT (86) or aetiological assessment of haematuria (38). All patients were assessed by cystoscopy, suprapubic vesical ultrasonography, and urine cytology.

RESULT

Cystoscopy revealed a bladder tumour in 30 patients. Urine cytology had a sensitivity of 53% and a negative predictive value (NPV) of 86%. Vesical ultrasonography had a sensitivity of 50% and an NPV of 85%. The false-positive and false-negative results of ultrasonography and urine cytology make these examinations unreliable when considered separately. The combination of ultrasonography and urine cytology had an overall sensitivity of 80% and an NPV of 93%. However, analysis of the group of patients undergoing postoperative surveillance for BT showed that although the combination of the two examinations had a diagnostic sensitivity of 100% in the case of high-grade tumour or CIS, this value was only 66% for low-grade tumours. The authors review other methods of bladder tumour diagnosis, but none of them appears to have demonstrated a sufficient reliability at the present time.

CONCLUSION

The diagnostic sensitivity of the combination of ultrasonography and urine cytology, accurate but not recommended in high-risk patients with a high-grade BT, does not appear to be sufficient for systematic surveillance of patients with low-grade BT, despite the low risk of recurrence.

[Hemostasis technics in partial nephrectomy]

The authors describe an original haemostasis technique during partial nephrectomy, combining provisional pressure haemostasis of the renal parenchyma using atraumatic vascular clamps, and application of haemostatic sutures on a strip of Gore-Tex Reinforcement Tissue. This technique, which has been used three times, appears to be simple, facilitates exposure of the renal section, and ensures effective haemostasis. It does not require control or clamping of the pedicle or local hypothermia. No postoperative complication (urinary fistula, secondary haemorrhage, Gore Tex infection) was observed.

Plasma neuroendocrine markers in patients with benign prostatic hyperplasia and prostatic carcinoma

PURPOSE

Approximately 50% of all malignant prostatic tumors contain neuroendocrine cells, which cannot be attributed to small cell prostatic carcinoma or carcinoid-like tumors, and which represent only 1 to 2% of all prostatic malignancies. Only limited data are available concerning the plasma levels of neuroendocrine markers in patients with prostatic tumors. Therefore, we determine the incidence of high plasma levels of neuroendocrine markers in patients with benign and malignant prostatic disease.

MATERIALS AND METHODS

The presence of elevated plasma neuropeptide levels was investigated in 135 patients with prostatic carcinoma and 28 with benign prostatic hyperplasia. Plasma chromogranin A, neurone-specific enolase, substance P, calcitonin, somatostatin, neurotensin and bombesin levels were analyzed by immunoassays, and were compared to clinical and pathological stages of disease. Plasma prostatic acid phosphatase and prostate specific antigen levels were also determined. All patients were followed for at least 2 years after inclusion in the study.

RESULTS

Significantly elevated levels of chromogranin A were detected in 15% of patients with prostatic carcinoma before any treatment. During hormone resistant prostate cancer progression plasma chromogranin A and neuron-specific enolase levels were elevated in 55% and 30% of the patients, respectively. In patients with stage D3 disease survival curves were generated by the Kaplan-Meier method, and log rank analysis revealed a statistically significant difference between groups positive and negative for chromogranin A. Substance P and bombesin were also occasionally elevated in prostatic tumors. Determination of neuroendocrine differentiation by neuron-specific enolase or chromogranin A immunoassays was not helpful in the prediction of progressive localized prostatic carcinoma.

CONCLUSIONS

Future studies of plasma neuropeptide levels should confirm whether these parameters can be used as prognostic markers during late progression of prostatic carcinoma or for the selection of patients suitable for evaluation of new antineoplastic drugs to be active against neuroendocrine tumors.

Total androgen blockade with Zoladex plus flutamide vs. Zoladex alone in advanced prostatic carcinoma: interim report of a multicenter, double-blind, placebo-controlled study

A double-blind, placebo-controlled, randomized, multicenter study was undertaken to investigate the effects of Zoladex plus flutamide vs. Zoladex plus placebo in patients with advanced prostatic cancer. Interim analysis has revealed no differences between the 2 groups in objective or subjective responses at 6 months' follow-up or in overall survival and time to disease progression at 15 months' follow-up.

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.

