[Should we consider a complementary treatment after a renal colic drained by an ureteral stent?]

PURPOSE

The aim of the study was to evaluate if only ureteral stent removing after complicated renal colic (RC) could prevent from complementary treatment (shock-wawe lithortripsy or ureteroscopy).

PATIENTS AND METHODS

Data from 95 patients, 39 women and 56 men, who had an ureteral stent for complicated RC from 2005 to 2010 were retrospectively collected. Mean age was 46.4 ± 17.2 years. After the initial management, another hospitalization was organized where patients had ureteral stent removing under local anesthesia, then an abdominal CT-scan without injection and complementary treatment of ureteral stones (none or ESWL or ureteroscopy). Parameters studied were age, sex, stone size, location of calcul. Quantitative values were compared with Student's t test. Qualitative values were compared with the Chi(2). P<0.05 was considered statistically significant.

RESULTS

Mean duration between the two hospitalizations were 1.58 ± 1.84 months. Sixty-one patients (64.2%) had no more urolithiasis. In these patients, mean size of urolithiasis was 5.85 ± 2.33 mm. Location of urolithiasis in distal, mild and proximal ureter was 77%, 3% and 20% respectively. Thirty-four patients (35.8%) had persistant lithiasis after CT-scan. Location of stone in distal, mild and proximal ureter was 17.5%, 5.8% and 76.7% respectively.

CONCLUSION

After management of complicated renal colic by ureteral stent, 64% of patients had spontaneous elimination of stones after removing of ureteral stent, especially in women and pelvic ureter.

[Radical cystectomy for urothelial bladder cancer: prognostic impact of lymph node metastasis and soft tissue surgical margins]

PURPOSE

To assess the association of soft tissue surgical margins (STSM) and/or lymph node metatstasis (pN+) with characteristics and outcomes of patients treated with radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB).

MATERIALS AND METHODS

We retrospectively collected the data of 242 patients treated with RC and pelvic lymphadenectomy for UCB between January 2005 and June 2009. Different parameters were studied: age, PSAt, pathological stage of cystectomy specimen (pT and pN), tumor grade, number (nb) of nodes (N) in lymphadenectomy, nb of metastatic nodes (nb N+), bigger diameter of N+, ganglionic density, nb of N with capsular ruptur, associated CIS, associated prostate cancer, follow-up, global and specific survival, date and etiology of death.

RESULTS

Positive STSM were identified in 22 patients (9.1%) and lymph node metastasis in 59 (24.4%). pN+ status was significantly associated with lower global (GS) and specific survival (SS) (P<0.003). So was it for patients with positive STSM R+ with actuarial 3-year GS and SS respectively of 5% and 25% versus 35% and 43.9% no STSM (P<0.001).

CONCLUSIONS

Positive soft tissue surgical margin and/or lymph node metatstasis on cystectomy specimen is a strong predictor of GS and SS from urothelial carcinoma of the bladder. So it is for capsular rupture, ganglionic density greater or equal to 0.10 and nb of N in lymphadenectomy less than 14 for pN+ patients.

[Orgasm after curietherapy with permanent iodine-125 radioimplants for localized prostate cancer]

OBJECTIVES

Orgasm is a domain of male sexuality that remains underreported in literature. Our aim was to realize the first detailed analysis of orgasm in patients treated by 125 I permanent prostate brachytherapy for localized prostate cancer.

PATIENTS AND METHODS

In a series of 270 sexually active men treated by prostate brachytherapy (125I permanent implantation), 241 (89%), mean age of 65 (43-80), participated in a mailed survey about sexual function after a mean time of 36 months (9-70). Erectile and ejaculatory functions and orgasm were explored using a mailed questionnaire. Two questions focused on orgasm. The first was about quality of orgasm (fast/intense/late, difficult/weak/absent) and the second about the presence of painful orgasm and its frequency (always/sometimes/often).

RESULTS

After prostate brachytherapy, 81.3% of sexually active men conserved ejaculation and 90% orgasm. There was a significant deterioration of the quality of orgasm (P=0.0001). More than 50% of the patients had an altered orgasm (weak, difficult, absent) after brachytherapy, vs 16% before implantation (P=0.001). Men with a diminished ejaculation volume often had a weak/difficult orgasm (P=0.007). Neoadjuvant hormonal therapy did not seem to impact the quality of orgasm or the frequency of painful ejaculation. Patients who had an IIEF-5 score higher than 12 had frequently intense orgasm (26.7% vs 2.7%; P<0.001) after brachytherapy. Sixty patients (30.3%) experienced often/sometimes painful ejaculation 12.9% (n=31) before implantation (P=0.0001).

CONCLUSION

Most of the patients treated by prostate brachytherapy conserved orgasm after treatment. However, most of the patients described a deterioration of the quality of orgasm.

Erectile dysfunction in liver transplant patients

The objectives of the study were to determine the frequency of erectile dysfunction (ED) after liver transplantation (LT) and discuss potential risk factors. Of 123 eligible LT men, 98 (79.7%) responded to a questionnaire about sexual function at a mean time posttransplant of 5.4 +/- 4.0 years (1.0-21). Erection was evaluated using the five-question international index for erectile function score, and sexual satisfaction by the patient-baseline treatment-satisfaction status (TSS) score. Questions also focused on patient perception of changes overtime. We found that after LT, the proportion of sexually inactive men decreased from 29% to 15% (p = 0.01), but the proportion of men with ED remained unchanged. The absence of sexual activity was associated with pretransplant sexual inactivity (p = 0.001), age (p = 0.008), cardiovascular disease (p = 0.03), use of diuretics (p = 0.04), anticoagulants (p = 0.001), statins (p = 0.01) and treatment for diabetes (p = 0.03). Cardiovascular disease (p = 0.05), posttransplantation diabetes (p = 0.04), alcohol abuse (p = 0.03), antidepressants (p = 0.05) and angiotensin II receptor blockers (p = 0.05) were associated with having ED after LT. Having a low TSS score was associated with a history of endocrine disease (p = 0.03), antidepressants (p = 0.04) and diuretics (p = 0.03). In conclusion, LT improves sexual activity, but ED is multifactorial and remains a long-term condition in the majority of patients.

