Terrible triad injury of the elbow: A PROCESS-compliant surgical case series from Eastern Morocco

Introduction

The terrible triad of the elbow (TTE) is a lesion associating a dislocation of the elbow, a fracture of the radial head, and a fracture of the coronoid process, with a high potential of complication. The treatment is based on the restoration of bone lesions and external capsular ligament repair. The systematic repair of the medial collateral ligament (MCL) is still debated in the literature. The aim of this study is to evaluate the clinical and functional results of the surgical treatment in a real-world series from Easter Morocco.

Patients and methods

This was a retrospective study of 6 cases of TTE operated by isolated external approach or combined approach (internal or anterior) of the elbow in the department of Traumatology-Orthopedics of the Mohammed VI University Hospital (Oujda Morocco), over a period of 7 years from 2013 to 2020. Radial head and coronoid process fractures were classified according to the Mason and Morrey-Regan classifications, respectively. The following clinical parameters were evaluated: Mayo Clinic Elbow Performance Score (MEPS), Quick Disabilities of the Arm, Shoulder and Hand (DASH), Visual Analog Scale (VAS), and arc of mobility in flexion-extension and prono-supination.

Results

6 male patients treated between May 2013 and December 2020 were included. The median follow-up was 48 months. All patients had frontal and lateral standard X-ray of over and under joints, and computed tomography (CT)-scan was delivered for 5 cases. The elbow dislocation was posterolateral in five cases, and posteromedial in only one patient. Radial head fractures were classified as type I in one case, type II in two cases, and type III in three cases. Coronoid fractures were type I in three cases, type II in one case, and type III in two cases. At the last follow up, the mean MEPS, Quick DASH, and VAS was 81, 28, 0.8, respectively. The mean arc of mobility in flexion was 120° and it was deficient by 20° in extension. In addition, the mean arc of mobility in protonation was 80°, while in supination it was 75°. Regarding complications, we noticed an instability of the elbow on valgus in a single case, elbow stiffness with heterotopic ossification in a single case, ulnar nerve damage in a single case during medial collateral ligament anchoring, and elbow hygroma in one single case.

Conclusion

The surgical management of TTE can provide good and long-term functional results after restoration of the stabilization of bone structures and the lateral ligament complex, without the need to repair the medial collateral ligament.

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The terrible triad of the elbow is a complex injury affecting both the bone and ligaments.

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A complete and accurate management of this entity during any trauma of the elbow is required.

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A careful clinical and radiological assessments must be performed during complex elbow trauma.

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The main objective of any treatment is to provide a stable elbow and avoid early arthrosis.

[Bladder infiltrating tumor: retrospective study of 225 cases]

The authors report a retrospective serial of 225 patients presenting an infiltrating bladder tumor. The infiltrating tumors represent 29.2% of bladder tumors. The middle age of our patients is 59 years with a sex-ratio of 7.3. In the histology, 80% of the tumors are a cell transitional carcinoma and 65% of the patients are classified stage T3T4. The surgical treatment has could be achieved at 73.3% of the cases and 66.7% of the patients had a radical cystectomy. The urinary diversion was essentially an continent urostomy using Benchekroun's hydraulic valve. At 28 months mean follow-up, a locoregional recurrence has been noted from 18% of the Tur achieved alone and 4% of the radical cystectomy. A metastasis has been noted from 18% of the patients and this in a mean delay of 12 months.

[Bladder paraganglioma (pheochromocytoma): report of a new case]

The authors report one case of vesical paraganglioma, not suspected in a 50-years-old female patient who presented gross hematuria as only symptom. The patient was not hypertensive. Radiologic and endoscopic investigations revealed a trigonal submucosal tumour. Complete transurethral resection of the tumor was performed with no intraoperative complications. The histopathological diagnosis indicated pheochromocytoma. Blood pressure was stable. There has been no recurrence for 18 months after transurethral resection.

[Vesico-vaginal fistula: report of 1050 cases]

The authors reports their experience of a large series of 1050 cases of vesico-vaginal fistulas recorded during 30 years and analyse their epidemiological, anatomo-clinical, and therapeutic aspects. Patients could be classified as a function of site of fistula into 3 types, according to the Benchekroun's classification: type I ureto-vaginal fistula (30%); type II cervico-vaginal fistula (22%); type III vesico-vaginal fistula (48%). Etiology was mainly obstetrical (93%). An associated lesion was detected in 10.4% of cases (uterine, ureteral and rectal). Treatment was only performed after a minimal period of three months with the following results in obstetrical vesico-vaginal fistulas. Type I fistula, using a low approach and requiring urethral refection in 100 cases, showed good results in only 60% of cases. Type II fistulae, usually treated through a low approach (80%), were treated with 80% good results. Type III fistula, were nearly always corrected (98%) after two procedures. The overall results are good in 80% of cases. The failures concerned in majority the complex vesico-vaginal fistulas type I, are treated by urinary diversion (51 Coffey, 5 Bricker) and since 1975, 73 continent ileocecal or ileal bladders using Benchekrouns' technique.