Correlations between radiography, ultrasonography, computed tomography and pathologic findings in prostatic disease

A total of 20 macroscopically normal or hypertropic prostates were taken from cadavers of men older than fifty, who died of causes other than urologic ones. The samples were studied in vitro by nonscreen x-ray films, ultrasonography, computed tomography, and then by a pathologist. There were 4 normal prostates, 12 with benign prostatic hypertrophy, 3 with carcinoma, and 1 with prostatitis. Conventional radiography which showed only prostatic calcifications was of no pathologic interest. Computed tomography is by no means of diagnostic use in distinguishing between benign prostatic hypertrophy and carcinoma, and should be used only as an alternative in the evaluation of regional extension of prostatic carcinoma. On the other hand, ultrasonography appears to be sensitive to detection of very small nonpalpable nodules. However, its specificity is poor and its use should be restricted as a guide in obtaining biopsy specimens or as a means of evaluating tumor volume.

[Percutaneous renal surgery. Analysis of 100 cases of percutaneous nephrolithotomy]

The authors review a series of 100 consecutive patients treated by elective percutaneous nephrolithotomy. The success rate was 83%, and the complication rate, under 2%. For these reasons, percutaneous nephrolithotomy is becoming an established procedure for the surgical management of kidney stones. After an initial phase, the one-stage manipulation was performed with a mean hospital stay of 4 days in 70% of cases.

Intraoperative localization of renal calculi by real-time ultrasonography

Experimental and intraoperative experiences in ultrasonographic localization of calculi are reported. With a small high-resolution real-time probe, we localized 1-mm calculi introduced in ex situ cadaver kidneys. During 13 operations all calculi of various sizes and nature were localized 11 times. This method seems to have many advantages: it is easy to use, it localizes calcific and noncalcific small calculi bidimensionally, and it shortens operative time.

[Developmental aspect of renal suppurations. Apropos of 2 cases]

The authors set out to differentiate between two types of renal parenchymal suppuration in the light of two personal cases treated recently - renal abscess and localized acute bacterial nephritis (LABN), which is perhaps no more than a preliminary stage in the formation of a renal abscess. Case 1 concerns a LABN, diagnosed by CT scan. The treatment was purely medical and monitoring scans show no anomalies. Case 2 was a gathered abscess, also diagnosed by CT scan, and treated by surgical drainage. The interest of the differentiation between these two types of suppuration is essentially therapeutic. Once gathered, the abscess must be drained surgically, whereas the LABN can be treated medically, with close supervision to ensure complete cure. The differential diagnosis between the two is mainly by scanner, with a study of the respective densities.

[Real-time ultrasonography. Application to the intra-operative location of renal calculi]

Real-time ultrasonography was used intra-operatively in 12 cases of renal lithiasis, in association with radiography. The 10 MHz instrument with sectorial probe is small and easy to sterilise. Calculi larger than 2 mm (including radiotransparent ones) were detected by this method in 10 patients. One of the two failures was due to the surgical incision hindering the positioning of the probe, and the other to the presence of air after pyelotomy of a dilated renal pelvis in front of a horseshoe kidney. Ultrasonography appears to be a sensitive method allowing tridimensional location of small calculi, even when they are transparent to X-rays. The site and size of nephrolithotomy can be selected according to the thickness of renal tissue and to the presence of arteries, also visible on ultrasounds. The operating time is shortened and the risk of residual lithiasis is reduced. Owing to the possibility of artefacts, such as air bubbles, suture material and clots, contact radiography should be combined with ultrasonography, at least for roughly locating the stones.

[Malignant adrenal cortical tumors. 9 cases]

Nine cases of malignant adrenal cortical tumour treated during the last decade are reported. As in many other series, these rare tumours were predominant on the left side (7/9) and affected mainly adult females (6/!) with a mean age of 44 years. The 8 secretory tumours were revealed by their hormonal effects: endocrine syndrome or arterial hypertension. The single, clinically non-secretory tumour presented as a palpable mass. The most common findings of hormonal exploration undertaken in 8 of the 9 patients were abolition of the cortisol nycthemeral cycle and non-response to dynamic tests. In 8 cases the tumour was demonstrated by intravenous urography, but its location and extension were best shown by CT scans. Two scintigraphies performed with labelled iodocholesterol were positive. All patients underwent complete excision of the tumour: 5 out of 9 had hepatic metastases at the time of surgery. The median survival of the 7 patients who died was 13 months; 6 of these had received Op'DDD (mitotane) post-operatively. Two patients, including one treated with Op'DDD, are still alive after 18 and 32 months respectively, without signs of recurrence.