Midodrine improves ejaculation in spinal cord injured men

PURPOSE

We evaluated the effect of the alpha1-adrenergic agonist midodrine given orally for anejaculation in spinal cord injured men.

MATERIALS AND METHODS

A total of 185 spinal cord injured patients who reported absent ejaculation during sexual intercourse and who failed to respond to penile vibratory stimulation were treated with midodrine 30 to 120 minutes before a new stimulation. The procedure was repeated weekly, increasing doses by 7.5 mg to a maximum of 30 mg. Cardiovascular effects were monitored throughout the procedure.

RESULTS

Antegrade or retrograde ejaculation was achieved in 102 spinal cord injured men (64.6%). A positive response was more frequent in patients with complete lesions (American Spinal Injury Association A) and upper motor neuron lesions above T10. Midodrine induced a significant but moderate increase (maximum 10 mm Hg) in mean arterial pressure in all patients. The highest systolic blood pressure (more than 200 mm Hg) was seen in patients with quadriplegia. No other significant side effect was recorded. The average dose of midodrine required for ejaculation was 18.7 mg.

CONCLUSIONS

Midodrine is a safe and efficient adjunct to penile vibratory stimulation for anejaculation in spinal cord injured patients.

[Functional results and early experience with the Hautmann neobladder. Comparative analysis of the Toulouse series and the Ulm series]

Orthotopic ileal urinary bladder replacement is an established method after radical standard cystectomy for both genders. In 1986 Hautmann described for the first time the technique of bladder reconstruction using the ileum at the University of Ulm. The W shape of the ileum buffers the coordinated peristaltic waves. The detubularized orthotopic ileal reservoir has been used worldwide ever since because of its technical simplicity, its reduced risk, and its good functional results. The good results published in the literature for this technique were reported by larger centers. With regard to these results, we wondered in 1994 if our smaller department with fewer patients might also offer this technique for male and female patients who had undergone cystectomy. The question was if this method would produce the same results as in large series, provided that patients were adequately selected and surgery carefully performed. This would provide the evidence that the surgical technique is simple, reproducible, and has the same complication rates, such as mortality and morbidity, also for departments with less experience.

A modified intussuscepted nipple in the Kock pouch urinary diversion: assessment of perioperative complications and functional results

OBJECTIVE

To assess the complications and continence of a modified intussuscepted nipple in Kock pouch urinary diversions.

PATIENTS AND METHODS

From February 1992 to December 2000, 40 patients (mean age 55.8 years, range 21-74) with bladder cancer (24), gynaecological tumours (eight) or previous lower tract reconstructive surgery (eight) underwent cystectomy and cutaneous continent urinary diversion using the Kock pouch procedure. The first 23 procedures (group I) used Henriet's technique, whereas a modified fixation of the intussuscepted efferent limb was applied in the last 17 (group II). Complications and functional results (focused on continence and the upper urinary tract) were reviewed.

RESULTS

The median (range) follow-up was 47.6 (10-124) months; one patient died 4 weeks after surgery. Early complications occurred in 11 (28%) and re-operation was required in two (5%). Of the late complications reported (38%), extussusception (8%) and efferent nipple prolapse (3%) only occurred in group I and required surgical revision. Late complications were minor (15%) including two asymptomatic refluxes and four with stoma sclerosis. The continence rate at 6 months in groups I and II were 78% and 94%, respectively (P = 0.13).

CONCLUSION

Efferent limb prolapse and extussusception of the Kock pouch were the main complications requiring surgical revision. Applying the modified nipple fixation the complications can be reduced and reservoir continence improved.

Pubourethral ligaments in women: anatomical and clinical aspects

The anatomy and histological structure of the proximal (PPUL), distal (DPUL) and intermediate (IPUL) pubourethral ligaments in women was examined to improve the understanding of their roles in female urethral physiology. An anatomical study of the pelvis was carried out in 10 adult female cadavers (60-102 years), the pelvis being removed and frozen prior to dissection. The pubourethral ligaments (PUL) were dissected in sagittal sections in seven specimens and in a frontal section in one specimen; the remaining two pelves were dissected using a hypogastric approach. The location, insertion, direction and histological structure of the ligamentous structures were studied. The PUL were identified in all 10 dissections, being paired, symmetrical, pearly-white, fibrous and resistant to stretching. The bony (parietal) insertion was variable on the posterior surface of the pubis, while the visceral insertion was located on the dorsal aspect of the proximal third of the urethra and neck of the bladder for the PPUL and on the distal third of the urethra for the DPUL. Histologically, the ligaments were composed of dense collagen fibres and bundles of axially orientated smooth muscle fibres. The PPUL was closely associated with the sphincter urogenitalis muscle, whereas the DPUL appeared to reinforce the role of the compressor urethra. It is suggested that the PUL plays an effective role in passive and active suspension of the urethra. The pubourethral ligaments are a constant anatomical entity which should be spared in urethral surgery in women in order to ensure an intact urogenital sphincter.

[Local staging of prostate carcinoma with phased array MR imaging: prospective study over 5 years]

PURPOSE

To assess by MRI, using a pelvic phased array coil, the accuracy for staging prostate carcinoma and to correlate the results with the rate of positive surgical margins.

MATERIALS AND METHODS

Between January 1995 and December 1999, 176 patients with localized prostate carcinoma underwent a preoperative MRI examination using a pelvic phased-array coil (1 Tesla). MRI and histological results were compared in a prospective study.

RESULTS

131 were classified T2 and 45 were classified T3 at MRI. Pathologic findings showed 103 pT2 and 73 pT3. The accuracy of MRI (extra capsular or vesicle extension) was 75%. The risk for a patient labelled T2 or T3 at MRI to have a positive surgical margin was respectively 13.7% and 31%.

CONCLUSION

This study shows that the phased-array coil has a low sensitivity but a good specificity to distinguish between organ-confined cancer or not. It shows that the risk of positive surgical margins is higher for T3 lesions at MRI. The low sensitivity should be improved by using a multi coil phased array.