[Perinephretic phlegmon: about 36 cases]

The authors report a series of 36 cases of perinephric phlegmon during 15 years. The patients are 27 men and 9 women. Mean age was 37 years (ranging between 25 and 70). The promoting factors of PPN are diabetes (27.8%), and kidney calculi (22.3%). Delay diagnosis is more than 3 weeks in 80% of the patients. The clinical symptomatology was dominated by pain, fever and flank mass. Diagnosis is carried out by ultrasonography in 84% and by CT scan whenever it is done. The common germs are negative Gram bacilli and staphylococcus. The treatment consists in antibiotherapy associated to a percutaneous drainage of the collection in 6 patients (16.7%) and a surgical drainage in 30 patients (83.7%). The follow-up are favorable in all cases.

[Superficial pT1G3 bladder tumor: 24 case reports]

The authors report 24 patients presenting a transitional tumor of bladder pT1G3 collected between January 1996 and December 2000. They represent 19% of the superficial tumors of bladder. Two patients had of straightaway a cystectomy after resection for an unverifiable tumor by endoscopy and another after a second resection discovering a real pT2. Only 5 patients received a BCG therapy is 24% of the cases. A recurrence without progression has been noted in 38% of the cases and a progression in 19% of the patients. These last patients had a cystectomy and with a follow-up to 28 months, no recurrence has been noted.

[Cutaneo-reno-colonic fistula in tubercular kidney with staghorn calculus: report of a case]

We report a rare case of colorenocutaneous fistula, in a patient with a stone of the left kidney. The fistula was successfully managed by single stage surgery (nephrectomy, fistulectomy and suture of colon). Histopathological examination revealed renal tuberculosis. Surgery was completed by an anti-tubercular treatment.

[Scrotal injuries. Report of 40 cases]

Between 1986 to 1998, 40 patients, 16 to 52 years old, consulted for trauma of the scrotum. The trauma was closed in 36 cases. The trauma occurred by accident of traffic in 19 cases, an accident of work in seven cases, an accident during sport in seven cases, aggression in six cases and brawl in one case. The clinical symptomatology was dominated by inflammatory big scrotum or haematoma in the tunic. Ultrasound imaging was performed in 20 patients, showed a contusion of the testicle in five cases, haematoma of the scrotum in ten cases and albuginal rupture in two cases. Thirty patients underwent surgical repair. Five patients underwent orchidectomy. Atrophy of the testis occurred in two patients who underwent resection of the pulp and two others who had haematoma of the haematocele.

[Foreign bodies of the bladder. Report of a new case]

In this paper we are relating the medical history of 30 year-old female patient with psychiatric medical background. This patient introduced multiple foreign bodies in her bladder via the urethra. Throughout this observation, we analyse diagnosis and therapeutic aspects of bladder foreign bodies.

[Testicular metastasis of prostatic adenocarcinoma. Report of a case]

Metastasis involvement of the testis form prostatic carcinoma is rare. Seventy cases have been reported between 1938 and 1990. We report another case treated by transurethral resection of the prostate, bilateral orchiectomy and nonsteroid androgens and a review of the literature is presented.

[Treatment of idiopathic retroperitoneal fibrosis]

Idiopathic retroperitoneal fibrosis is a rare disease and a delay in diagnosis may cause renal failure. Medical treatment i.e. corticotherapy or more recently, tamoxifene has been used successfully. This approach is recommended in patients either with moderate obstruction of the upper urinary, risk of major surgery or in cases of recurrence after surgical treatment. Ureterolysis using conventional surgery or laparoscopy remains the treatment of choice. This procedure should be considered in patients with neoplasic fibrosis, corticoresistant fibrosis or in cases of peri-aneurysm fibrosis.

[Consultation skills in urology: a model for teaching and evaluation]

OBJECTIVE

Consultation activity is an important aspect of urological practice, but the specific teaching of this activity is underdeveloped. The objective of this study was to establish a list of consultancy skills as a basis for a planned and structured approach to teaching and evaluation of consultancy skills in urology.

MATERIAL AND METHOD

Two-step qualitative protocol: 1) Establishment of an initial list of skills based on data of the literature; 2) Submission of this list to a series of "focus groups" (urologists, interns, referring physicians) in order to validate and progressively refine the model.

RESULTS

The items identified were classified into 3 distinct lists: 1) theoretical knowledge; 2) technical skills specific to urology, predominantly performed in the consulting setting, 3) interpersonal skills exclusively concerning the consultant-referring physician relationship.

CONCLUSIONS

The consensual specification of these skills can be used to objectively define teaching and evaluation strategies for urology consultancy skills.

[Staghorn lithasis. Report of 98 cases]

In cases of staghorn lithiasis, the calculus is formed in the excretory cavities of the kidney. It is considered to be a severe type of calculus due to its effect on renal function, associated urinary infection, and its frequent recurrence. In the present study, 98 cases of staghorn calculi have been reported, which were treated over an 8-year period (1990-1997). The patient population consisted of 56 women (62%) and 34 men (38%). The mean age was 46 years (age range: 20-73 years). A history of urolithiasis was noted in 23 cases (26%). The mean time from the onset of symptoms to diagnosis was four years. The clinical symptomatology was as follows: in the right kidney was involved in 54 cases, and both kidneys were affected in eight cases. The calculus was radio-opaque in 94 cases (96%), complete in 29 cases (29%), partial in 69 cases (71%), and associated with caliceal extension in 36 cases (40%). In 47 subjects (52%) other lithiasic sites were found, i.e., caliceal in 41 cases, and ureteral in six cases; Impairment of the renal parenchyma was noted in 33 cases (45%). Urinary infection were found in 30 cases (34%). Renal function was impaired in 15 patients. Staghorn lithiasis was severe in a significant number of subjects, i.e., in 59 cases (60%). Surgical treatment consisted of nephrolithotomy (37 cases), pyelonephrolithotomy (28 cases), pyelolithotomy (18 cases) total nephrectomy (14 cases), and partial nephrectomy (one case).

[Unusual tumor: liposarcoma of the spermatic cord]

Spermatic cord liposarcoma is a rare tumour, as only 60 cases have been reported in the literature. They represent 7% of all malignant spermatic cord tumours. The authors report a new case of spermatic cord liposarcoma unusual by its inflammatory and fibrotic features, occurring in an 83-year-old man in poor general health. Treatment consists of surgical resection as widely as possible. Adjuvant radiotherapy is sometimes effective on local recurrences. Despite the slow rate of progression of this tumour, prolonged surveillance is required due to the high risk of late recurrence.

[Contribution of lumboscopy in the treatment of pyeloureteral junction syndromes. Report of 25 cases]

OBJECTIVE

Evaluation of the results of lumboscopic repair of ureteropelvic junction syndromes.

MATERIAL AND METHOD

Retrospective study of 25 consecutive lumboscopic retroperitoneal pyeloplasties performed over 3 years in 14 women and 11 men with symptomatic ureteropelvic junction syndrome.

RESULTS

The mean operating time was 200 minutes (range: 120-360 minutes) and mean blood loss was 60 ml. Surgical conversion was necessary in three cases due to the difficulty of dissection and in one case because of rupture of the ureter. Analgesic prescription was generally only necessary for the first 2 postoperative days. The mean hospital stay was six days (range: 2-16 days). Patients were able to return to work an average of 10 days after the operation. With a mean follow-up of 9 months (range: 6 to 18 months), all patients were asymptomatic except for one patient who reported pain at a trocar site. Follow-up urography at 3 months showed marked improvement in 18 patients (85.7%), moderate pyelocaliceal dilatation in 2 cases and one failure.

CONCLUSION

Lumboscopic pyeloplasty is an alternative to endopyelotomy. It provides a comparable success rate to that of conventional surgery, while reducing the morbidity, length of hospital stay and convalescence. However, it requires mastery of intracorporeal suture techniques.

The hydraulic antireflux valve: a new technique for reimplanting dilated ureters

PURPOSE

Wide ureters have a high risk of urinary reflux if they are implanted in the intestinal segment. Since 1978, we used the continence hydraulic valve as an antireflux device without staples.

MATERIALS AND METHODS

A total of 40 patients, 20-65 years old (mean age 50), 36 with bilaterally severely dilated ureters and 4 with unilaterally dilated ureters underwent reconstructive surgery by intestinal segments with a hydraulic antireflux valve (HAV).

RESULTS

Mean follow-up was 62 months (range 14-110); upper tract dilatation had improved or stabilized in all patients but one in whom bilateral dilatation occurred with HAV stenosis. All patients underwent follow-up loopogram studies which revealed 2 cases of reflux (4 ureterorenal units). In 1 of the 2 patients the urinary reflux occurred after dessusception (disinvagination) of the nipple.

CONCLUSIONS

The HAV is a safe and reliable procedure in preventing reflux when implanting wide ureters into intestinal segments. This technique can be used in continent urinary diversions with intestinal pouches, and can also be used at the proximal level of an ileoureteroplasty. There is no need for staples.

[Urinary candidiasis revealed by ureteral obstruction: report of 2 cases]

There has been an increase in the frequency of candidiasis urinary infections, which mainly affect diabetic or immunodepressed patients. However, the obstruction of the upper urinary tract by fungal infection is a rare occurrence. The introduction of novel antifungal agents has improved the treatment of fungal infection. In this study, two cases have been reported of urinary candidiasis infections with obstruction of the upper urinary tract which were successfully treated with fluconazole in combination with ureteral catheterization.

[Nephrogenic metaplasia of the ureter]

The authors report a case of nephrogenic metaplasia of the ureter in a 35-year-old patient presenting with left low back pain, haematuria and frequency. Physical examination was not contributive. IVU showed a filling defect in the left iliac ureter. Ureteroscopy demonstrated a tumour nodule in the left iliac ureter. Ureteroscopic biopsy with histological examination showed nephrogenic metaplasia of the ureteric mucosa. Treatment consisted of ureterotomy with resection of the ureteric polyp, followed by closure of the ureterotomy over a double J stent. The course was favourable and postoperative follow-up (IVU, cystoscopy) at 6 months and 12 months was normal.

[Urethrorectal fistula. Report of 11 cases]

The authors report a series of 11 urethrorectal fistulas observed over a 25-year period. The mean age of the patients was 37 years (range: 15 to 70 years). The aetiologies were surgical trauma (5 cases), fracture of the pelvis (2 cases), inflammatory lesions (3 cases), and one fistula was congenital. The clinical features were dominated by urine discharge from the anus (11 cases), urinary tract infection (8 cases), spurious diarrhoea (6 cases), faecaluria (4 cases), pneumaturia (2 cases). Digital rectal examination was normal in 7 patients. IVU demonstrated opacification of the rectum in 5 out of 8 cases. Cystourethrography, performed in 9 patients, demonstrated the communication in each case. Urethrocystoscopy visualized the fistula in each case in which it was performed. Treatment consisted of bladder drainage by urethral catheter in all patients, allowing closure of the fistula in 2 patients. Colostomy was performed in 2 patients, internal urethrotomy and urethral catheter was performed in 2 cases. Surgical closure of the fistula was performed in 7 patients, via an abdominoperineal (3 cases), perineal (2 cases), transperitoneal (1 case) or transanosphincteric incision (1 case).