Multi-institutional study of complications in 1085 laparoscopic urologic procedures

OBJECTIVES

To assess the incidence of the complications in laparoscopic urologic procedures with regard to clinical presentation, etiology, and treatment.

METHODS

From January 1994 to December 2000, 1085 laparoscopic procedures were performed at three institutions in 1075 patients (702 men, 373 women). A referent surgeon for laparoscopy was at each institution. The major procedures were radical prostatectomy (n = 232), different types of nephrectomy (n = 171) and nephroureterectomy (n = 15), adrenalectomy (n = 130), pyeloplasty (n = 61), pelvic lymph node dissection (n = 130), genitourinary prolapse repair (n = 86), bladder neck suspension (n = 104), and treatment of benign kidney pathologic findings (lithiasis, cysts, and diverticula, n = 55). The complications were listed by incidence and etiology according to the procedure attempted.

RESULTS

A total of 75 complications (6.9%) occurred in this multi-institutional series. The mortality rate was 0.09%, and the conversion rate was 2.1%. Vascular (n = 7) and visceral injuries (n = 11) occurred in 24% of complications. Hematomas (n = 10), urinomas (n = 8), and wound infections (n = 7) at the trocar sites were the most frequent postoperative surgical complications. Pulmonary disorders (n = 9) and urinary infections (n = 9) were predominant in the postoperative medical problems.

CONCLUSIONS

Even though it appears to be minimally invasive, laparoscopy remains major surgery, with serious complications possible. These complications should be preventable with better mastery of the different steps of the procedures. Increased knowledge of the possible complications is essential for urologists in laparoscopic training and may help them improve their learning curve.

Assessment of morbidity and functional results in bladder replacement with Hautmann ileal neobladder after radical cystectomy: a clinical experience in 55 highly selected patients

OBJECTIVES

To analyze the morbidity and functional results of the ileal neobladder in a series of 55 highly selected patients. The ileal neobladder is a commonly used technique for orthotopic bladder reconstruction after radical cystectomy in both sexes. Good results have been published from Ulm University, where the technique was popularized.

METHODS

From February 1994 to June 2000, 55 patients (47 men and 8 women), 32 to 75 years old (mean age 58) with good performance status (American Society of Anesthesiologists score 1 and 2), underwent radical cystectomy for bladder cancer and Hautmann ileal neobladder reconstruction. Functional assessments were done at 3 months and every 6 months thereafter, with special attention to urinary continence and upper urinary tract status.

RESULTS

The median follow-up was 28.8 months (range 8 to 96). One perioperative death occurred. Early complications occurred in 23.6% without repeated surgery and late complications occurred in 25.4%, with three repeated operations for occlusive syndromes. The daytime and nighttime continence rates at 3, 6, and 12 months were 59.6%, 80.8%, and 88.5% and 38.5%, 61.5%, and 78.8%, respectively. The overall continence rate in patients younger than 70 years old was 80.8%. Three patients required self-catheterization to empty their neobladder. Eleven patients died of metastatic evolution of their bladder cancer or intercurrent disease at 6 to 36 months.

CONCLUSIONS

In highly selected patients, the ileal neobladder provides good functional results regarding continence with an acceptable complication rate. In this series, the results were comparable to those reported in the referent institution.

[Retroperitoneoscopic pyeloplasty for primary hydronephrosis: preliminary results of the first 30 procedures]

OBJECTIVE

To evaluate the preliminary results of retroperitoneoscopic pyeloplasty (RP) for the treatment of primary ureteropelvic junction syndrome (PUPJS) in terms of operating time, operative and postoperative complications, clinical functional and radiographic results, length of hospital stay and resumption of physical activity.

MATERIAL AND METHODS

From November 1997 to June 2000, from a consecutive series of 59 patients treated for an anomaly of the ureteropelvic junction (UPJ), the 29 patients (18 females and 11 males, mean age: 35.6 years [range: 17-68]) operated by RP for PUPJS (bilateral in one case) were reviewed. Twelve patients presented a lower pole vascular pedicle and 24 patients had an extrasinusal renal pelvis. The RP technique was identical for all patients (4 ports) and the UPJ repair was performed according to the technique described by Anderson-Hynes and Küss (28 cases) or Y-V plasty (2 cases).

RESULTS

The mean operating time was 150 minutes (range: 120-240) and the mean hospital stay was 4.2 days (range: 3-10). There were no intraoperative complications, but one conversion (3.3%) was necessary because of major adhesions. postoperative complications (23.3%) consisted of: four urinary tract infections with one case of acute pyelonephritis, perirenal haematoma, urine leak in the Redon drain due to obstructed double J stent, migration of the double J stent underneath the anastomosis leading to unstentable cicatricial stricture (treated by open pyeloplasty 3 weeks later). With a mean follow-up of 19.7 months (range: 7-40), 28 patients were asymptomatic and one patient presented persistent lumbar pain at 9 months with no signs of recurrence. The 3-month IVU, performed in 27 patients, showed reduction of hydronephrosis in 85.7% of cases and a patent ureteropelvic junction in 96.3% of cases. Complete resumption of physical activity and return to work were possible an average of 1 month postoperatively (a fortnight for the population under the age of 40 years).

CONCLUSION

PUPJS can be treated by RP according to the same principles as conventional surgery. RP pyeloplasty can be performed with an acceptable operating time and morbidity. The functional and radiological results in terms of patency of the UPJ need to be assessed in the longer term.

Impact of a modified apical dissection during radical retropubic prostatectomy on the occurrence of positive surgical margins: a comparative study in 212 patients

OBJECTIVES

To assess the impact of a modified technique of apical dissection during radical retropubic prostatectomy on the occurrence of positive surgical margins (PSMs).

METHODS

Between 1992 and 1998, 212 nonconsecutive patients with localized prostate cancer (57 T1, 155 T2) underwent radical retropubic prostatectomy and were divided into two groups: group 1, 85 patients who underwent surgery before January 1994; and group 2, 127 patients who underwent surgery with the modification of the apical dissection after January 1994. The modified technique consisted of a wide excision of periprostatic soft tissue at the apex, including the bilateral neurovascular bundles. The clinical data (age, prostate-specific antigen, clinical staging) and pathologic findings (pathologic staging, Gleason score, PSM rate) of the two groups were compared.