[The Martius flap in the treatment of vesicovaginal fistulas. Report of 20 cases]

The authors report a series of 20 cases of vesicovaginal fistula (VVF) treated according to the Martius procedure. The mean age of the patients was 30 years (range: 20 to 37 years). All fistulas were secondary to obstetric trauma. The mean diameter of the fistula orifice was 4 cm. Fourteen fistulas were cervico-trigonal and 6 were urethro-cervico-trigonal. A rectovaginal fistula was associated with VVF in 2 patients. Five of the 20 patients had never been previously operated, while 15 patients had already been operated without success. Fifteen patients were cured immediately, while a second Martius procedure was necessary in 3 cases. Failure was considered to be definitive in 2 cases.

[Vesico-uterine fistulas. Report of 30 cases]

The authors report a series of 30 vesico-uterine fistulas (VUF) observed over a 25-year period. The mean age of the patients was 28 years (range: 18 to 40 years). VUF were secondary to caesarean section (23 cases), abnormal delivery (5 cases) and rupture of the bladder and uterus (2 cases). The presenting complaint was a permanent total and isolated urinary incontinence (22 cases), partial urinary incontinence associated with menstrual haematuria (4 cases), vesical menstrual bleeding associated with a oligomenorrhoea (3 cases) and menouria (1 case). The diagnosis was established on clinical findings in 14 patients. IVU, performed in 30 patients, visualized the uterine cavity in only 12 patients. Retrograde cystography, performed in 4 cases, demonstrated opacification of the uterine cavity. Hysterosalpingography, performed in 6 cases, confirmed the diagnosis of VUF in all 6 patients. Treatment was surgical, via a transperitoneovesical incision (22 cases) or a transvesical incision (8 cases) and consisted of isolation of the bladder and uterus and uterine and vesical suture. Urine drainage was performed by urethral catheter (28 cases) or cystostomy (2 cases). Urinary continence was perfectly restored in 24 patients, 6 patients presented residual fistulas another patient had a reduction of her bladder capacity. The objective of this study is to analyse the aetiological, diagnostic and therapeutic aspects of this disease.

[Traumatic rupture of the bladder. Report of 12 cases]

Over the previous 8 years, the authors have treated 12 patients (11 males and 1 female with a mean age of 32 years (26 to 54 years)) with traumatic rupture of the bladder. Rupture was secondary to direct trauma to the full bladder in one case and pelvic trauma in 11 cases. Associated lesions were pelvic trauma (11 cases), head injury (4 cases), chest trauma (2 cases), rupture of the spleen (1 case) and small bowel perforation (1 case). The clinical features were dominated by suprapubic pain (11 cases), haematuria (10 cases), haemorrhagic shock (4 cases) and peritoneal syndrome (3 cases). IVU confirmed the diagnosis in 6 out of 8 cases. Retrograde cystourethrography was conclusive whenever it was performed. The retroperitoneal rupture was treated by indwelling catheter for 15 days. Intraperitoneal ruptures were treated surgically. The breach was situated in the dôme in 10 cases and on the posterior surface in 1 case. The size of the wound ranged from 2 to 8 cm. Treatment consisted of suture of the rupture and indwelling catheter for an average of 12 days. Cure was always obtained without sequelae.

[Thyroid cancer metastasizing to the kidney. Report of a case]

The authors report a case of renal metastasis from a thyroid adenocarcinoma in a 56-year-old man, occurring 3 years after isthmolobectomy for papillary thyroid carcinoma. He predominant clinical symptoms were low back pain, haematuria and deterioration of the general state. Ultrasonography showed a hypoechoic left renal mass, 56 mm in diameter, with a thickened wall. Renal CT showed a homogeneous low-density formation with a thickened wall in the left kidney. Iodine 131 whole body scan showed increased uptake in the left kidney. The patient wes treated surgically via a subcostal incision. The surgical procedure consisted of radical nephrectomy. Macroscopic examination of the lesion showed a cystic mass. Histological examination of the mass revealed a renal metastasis from moderately differentiated thyroid adenocarcinoma.

[Adrenal gland pheochromocytoma. Report of 26 cases]

The authors analyse of a series of 26 patients (17 females and 9 males) with a mean age of 32 years (range: 18 to 55 years) operated for adrenal phaeochromocytoma. All patients were hypertensive. The laboratory assessment (assay of blood catecholamines and urinary catecholamine metabolites) performed in more than 2/3 of cases confirmed the diagnosis in more than 80% of cases. The topographic diagnosis was facilitated by computed tomography. Fifteen patients received preoperative treatment with alpha-blockers or calcium channel blockers. Various incisions were used, but a lumbar incision was the most frequent. Blood pressure was controlled postoperatively in 24 patients. Two patients died 1 and 2 postoperatively. New diagnostic modalities (CT, MRI) have facilitated the diagnosis and the site of localization of phaeochromocytomas, thereby improving the choice of incision. Patient-specific preoperative preparation and appropriate anaesthesia facilitate successful adrenal gland surgery.