RESULTS

No significant difference was found between the two groups regarding the median prostate-specific antigen level (10.8 ng/mL and 9.5 ng/mL), Gleason score, and pathologic staging. Overall, the PSM rate was 53% in group 1 and 20.5% in group 2 (P <0.001). The number of PSMs decreased 2.6-fold in group 2. The PSM rate was significantly reduced at the apex with the new technique (group 1, 33.3%; group 2, 7.7%; P = 0.008). The PSM rate expressed with the odds ratio was 4.4-fold lower for patients in group 2 than for those in group 1.

CONCLUSIONS

The modified apical dissection in radical retropubic prostatectomy significantly improves the PSM rate in patients with localized T1-T2 prostate cancer.

Assessment of the risk of positive surgical margins with pelvic phased-array magnetic resonance imaging in patients with clinically localized prostate cancer: a prospective study

OBJECTIVES

We assessed magnetic resonance imaging (MRI) performance in the prediction of positive surgical margins (PSMs) before radical prostatectomy in a prospective study correlating the MRI results and pathologic findings.

METHODS

Between January 1995 and December 1999, 176 patients (mean age 64.2 years, range 49 to 75), with localized prostate cancer (49 with Stage T1 and 127 with Stage T2) underwent preoperative MRI with a pelvic phased-array coil (Tesla-1, Siemens) at a mean interval of 35 days after randomized transrectal biopsies. The mean preoperative prostate-specific antigen level was 10.9 ng/mL (range 1.2 to 39). The MRI studies and specimen analysis were performed by one radiologist unaware of the clinical and biopsy findings and by one pathologist, respectively. Multivariate analysis was performed to compare the predictive value of MRI staging, prostate-specific antigen value, and preoperative Gleason score to identify the PSM rate.

RESULTS

Of the 176 patients, 131 (74%) had Stage T2 disease by MRI and 45 (26%) Stage T3 disease by MRI. Pathologic staging showed 103 with pT2 and 73 with pT3. Overall, the PSM rate of the series was 18%. The PSM rate was 13.7% and 31% for patients with T2 and T3 disease by MRI, respectively. For the T3 MRI cases, the PSM rate was 2.32-fold higher. MRI staging, like the prostate-specific antigen value, was a predictive factor of PSMs (P = 0.05).

CONCLUSIONS

The results of this study show that preoperative MRI staging with the phased-array coil may be helpful in predicting the PSM risk in radical prostatectomy candidates with clinically localized prostate cancer.

Experience with retroperitoneal laparoscopic adrenalectomy in 115 procedures

PURPOSE

Laparoscopic adrenalectomy has become an effective option for removing small adrenal tumors. We evaluated the retroperitoneal approach with regard to operative complications, morbidity and hospital stay.

MATERIALS AND METHODS

Between January 1995 and March 2000 we performed a total of 115 laparoscopic adrenalectomies via the retroperitoneal approach, including 70 on the left and 45 on the right side, in 64 women and 42 men 17 to 74 years old (mean age 49.3) with adrenal neoplasms. Average adrenal tumor size was 31 mm. (range 10 to 65). All procedures required 4 trocars and mean operative time was 118 minutes (range 45 to 240).

RESULTS

There were no patient deaths. The conversion rate to open surgery was 0.8% and estimated blood loss was 77 ml. (range 0 to 550). At a mean followup of 23.4 months, morbidity was 15.5% with intraoperative vascular injury in 3 cases (3.4%) and postoperative complications in 12.1%, including wound infection, deep hematoma, parietal dehiscence and severe pneumopathy. Average hospital stay was 4 days and mean duration of analgesic requirement was 2 days (range 1 to 5).

CONCLUSIONS

The retroperitoneal approach to laparoscopic adrenalectomy appears to be minimally invasive and safe for adrenal tumors not larger than 5 cm.

Extraperitoneal laparoscopic pyeloplasty: a multicenter study of 55 procedures

PURPOSE

We assessed the feasibility, reproducibility and morbidity of retroperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction.

MATERIALS AND METHODS

A total of 55 retroperitoneal laparoscopic pyeloplasties were performed at 3 institutions between September 1996 and May 2000 in 33 women and 21 men. Results were analyzed in regard to radiological assessment by excretory urography at 3 months, complications and hospital stay.

RESULTS

We performed dismembered pyeloplasty in 48 cases and Fenger plasty in 7 cases. Crossing vessels were noted in 23 patients. The conversion rate was 5.4%. Mean operative time was 185 minutes (range 100 to 260), mean hospital stay was 4.5 days (range 1 to 14) and mean followup was 14.4 months (range 6 to 43.6). The overall complication rate was 12.7%. Complications in 7 patients included hematoma in 3, urinoma in 1, severe pyelonephritis in 1 and anastomotic stricture in 2 requiring open pyeloplasty at 3 weeks and delayed balloon incision at 13 months, respectively. Excretory urography in 50 patients and ultrasound in 4 showed decreased hydronephrosis in 88.9% at 3 months. Normal physical activity and absent pain were reported by 47 patients (87%) 1 month after surgery.

CONCLUSIONS

Retroperitoneal laparoscopic pyeloplasty seems to be a valuable alternative to open pyeloplasty for ureteropelvic junction obstruction. The long-term outcome must be assessed before this procedure may be definitively validated.

Experience with retroperitoneal laparoscopic adrenalectomy for pheochromocytoma

PURPOSE

Although laparoscopic adrenalectomy has become the preferred surgical treatment of benign adrenal masses, for pheochromocytoma it is limited by concerns over hypertensive events related to early access to the adrenal vein. We report our experience with retroperitoneal laparoscopic adrenalectomy for pheochromocytoma.

MATERIALS AND METHODS

From January 1995 to December 1999, 21 retroperitoneal laparoscopic adrenalectomies (left 12 and right 9) were performed for symptomatic pheochromocytoma in 11 men and 9 women 17 to 68 years old (mean age 46). To our knowledge pheochromocytoma was always diagnosed by increased urinary catecholamine, computerized tomography, magnetic resonance imaging and 131iodine iobenguane scintigraphy.