[Hydatid cyst of the kidney. Report of 45 cases]

The kidney is a rare site of hydatid disease. It remains clinically silent for a long time and only presents at the stage of complications. The diagnosis is essentially radiological. Renal hydatid cyst (RHC) raises therapeutic problems due to its complications, which sometimes make kidney-preserving cyst resection surgery difficult. The authors report a series of 45 cases of RHC treated in their department during a 20-year period. This series consisted of 27 men and 18 women with a mean age of 47 years (26-80 years). The clinical features were dominated by pain (80%), flank mass (42%), hydaturia (22%), haematuria (13%), urinary tract infection (6%), hypertension (3%). IVU, performed in all patients, showed calcifications in 35% of cases, renal tumour syndrome in 71% of cases and silent kidney in 22% of cases. Surgery was usually performed via a lumbar incision (75%) or a BARAYA incision (15%). Treatment consisted of 18 cyst roof resections (40%), 6 pericystectomies (13%), partial nephrectomy in 2 cases (4%) and total nephrectomy in 18 cases (40%). The postoperative course was marked by urinary fistula in two patients and one death at the 2nd postoperative month related to associated renal sarcoma. The objective of this study is to analyse the epidemiological, pathological and therapeutic features of this disease, which still constitutes a public health problem in Morocco.

[Urethral diverticula in women. Apropos of 15 cases]

Urethral diverticulum is a rare disease, arising in the urethrovaginal septum and communicating with the urethra through an orifice. Characterised by clinical polymorphism, it is diagnosed by urethrocystography and transvaginal ultrasound. We report a series of 15 cases of urethral diverticulum over a 10-year period. The mean age of the patients was post-voiding was 36 years (range 24-50). The symptoms were recurrent urinary tract infections (66%), post-voiding urethral leakage (22%), vaginal pain (22%). Clinical examination found a vaginal mass in all patients. Retrograde urethrocystography showed the diverticulum in every cases, while IVP confirmed the diagnosis in only 62% of cases. Treatment is surgical and consists of removing the diverticulum via a vaginal approach. Short and long-term course is favourable. All patients were asymptomatic and the follow-up urethrocystography showed no diverticular recurrence.

[Spontaneous rupture of bladder diverticulum. Apropos of a case]

We report a case of spontaneous rupture of a bladder diverticulum. A 65-year-old man presented with urinary retention and serious infection. At clinical examination, the patient had a distended abdomen, tenderness of the left flank and left lumbar region and benign prostatic hyperplasia. Urinary catheterisation yielded bloody and purulent urine. CT scan showed a paravesical collection extending to the left lumbar region. Blood count showed anaemia and leukocytosis. Emergency surgical exploration found a large infected bladder diverticulum with necrosis and perforation of the wall. Treatment consisted of resection of the necrotic tissue and suture of the diverticulum neck. Convalescence was uneventful.

[Inguinal hernia of the bladder. Report of 6 cases]

The authors report 6 cases of inguinal hernia of the bladder seen between 1976 and 1996. All patients were males with a mean age of 67 years (range: 53 to 80 years). The hernia was situated in the right groin in all patients. No patients presented any suggestive clinical features. In 5 patients, the diagnosis was established by IVU, indicated for another disease associated with the hernia and, in one patient, the hernia was discovered after an operative wound to the bladder. Treatment consisted of elimination of bladder neck obstruction in 3 patients and reintegration of the bladder and abdominal wall repair in 4 patients. The postoperative course was uneventful.

[Carcinosarcoma of the prostate. Case report]

We report one case of carcinosarcoma of the prostate in a patient of 43 years old. The clinical symptomatology was dominated by pollakiurie, dysuria digestive disorders, oedema of the lower limbs and the alteration of the general status. Digital rectal examination showed a big prostate, hard and irregular. The rate of PSA increased. Echography revealed a pelvic echogenic mass corresponding to a bulky prostate. CT scan of the abdomen and the pelvis showed a tissular, heterogeneous mass of 11 cm occupying the vesicoprostatic space and invading the basis of the bladder and the adjacent muscles (muscles obturateurs internes). Histology of a biopsy fragment of the mass revealed an adenocarcinoma and a mesenchymatous component calling up a prostatic carcinosarcoma. The treatment consisted in chemotherapy VAC. The evolution was deadly after 2 months.

[Bilateral adrenal pheochromocytoma. A case report]

The authors report a case of apparently isolated bilateral adrenal phaeochromocytoma in a 25-year-old man presenting with abdominal pain and neurosensory signs of HT, but ignored and complicated by heart failure. Ultrasonography and abdominal CT revealed a bilateral adrenal tumour. The hormonal assessment, particularly metanephrines and normetanephrines, was normal. The diagnosis of phaeochromocytoma was proposed despite the negative hormonal assessment and was supported by positive MIBG scintigraphy, compatible with bilateral adrenal phaeochromocytoma with no other sites. Treatment consisted of right adrenalectomy and left tumour excision. The postoperative course was uneventful, and 3-year follow-up showed regression of the functional symptoms and control of blood pressure without any other treatment.

[Uretero-vaginal fistulas. 45 cases]

The authors report a series of 45 cases of ureterovaginal fistula (UVF) observed over a 25-year period. The patients had a mean age of 34 years (20 to 50 years). 32 UVF (71%) were secondary to obstetric procedures and operations and 13 UVF (29%) were due to hysterectomy for gynaecological diseases. The clinical features were dominated by urine leak via the vagina with persistent micturition (68.8%) and low back pain (40%). UVF was associated with vesicovaginal fistula in 11 patients and acute renal failure was observed in 4 patients. IVU confirmed the diagnosis in 36 patients (87%) and revealed 23 cases of uretero-hydronephrosis and 4 silent kidneys. Retrograde ureteropyelography, performed in 4 cases, confirmed the diagnosis of UVF. The lesion was situated on the right side in 26 patients and was bilateral in the other 3 patients. The commonest lesion was section (48.8%). Treatment consisted of ureterovesical reimplantation (27 cases), Boari-Küss bladder flap of (3 cases), psoas bladder (5 cases), nephrectomy (2 cases), end-to-end anastomosis (2 cases), appendico-ureteroplasty (2 cases), double J stent (2 cases) and ileoureteroplasty (1 case). The course was favourable in 35 patients (77%).

[Rupture of the corpora cavernous. 50 cases]

The authors report a series of 50 cases of rupture of the corpora cavernosa observed over a 20-year period. The patients had a mean age of 27 years (16-55 years). The commonest mechanism was sudden and forced manipulation of the erect penis (31 cases). The diagnosis is simple in view of the stereotyped clinical features, dominated by penile pain (48 cases), penile haematoma (36 cases) and crackling (25 cases). All patients were treated surgically, with evacuation of the haematoma and suture of the tunica albuginea (48 cases), suture of the corpora cavernosa and corpus spongiosum (1 case), and fascia lata corporoplasty (1 case). A favourable course was observed in 30 cases, while 11 patients presented painful erection, and 9 patients developed induration and deviation of the penis.

[Pathological horseshoe kidney. 30 case reports]

The authors report a series of 30 horseshoe kidneys observed over a 20-year period. This series consisted of 20 men (66.6%) and 10 women (33.4%) with a mean age of 35 years (20-65 years). The clinical features were dominated by abdominolumbar pain (22 cases), haematuria (12 cases) and pyuria (2 cases). Horseshoe kidney was associated with renal stones (20 cases), ureteropelvic junction syndrome (8 cases), upper urinary tract tumour (1 case). Treatment was surgical depending on the aetiology. The objective of this study was to analyse the epidemiological and diagnostic features of this disease, as well as the therapeutic features specific to each uropathy associated with horseshoe kidney.

[Continent urostomy: sigmoid reservoir and sigmoid hydraulic valve]

We report our experience of continent sigmoidostomy. The technique consisted in urinary diversion with sigmoid pouch and hydraulic valve. Eleven patients underwent this procedure (10 men and 1 women, mean age 48 years, range 20 to 77 years). Indications were bladder tumor in 7 cases, bladder exstrophy in 2 patients, neurogenic bladder in 1 case and 1 bladder with a small capacity secondary to a stricture of traumatic urethra. The pouch was made according to the detubularized model. The sigmoid was opened on its antimesenteric edge, leaving the distal portion of the sigmoid intended to do the sigmoid valve. The posterior edges of the colonic segment opened were alined then secured by a Dexon 3/0 whipping then the anterior adges were secured, as the former after reimplantation of the ureters according to Camey Leduc or Politano Leadbetter's procedure. The post operative follow-up was marked by a fistula of the pouch in one case treated by securing it. All the patients were continent day and night. The purpose of this study was the description of the technique and the results of the continent sigmoïdostomy.

[Gangrene of the external genital organs. Apropos of 55 cases]

Gangrène of the male external genitalia (GMEG) is characterized by necrotizing cell evolving toward necrotizing of the soft tissues of the male genitalia and possibly death. The cause may be primary infection called Fournier's gangrene (5%) or secondary infection (95%) due to general or local factors. GMEG is a real urinary emergency because of its local and general complications which lead to death in 20% of cases. Precocious and massive antibiotherapy, a surgery to unbridle and possibly reanimation, oxygenotherapy, urinary diversion or colostomy, are required. We have treated 55 men with this affection from january 1988 to may 1996. Mean age was 58 years (range 20 to 85). The prodromial period was about 12 days. Toxi-infectious shock was noted in 8 patients (14%). Six patients (10%) developed renal acute insufficiency. Lesions were localized to the male external genitalia in 24 cases and stretched to the inguinalis, to the abdomen or to the thorax in 34 patients. The cause was a stricture of urethra in 23 cases (41%) diabetes in 18 cases (32%), anal abscess in 7 cases (13%). No etiology was found in 6 cases (10%). Emergency treatment involved three antibiotics, surgery to unbridle necrotizing tissue in all patients, reanimation in 20 patients (35%), oxygenotherapy in 4 patients (7%), colostomy in 2 cases and urinary drainage in 23 patients (42%). Free skins grafts were necessary in 6 patients (10%), 5 patients (9%) died due to septic shock. On the basis of these observations and a review of the literature, we analyzed the ethiopathogenic, bacteriological and therapeutic aspects of this affection marked by high mortality in spite of therapeutic progress.

[Retroperitoneal liposarcoma. Apropos of 2 cases]

We report two cases of retroperitoneal liposarcoma that required multiple surgical excisions for locoregional relapse diagnosed by surveillance based on CT-scan. One patient has had adjuvant radiotherapy. With the literature review, we discuss the pathologic and therapeutic aspects of these lesions.