RESULTS

There were no conversions to open surgery. The operating time ranged from 100 to 150 minutes (mean 116). Mean blood loss was 140 ml. (minimum 550), and none of the patients required transfusion. Hemorrhage due to adrenal vein injury occurred in 1 patient and was controlled intraoperatively. Average postoperative hospital stay was 3.4 days (range 1 to 12). The mean diameter of the excised masses was 38 mm. (range 15 to 70). Postoperative complications occurred in 4 cases, including hematoma in 1, trocar wound infections in 2 and eventration in 1 after 1 year. With a mean followup of 21.6 months (range 6 to 46), all patients had normal urinary catecholamine levels and 18 had normal blood pressure without treatment.

CONCLUSIONS

Retroperitoneal laparoscopic adrenalectomy can be safely performed for small (less than 5 cm. diameter) pheochromocytoma. Retroperitoneal laparoscopy is a direct approach that allows the surgeon to control the adrenal vein first, thereby avoiding hypertensive events.

[Retroperitoneal laparoscopic adrenalectomy: a safe and reproducible technique]

INTRODUCTION

Laparoscopic adrenalectomy has become one of the reference techniques for resection of small tumours of the adrenal gland. The objective of this study was to evaluate the retroperitoneal approach in terms of its intraoperative complication rate, morbidity and length of hospital stay, comparing two centres using the same surgical technique.

MATERIAL AND METHOD

Between January 1995 and March 2000, two different centres respectively performed 55 and 60 laparoscopic adrenalectomies (70 left, 45 right) using a retroperitoneal incision in 106 patients (64 women and 42 men) with a mean age of 49.3 years (range: 17 to 74 years). The mean size of the adrenal tumour was 31 mm (range: 10 to 61 mm). Five trocars were used in every case.

RESULTS

No difference was observed between the two centres in terms of operating time (100 min vs 135 min), conversion rate (0% vs 1.7%), and blood loss (74 ml vs 80 ml). With a mean follow-up of 23.4 months, no difference was observed for morbidity rate (12.7% vs 16.7%), including intraoperative complications (1.8% vs 5%) with 3 vascular injuries, and postoperative complications (10.9% vs 11.7%) comprising wound abscesses, deep haematomas, a hernia at the trocar orifice and one case of severe pneumonia. The mean hospital stay was 3 days vs 5 days with a mean duration of analgesic consumption of 2 days (range: 1 to 5 days).

CONCLUSION

Laparoscopic retroperitoneal adrenalectomy appears to be a reliable and reproducible approach for resection of adrenal gland tumours less than 6 cm in diameter.

[Leiomyosarcoma of the renal vein]

The authors report a new case of leiomyosarcoma of the right renal vein, marked by a rapidly fatal course within 9 months, despite the initial absence of metastasis. This exceptional vascular tumour (only about thirty cases have been published) must be distinguished from primary renal leiomyosarcoma and retroperitoneal leiomyosarcomas involving adjacent structures. This difficult diagnosis was suggested by preoperative CT and angiography. Leiomyosarcomas of the renal vein generally have an unfavourable outcome in the medium term. The prognosis is related to the localized nature of the tumour and the risk of local and distant recurrence. Limited tumour resection is rarely sufficient and radical nephrectomy is usually necessary, possibly associated with a vascular procedure on the inferior vena cava in the case of contiguous extension.

The tension-free transvaginal tape procedure in the treatment of female urinary stress incontinence: a French prospective multicentre study

OBJECTIVE

To evaluate in a prospective multicentre study (five centres) the preliminary results regarding efficacy and morbidity of the new tension-free transvaginal tape (TVT) technique in the treatment of urinary stress incontinence (USI) in women.

METHODS

From November 1996 to May 1999, 52 women of mean age 64 (range 37--91) years underwent the TVT procedure to treat isolated grade 2 or 3 USI (44 cases) or grade 1 or 2 USI associated with uterine or rectal prolapse surgery (8 cases). Twenty-nine patients (55.8%) presented recurrent USI (1--4 previous procedures). Clinical data showed urethrovesical junction hypermobility in 35 cases (67.3%), isolated intrinsic sphincter deficiency (ISD) in 17 cases (32.6%) and pelvic organ prolapse in 8 cases. Urodynamics confirmed ISD in 27 cases (51.9%) with a mean urethral closure pressure of 18.5 (range 7--25) cm H(2)O. All data were collected by surgeons on a questionnaire.

RESULTS

The surgical procedure was performed under spinal cord anaesthesia in 82.7% of patients (local anaesthesia 11.5%) with a mean operation time of 30 (range 20--60) min for TVT implantation. Six bladder injuries (11.5%) were identified and the needle was repositioned. Mean hospital stay was 2.5 (range 1-7) days in the group who underwent TVT alone. Mean follow-up of continence was 15.2 (range 6--36) months: 83% of patients were dry and 17% were improved. Nine patients (17.3%) required self-catheterization for 2--10 days postoperatively. No recurrence of USI, defect healing or tape rejection were reported.

CONCLUSION

TVT is a new technique for the surgical treatment of USI which is useful for recurrent cases. The advantages are simplicity, low morbidity, reproducibility and reduced operative time. These early results indicate the technique is effective in correcting incontinence and is locally well tolerated. But these are preliminary data and the long-term outcome on USI and the urethra is needed.

Urological complications of laparoscopic surgery: experience with 350 procedures at a single center

PURPOSE

We assessed our experience with urological complications of laparoscopic surgery in regard to incidence, etiology, treatment and possible prevention.

MATERIALS AND METHODS

A total of 350 laparoscopic procedures were performed at our institution between June 1993 and December 1999 in 206 men and 139 women. These procedures included pelvic lymph node dissection in 102, bladder neck suspension in 99, adrenalectomy in 54, varicocelectomy in 23, pyeloplasty in 22, nephrectomy in 20, treatment of benign renal pathologies, including cyst, diverticula and calculi, in 13, genitourinary prolapse repair in 11 and miscellaneous procedures in 6 patients. Complications were evaluated according to the procedure attempted and were listed by incidence and etiology.

RESULTS

A total of 19 (5.4%) complications occurred in our series. The associated mortality rate was 0.3% and conversion rate was 1.1%. Most intraoperative complications (2.6%) were vascular (4) and visceral injuries (5), while postoperative complications (2.8%) were predominantly thromboembolism (3) and wound infection (2) at trocar sites. The complication rate decreased from 9% for the first 100 to 4% for the subsequent 250 procedures.

CONCLUSIONS

Critical documentation of complications of laparoscopic surgery is important for further development of the technique and information for urologists in training. Most of our serious complications should be preventable with better mastery of the different procedural steps. However, laparoscopy must be regarded as major surgery with a significant learning curve.

Radical cystectomy in patients older than 75 years: assessment of morbidity and mortality

OBJECTIVE

We have reviewed our surgical experience to assess intra- and postoperative morbidity and mortality in 25 patients 75 years old or older with invasive bladder cancer who underwent radical cystectomy and urinary diversion or bladder substitution.

METHODS

Between January 1993 and February 1999, of 190 patients who underwent radical cystectomy, 23 men and 2 women were aged from 75 to 87 (median 79) years. Urinary diversion was performed in 23 cases and bladder substitution in 2. All patients had significant comorbidity and 15 patients were ASA II and 10 ASA III.

RESULTS

Median operating time was 4 h. Perioperative mortality rate was 4%. Intraoperative, early and late postoperative complications occurred in 15, 16 and 6 patients, respectively. The most common early complications were pyelonephritis (32%), disorientation (20%), additional pulmonary infection (20%) and prolonged ileus (32%). No secondary procedures were necessary. The most common late complication was ureteroileal anastomotic stricture (16%). The median hospital stay and intensive care unit stay were 24 and 14 days, respectively. With a median follow-up of 14 (5-50) months the overall mortality rate was 32%.

CONCLUSIONS

Radical cystectomy can be performed in elderly patients with acceptable perioperative mortality and morbidity. However, because of the high incidence of minor medical complications, hospital stay is often prolonged.

[Primary carcinoid tumor and horseshoe kidney: potential association]

The authors present the ninth case of primary carcinoid tumour arising in a horseshoe kidney. The diagnosis and treatment were delayed due to the benign cystic appearance of the initial lesion. This exceptional association must be kept in mind, as horseshoe kidney is associated with an increased risk of malignant tumours, especially for carcinoid tumours. The minimally aggressive nature of these tumours generally allows limited surgical resection.

Retroperitoneal laparoscopic versus open pyeloplasty with a minimal incision: comparison of two surgical approaches

OBJECTIVES

To compare the complications, hospital stay, and functional results of retroperitoneal laparoscopic (RL) pyeloplasty versus open pyeloplasty (OP) with a minimal subcostal incision.

METHODS

From October 1997 to January 2000, 53 consecutive nonrandomized patients underwent 26 RL pyeloplasties, of which 1 was bilateral (group 1), and 28 OP (group 2). The decision between the two techniques depended on the patient's anesthetic ability to tolerate RL, previous ureteropelvic junction surgery, associated renal pathologic findings, and the surgeon's laparoscopic experience. Subjective outcomes as to postoperative pain and convalescence and objective findings on intravenous urography were assessed at 3 months postoperatively in both groups.

RESULTS

The mean operating time (165 versus 145 minutes) and mean blood loss (92 versus 84 mL) were similar in both groups. No intraoperative complications occurred in either group; in group 1, 1 patient required open conversion. Postoperative complications occurred in 11.5% of group 1 and 14.3% of group 2. The mean hospital stay was 4.5 days for group 1 and 5.5 days for group 2. At 3 months, 23 patients (92%) in group 1 and 25 (89.2%) in group 2 were pain-free or improved. Intravenous urography showed a patent ureteropelvic junction in all cases and improvement of hydronephrosis in 88.5% of group 1 and 89.3% of group 2.

CONCLUSIONS

The incidence of complications, hospital stay, and functional results were equivalent for RL pyeloplasty and OP with a minimal incision, but the return to painless activity was more rapid with laparoscopy in younger patients.

Retroperitoneal laparoscopic adrenalectomy: clinical experience in 52 procedures

OBJECTIVES

Laparoscopic adrenalectomy has become an effective option for removal of small adrenal tumors. The aim of this prospective study was to evaluate the retroperitoneal approach with regard to intraoperative complications, morbidity, and length of hospital stay.

METHODS

Between September 1996 and October 1999, we performed 52 laparoscopic adrenalectomies (31 left, 21 right) for benign lesions by a retroperitoneal approach in 44 patients (27 women, 17 men) with a mean age of 46.9 years (range 17 to 74). The average adrenal tumor size was 32 mm (range 10 to 63). All procedures required four trocars and a mean operative time of 135 minutes (range 75 to 240).

RESULTS

There was no mortality, conversion rate to open surgery was 1.9%, and estimated blood loss was 80 mL (range 30 to 200). With a mean follow-up of 16 months, morbidity was 17.2%, which included intraoperative complications (5. 7%) with two vascular injuries, and postoperative complications (11. 5%) with wound infections, deep hematoma, and parietal dehiscence. Average length of hospital stay was 5 days with a mean analgesic consumption of 2 days (range 1 to 5).

CONCLUSIONS

The retroperitoneal approach in laparoscopic adrenalectomy appears to be a minimally invasive and safe therapeutic option that may become the standard for unilateral or bilateral adrenal tumors not larger than 7 cm. However, a learning curve in laparoscopy is indispensable before starting this type of procedure.

[Pfannenstiel short horizontal laparotomy in retropubic radical prostatectomy]

OBJECTIVE

To evaluate the feasibility of the Pfannenstiel short horizontal laparotomy to perform retropubic radical prostatectomy and its consequences on postoperative analgesic consumption.

MATERIALS AND METHODS

From December 1998 to February 2000, 62 radical prostatectomies were performed via a short horizontal suprapubic incision. The mean length of the incision in the lower abdominal fold was 10.2 cm (range: 8 to 14 cm). The mean duration of radical prostatectomy was 130 minutes (range: 90 to 210 min). Double drainage (retropubic and subaponeurotic) was systematically maintained for an average of 48 hours. Postoperative narcotic analgesic consumption, and the modalities and duration of prescription were compared between 30 patients operated by this technique and 30 patients previously operated via a midline infraumbilical incision.