[Cysts of the prostate. Apropos of 2 cases]

Two prostatic cysts have been diagnosed by us since 1993. The first patient presented with dysurial the second cyst was discovered incidentally. Transrectal ultrasound examination was useful for diagnosis. Treatment was a puncture--aspiration of the cyst in the first case, and abstention in the second one. A review, of the epidemiological, pathological and therapeutic aspects of the prostatic cysts is presented.

[Renal angiomyolipoma. Apropos of 11 cases]

The authors report their experience of 11 cases of renal angiomyolipoma over an interval of 20 years, observed in 10 women (90.9%) and one man (9.1%) with a mean age of 46 years (range: 21 to 63). Clinical symptoms were dominated by loin pain (100%), haematuria (45.4%), lumbar mass (72.7%), fever (18%). In one woman, AML was associated with "tuberous sclerosis". Preoperatively, the diagnosis was established by ultrasound and CT scan in 45.4% of patients. The size of the tumour varied from 7 to 14 cm in 10 patients and in one patient was only about 3.6 cm. Two women had bilateral tumours. Treatment consisted of total nephrectomy in 7 patients, partial nephrectomy in 3 patients and tumourectomy in one patient. The purpose of this study is to analyse the epidemiologic, diagnostic and therapeutic aspects of this disease.

[Cancer of the kidney in adults. Apropos of 60 cases]

The authors report a series of 60 cases of renal cancer observed over a 10-year period. Patients consisted of 35 women (58%) and 25 men (42%), with a mean age of 52 years (range: 21-72 years). The clinical features were polymorphic, dominated by loin pain (76%), haematuria (75%), a lumbar mass (46%), alteration of the general state (30%). The diagnosis was established by ultrasonography in 58 patients and CT scan in 38 patients. The mean tumour diameter was 11.5 cm (5-25 cm) and two cases presented bilateral tumours. The tumour was located in the upper pole in 40% of cases and was mid-renal in 30% of cases. The time to diagnosis ranged from 2 months to 3 years. Staging reflected the advanced stage of the cancer. Treatment was surgical for 53 patients (88%). A lumbar incision was generally performed (83%). The surgical procedure consisted of nephrectomy and regional or hilar lymph node dissection. Nephrectomy was simple for 27% of patients, radical for 69% of patients and partial for 4% of patients. The postoperative course was marked by one death due to pulmonary embolism, and a stercoral fistula in 2 patients. Histological examination of the specimen showed clear cell adenocarcinoma in 92% of cases. The tumour weight was often considerable, with a maximum of 3.750 kg. The lymph nodes removed were invaded in 50% of cases. The mean follow-up was 46 months (12 to 120 months). Follow-up was normal at 3 years for 23 patients (43%) and at 10 years for 4 patients (8%). Tumour recurrence in the renal compartment was observed in 3 patients after 3 years. Asynchronous metastases occurred in 10 patients (23%). The mean interval to metastases was 20 months (4 to 36 months).

[Paratesticular rhabdomyosarcoma. A case report]

The authors report a case of paratesticular rhabdomyosarcoma in a 21-year-old patient. The clinical features were dominated by left loin pain, inguinoscrotal pain and scrotal swelling. Transillumination was negative. Laboratory markers (alpha-foetoprotein, beta HCG) were normal. Testicular ultrasound showed an enlarged testis, comprising heterogeneous nodules with infiltration of the spermatic cord. Abdominal ultrasonography and CT scan showed a latero-aortic retroperitoneal lymph node mass and a large left kidney. Chest x-ray was normal. Treatment consisted of radical orchidectomy. Histological examination of the operative specimen confirmed the diagnosis of paratesticular rhabdomyosarcoma. The patient was treated by chemotherapy and subsequently developed recurrence with metastases.

[Priapism in adults. 16 cases]

Priapism is a rare disease, characterized by prolonged, painful and irreducible erection, not resulting in ejaculation. It is an andrological emergency with a poor prognosis, as the risk of impotence is 50% despite appropriate management. Treatment is essentially surgical. The authors report their experience of 16 cases of priapism observed over a 15-year period. The mean age of the patients was 36 years (range: 21 to 56 years). The diagnosis was clinical. The mean time to consultation was 8 days (range: 1-28 days). Priapism was secondary to neuroleptics in 6 cases (37%), chronic myeloid leukaemia in 2 cases, sickle-cell anaemia in one case, radiotherapy in 1 case and the cause remained unknown in 6 cases (37%). Treatment was surgical in every case and consisted of spongiocavernous anastomosis in 11 patients (Winter's procedure in 1 case, Al-Ghorab's procedure in 6 cases and transperineal in 4 cases, with saphenocavernous anastomosis in 5 cases). The overall failure rate of surgical treatment was 37%. The success rate of spongiocavernous fistula was 70% and the authors preferred the Al-Ghorab type of spongiocavernous fistula.