RESULTS

The abdominal wall opening and closing time was about 20 minutes. The operation was always performed via this incision, allowing excellent exposure of lymph node areas and the prostate. Postoperative complications related to this incision consisted of a single subaponeurotic haematoma, which was not drained. The mean dosage and duration of postoperative analgesic consumption decreased by 44% compared to the reference group. Postoperative assessment of the abdominal wall showed almost complete disappearance of the scar at 3 months and no secondary wound dehiscence.

CONCLUSION

The Pfannenstiel short horizontal laparotomy is a simple and reproducible technique for retropubic radical prostatectomy. This feasibility study was accompanied by a reduction of postoperative analgesic consumption in the study group.

[Repair of female urinary incontinence with prolene "TVT": preliminary results of a multicenter and prospective survey]

OBJECTIVES

A multicentre, prospective study (6 private centres, 1 general hospital and 1 teaching hospital) was conducted to evaluate the perioperative morbidity and short-term functional results of the TVT procedure in the treatment of the female urinary stress incontinence.

PATIENTS AND METHODS

From November 1996 to September 1999, 120 patients with a mean age of 65.2 years (range: 37-91) were operated according to the tension-free vaginal tape (TVT) technique for isolated urinary stress incontinence (stage 2 or 3) in 94 cases and associated with pelvic tone disorder in 26 cases. 59 patients (49.2%) presented recurrence of urinary incontinence that had already been operated between 1 and 4 times. Physical examination demonstrated hypermobility of the urethra in 73 cases (60.8%), isolated clinical sphincter incompetence in 47 cases (39.2%) and pelvic tone disorders in 31 cases. Urodynamic studies, performed in 113 patients, demonstrated sphincter incompetence in 65 cases (57.5%) with a mean maximum urethral closure pressure of 18 cmH2O (range: 5-29).

RESULTS

The operation, performed under spinal anaesthesia in 97 cases (80.8%), general anaesthesia in 16 cases (13.3%) and local anaesthesia in 7 cases (5.8%) lasted an average of 28.7 min (range: 15-60) for insertion of the TVT. Perioperative complications consisted of twelve bladder injuries (10%) and two pelvic haematomas (1.7%). No cases of infection, erosion or migration of the tape were reported. In the group of 94 patients operated exclusively by TVT, the mean hospital stay was 2.6 days (range: 1-7). Twelve patients (10%) required self-catheterization for 2 to 30 days. With a mean follow-up of 15.2 months (range: 36-6), continence was restored in 104 patients, corresponding to a cure rate of 86.7%. A marked improvement was obtained in 11 cases (9.2%) and five cases (4.2%) were considered to be failures.

CONCLUSION

The TVT procedure is a new approach to the treatment of female urinary stress incontinence. Its advantages are its simplicity, the rapidity of the technical procedure and the short-term efficacy on continence. A longer follow-up is essential to assess to the functional outcome and the long-term urethral tolerance.

[Assessment of urinary continence in Hautmann neobladder]

OBJECTIVE

The Hautmann neobladder is a bladder replacement technique frequently proposed after total cystectomy for bladder cancer. The objective of this prospective study was to evaluate the patients' urinary continence after this operation, based on clinical and urodynamic data.

MATERIALS AND METHODS

The functional assessment was based on 26 patients from a series of 45 consecutive Hautmann bladder replacements performed between February 1994 and May 1999. These 26 nonselected patients (21 men and 5 women) with a mean age of 56 years (range: 38-68) accepted the principle of functional assessment of continence at visits held 1, 3, 6 and 12 months postoperatively including clinical interview, urodynamic studies and fibroscopy. Only one patient presented with preoperative stress incontinence. The mean follow-up of these 26 patients was 22 months (range: 10-60). Three patients, including two women, died from progression of their bladder tumour at the 12th, 20th and 32nd postoperative months.

RESULTS

Urodynamic studies showed a mean maximum capacity of the ileal reservoir of 420 ml (range: 316-571), a maximum filling pressure of 15 cmH2O (range: 2-24) and a maximum urethral closure pressure of 49 cmH2O (range: 31-74). According to the evaluation criteria used, the satisfactory continence rates, as assessed by the patients were 62%, 77%, 84.6% during the day and 42%, 615%, 77% at night, at 3, 6 and 12 months, respectively.

CONCLUSION

The Hautmann neobladder ensures satisfactory diurnal and nocturnal urinary continence in more than 75% of cases after the 6th postoperative month. Continence is an evolving parameter especially during the first postoperative year. The selection of patients in good general condition and motivated for management of their new urinary situation remains an essential prerequisite to obtain a good functional result.

[Urethral instability]

Urethral instability is an abnormal behaviour of the urethra associated with sudden reduction of urethral pressures. This disease is rarely described in view of its nonspecific clinical features and the abnormalities only detected on continuous urethral recording. Alteration of the voiding reflex is the most likely aetiopathogenic basis, although other urethral and neurological diseases have been observed. The numerous treatment options reflect the limited knowledge concerning aetiological factors.

Role of preoperative positive apical biopsies in the prediction of specimen-confined prostate cancer after radical retropubic prostatectomy: a multi-institutional study

OBJECTIVES

A multi-institutional study of 280 radical prostatectomy specimens obtained from three independent academic hospitals was undertaken to validate a nomogram developed for the prediction of specimenconfined protstate cancer after prostatectomy.

METHODS

Three preoperative factors - the Gleason score, prostatespecific antigen (PSA) and apical location of positive biopsies - that were identified with a previous logistic regression formula were collected. Links between margin status and preoperative criteria were confirmed by univariate methods. Subsequently, the predictive indexes of positive margins were calculated and compared to the actual margin status in terms of predictive characteristics.