[Ureterosigmoidostomies. 35 cases]

35 patients underwent ureterosigmoidostomy between 1986 and 1996, corresponding to 25 males (71%) and 10 females (29%) with a mean age of 48 years (range: 21 to 81 years). 25 (71%) of these patients had invasive bladder cancer, 4 (12%) had a vesicovaginal fistula, 3 (9%) had bladder exstrophy and 3 (9%) had urethral trauma. All patients had normal renal function. In 2 patients, the ureter was dilated and in 3 other patients, one kidney was silent. The postoperative course are marked by death in 2 cases (6%) due to myocardial infarction, mechanical obstruction in 2 cases (6%), anastomotic dehiscence in 2 cases (6%). The mean follow-up was 4 years (range: 2 to 10 years). Eight patients (22%) developed impaired renal function, isolated hyperchloraemic acidosis was observed in 10 cases (28%), hypokalaemia was observed in 2 cases (6%), and episodes of acute pyelonephritis were reported in 4 cases (11%). Radiological signs of upper urinary tract deterioration were observed in 6 cases (17%). A tumour of the sigmoid colon was observed in one case after a follow-up of 10 years. 25 patients (72%) remain dry throughout the night, while 8 (22%) need to empty their rectum during the night. The poorly tolerated Coffey diversion was replaced in 6 patients (17%). The objective of this study is to analyse the results of ureterosigmoidostomy and to emphasize the advantages and disadvantages of this urinary diversion technique.

[Urogenital tuberculosis. 80 cases]

Urogenital tuberculosis raises major diagnostic problems due to the frequently atypical and misleading clinical features. It is a serious disease as the lesions are often multifocal and extensive, requiring major surgical resection and urinary tract reconstruction. Prevention of this disease is based on generalization of BCG immunization and adequate treatment of pulmonary tuberculosis. Between 1985 and 1995, 80 patients with urogenital tuberculosis were treated in our department. These patients consisted of 50 males (62.5%) and 30 females (37.5%) with a mean age of 38 years (range: 20 to 50 years). IVU revealed silent kidney in 26% of cases, ureterohydronephrosis in 36% of cases, small bladder in 17% of cases, and was normal in only 5% of cases. Renal function was impaired in 32% of patients. The diagnosis was confirmed by a positive test for AFB in the urine in 64% of cases, bladder biopsy in 20% of cases and pathological examination of the operative specimen in 20% of cases. Treatment consisted of temporary urinary diversion (32%), antituberculous chemotherapy in all patients, and corticosteroid therapy in 8.7% of patients. Surgical treatment was required in 95% of patients: partial nephrectomy (2.5%), nephrectomy (50%), enterocystoplasty (18%), ileoureteroplasty (5%), ureteric reimplantation (12.5%), ureterocaliceal anastomosis (1.2%).

[Kidney injuries. Apropos of 30 cases]

Renal trauma remains a topical subject due to its high incidence and the fact that it still raises therapeutic problems. The features of this disease were reviewed by means of a retrospective study of 30 cases of renal trauma observed over a 10-year period. The patients consisted of 27 males (90%) and 3 females (10%), with a mean age of 27 years (range: 20 to 60 years). The aetiology was largely dominated by road accidents (53%), falls (26%) and assaults (16%). Trauma was unilateral, predominantly affecting the left side (60%). The clinical features were dominated by haematuria (93%) and low back pain (90%). Trauma was associated with skeletal or visceral lesions in 46.6% of patients. Assessment of the lesions was based on IVU, ultrasonography and CT. Eight patients (26.6%) presented with moderate or minimal trauma (Chatelain stage 1 and 2) and were treated medically. Twenty-two patients (73%) were operated: 6 of them underwent total nephrectomy and 16 were treated conservatively. Seven of the operated patients subsequently developed complications.

[Ureter injuries. Apropos of 42 cases]

Ureteric trauma constitutes a serious disease which can induce renal complications. Ureteric trauma is often iatrogenic, mainly due to gynaecological surgery. The authors report a series of 42 cases of ureteric trauma observed over a 20-year period. These patients consisted of 33 females (78%) and 9 males (21%) with a mean age of 38 years (range: 20 to 65 years). 24 ureteric lesions (57%) were secondary to obstetric procedures and operations, 9(21%) were due to gynaecological operations (hysterectomy), ureteroscopy was responsible in 3 cases, 2 lesions were due to lumbar sympathectomy, one case was secondary to resection of the rectum and 2 cases were secondary to abdominal trauma. The most frequent lesion was ureteric section (21 cases), usually affecting the pelvic ureter. Iatrogenic lesions were associated with iliac vessel ligation (1 case) and vesicovaginal fistulas (8 cases). The clinical features were dominated by vaginal urinary fistula (33 cases) and low back pain (15 cases). The diagnosis was essentially based on IVU, which showed ureterohydronephrosis in 18 cases and a silent kidney in 2 cases. Eight ureteric lesions were diagnosed at operation, 31 after an interval of 3 to 20 days and 2 after an interval of 3 months. Treatment consisted of ureterovesical reimplantation in 17 cases, Boari-Kuss bladder flap in 3 cases, psoas bladder in 6 cases, end-to-end ureterorraphy in 5 cases, ileoureteroplasty in 3 cases, nephrectomy in 2 cases, appendicoplasty in 1 case, double J stent in 2 cases. The course was marked by the development of hydronephrosis (4 cases), ureteric stenosis (2 cases), vesico-ureteric reflux (1 case), urinary fistula (2 case) and lengthening of the ileal graft (1 case).

[Internal urethrotomy in the treatment of urethral stenoses (longterm results)]

The authors report their experience of a series of 100 patients undergoing internal urethrotomy for urethral stricture, with a follow-up ranging from 12 months to 5 years. The morbidity was 16%. A satisfactory result was obtained in 54% of cases. The site and aetiology of the stricture did not influence the results. Better results were obtained in shorter, isolated strictures. Poor results were reported in cases with extensive stricture or in patients with a history of urethral surgery. These cases underwent repeated urethrotomy with less favourable results.