RESULTS

This control series, independent of the initial series that was used to identify the relevant preoperative factors, confirmed that positive apical biopsies(p<0.001), PSA (p<0.005) and the Gleason score (p<0.005) were strongly linked to the occurrence of positive margins. Different cutoff values for the predictive index were compared in a receiver operating characteristic curve. A value of 0.5, similar to the one described in the original series, gave an adequate compromise between sensitivity and specificity with respective values of 68 and 73% and a test accuracy of 72%. In practical terms, it was possible to predict 85% of negative margins, and to delineate two groups with different rates of positive margins (14.5 vs. 50%).

CONCLUSIONS

We demonstrated that PSA, the Gleason score and apical biopsy status are cumulative risk factors for positive margins. Risk of positive margins increases when it is not possible to obtain a wide excision of periprostatic fascia, as at the apex. This study substantiates the independent prognostic value of positive preoperative apical biopsies for predicting positive surgical margins.

[Kock's pouch: experience and clinical course in 31 patients]

OBJECTIVES

To analyse the morbidity and functional results of Kock's continent urinary diversion performed since 1992 in cystectomized patients in whom the urethra could not be used.

MATERIAL AND METHODS

From March 1992 to June 1998, 31 Kock's pouches were performed by 2 surgeons on a group of patients with a mean age of 54 years. Henriet's technique was used in 23 patients until 1996, and was then modified the last 8 patients in order to create a continent valve. The diversion was performed after cystectomy for bladder or gynaecological tumour in 23 cases and 1 urinary tract reconstruction in 8 cases (neurogenic bladder, destroyed urethra, conversion of Bricker diversion).

RESULTS

With a mean follow-up of 42 months (12 to 84), the perioperative mortality was 3.4% and immediate complications were 26%, justifying reoperation in 6.4%. Late complications predominantly consisted of disinvagination of the valve with a reoperation rate of 13%. No surgical revision for newly modified antireflux valves has been performed since 1996. The continence rate of the system, evaluated between 3 and 6 months, was 90%.

CONCLUSION

Kock's pouch is a delicate operation, clearly associated with a high morbidity in this series, as in the literature, although the results improved with experience. Indications must be confined to patients in good general condition, motivated for self-catheterization (ATS) and in whom the urethra cannot be used for bladder replacement.

[Renal adenocarcinoma with retrohepatic vena cava thrombus: role of extracorporeal circulation in a retrospective series of 10 cases]

INTRODUCTION

Renal cell carcinoma is accompanied by tumour thrombus in the inferior vena cava (IVC) in 4 to 10% of cases. Since the use of cardiopulmonary bypass (CPB), surgery for extensive thrombus has been improved by reduction of blood loss, facilitating complete resection of the kidney and thrombus and possible repair of the inferior vena cava.

OBJECTIVES

To analyse a retrospective series of 10 cases and to compare the complications of CPB and conventional surgery by direct clamping.

MATERIAL AND METHODS

From February 1985 to December 1997, 413 patients were operated for renal cancer, including 23 (5.6%) patients with tumour thrombus in the inferior vena cava. Ten of these 23 cases of inferior vena caval thrombus were retrohepatic. Group I (5 patients) was operated under CPB and profound hypothermia at 16 degrees C (mean duration of bypass: 30 min). Group II (5 patients) was operated by conventional surgery (CS) (mean clamp time: 12 min).

RESULTS

No difference in terms of intraoperative complications was observed between the two groups, but 2 deaths occurred in group II due to respiratory decompensation, 1 and 2 weeks postoperatively.

CONCLUSION

The level of the thrombus in the inferior vena cava determines the mode of vascular management. The presence of invasion of the inferior vena cava wall is difficult to predict because of the poor sensitivity of radiological examinations. CPB did not induce any excess morbidity in this series. The use of CPB in renal cancers with retrohepatic thrombus facilitates the resection procedure and allows inferior vena cava reconstruction in a bloodless environment.

[Risk of second non-germ cell cancer after treatment of stage I-II testicular seminoma]

OBJECTIVE

To determine the incidence of second non-germ-cell cancers (SNGC) in patients treated for stage I-II testicular seminoma.

MATERIAL AND METHODS

This study is based on 131 evaluable patients treated at the Institut Claudius Regaud between 1970 and 1990. Treatment modalities, including salvage therapy for 6 patients developing recurrence, were as follows: infradiaphragmatic irradiation (infraDI) only in 55 cases, infra- and supradiaphragmatic irradiation (infraDI + supraDI) in 64 cases, and irradiation and chemotherapy (IC) in 12 cases. Five patients were lost to follow-up 4 months to 14 years after primary treatment (mean follow-up: 11 years). The cumulative incidence of SNGC was compared to the overall cancer incidence in the age-matched male population reported in the Tarn Cancer Registry. The relative risk was expressed as the Standardized Incidence Ratio (SIR).

RESULTS

The cumulative incidence of SNGC was 10.7% (14/131 patients). SIR was equal to 2.81 (p < 0.001) and increased with the duration of follow-up. SIR was significantly increased in 64 patients treated with infraDI + supraDI (SIR) = 3.25; p = 0.002), but not in the 55 patients treated with infraDI only (SIR = 0.62; p = 0.8). The 12 treated patients with IC had an SIR of 26.2 (p < 0.001). Three of the 4 patients who developed a haematological malignancy belonged to the IC group.

CONCLUSIONS

The risk of SNGC is increased after infraDI + supraDI. The risk of SNGC after infraDI only is not increased with a median follow-up of 6 years, but this follow-up is too short to allow any definitive conclusions. The risk of SNGC and particularly haematological malignancy appears to be increased by the combination of radiotherapy and chemotherapy.

[Large-cell calcifying Sertoli cell tumors: apropos of a case and review of the literature]

The authors report the case of a 22-year-old man presenting with a tumour of the lower pole of the left testis, present for 4 months, which proved to be a calcified Sertoli large cell tumour, an extremely rare group of sex cord tumours of the testis presenting specific clinical and histological features. These tumours are usually benign, occur during the first two decades of life and can be associated with dysplastic complexes or endocrinopathies (Carney's complex, Peutz-Jeghers syndrome). They present either in the form of bilateral, multifocal tumours in the context of a pathological association, or in the unilateral form, without association. Several malignant forms with metastases have been described. Conventional treatment is transinguinal radical orchidectomy.