Biomedical subjects
Publications and source records attributed to C Coulange.
Prostate specific antigen is the "gold standard" prostate tissue marker. Based on a reviews of the literature, we present the metabolism, method and lassay clinical use for diagnosis, staging and prostate cancer as well as for monitoring response to treatment. The authors also discuss some situations able to increase the level of this marker.
OBJECTIVE: Assess the surgical treatment of iatrogenic stenosis of the ureter. METHODS: Seventeen cases of iatrogenic stenosis of the ureter operated between 1991 and 1995 were reviewed. There were 10 women and 7 men, mean age 52 years with pelvic (n = 12), iliac (n = 4) and lumbar (n = 1) stenosis. Ten persons had ureterovesicular reimplantation, including 6 with psoic bladder, 2 with homolateral ureteroureterostomy and 5 with ureteroileoplasty. Mean follow-up was 24 months. RESULTS: Treatment was successful in 14 patients. There were 3 failures, 2 recurrences with reflux which were treated by reoperation with success. CONCLUSION: Our results were in agreement with those reported in the literature. Classical surgery gives sur results in case of endourologic treatment of iatrogenic stenosis of the ureter.
OBJECTIVE: To identify certain prognostic factors of renal cell carcinoma in a retrospective series of 233 patients. PATIENTS AND METHODS: 233 patients (162 males and 71 females with a mean age of 60 years) were operated for renal cell carcinoma between January 1980 and December 1991. sith a mean follow-up of 41.7 months. Statistical analysis was performed according to the Kaplan-Meier method for survival curves, according to the Mantel-Cox model for univariate or multivariate analysis and according to Student's t test and Chi-square test for comparison of quantitative and qualitative variables. RESULTS: The operative and global mortality was 2.2% and 28%, respectively. The following prognostic factors were identified: visceral metastases (p = 0.0001), lymph node invasion (p = 0.001), symptomatic nature of the tumour (p = 0.0004), local pathological stage (p = 0.0001) and nuclear grade (p = 0.0001). Multivariate analysis showed that the first 3 factors were the most pejorative (relative risk (RR) = 6.7, 4.6, and 1.7, respectively). Venous invation, multifocal tumours, and cell type were not studied in our series. CONCLUSION: This study confirmed that metastases, lymph node invasion and symptomatic tumours were the most pejorative prognostic factors.
BACKGROUND: The authors assessed the interest and the value of Fuhrman's nuclear grade as a possible prognostic factor for renal cell carcinoma (RCC). METHODS: An 11-year retrospective study of 190 patients with RCC treated by radical nephrectomy was performed. The distribution by grade was: Grade I, 54 patients; Grade II, 58; Grade III, 58; and Grade IV, 20. The distribution of the patients by tumor stage according to the TNM15 classification was: pT1, 56 patients; pT2, 41; pT3a, 55; pT3b, 25; pT3c + pT3d + pT4b, 5; and pT4a, 8. Significant correlations with other prognostic parameters were noted. Survival curves by grade were evaluated by the Kaplan-Meier method. RESULTS: Nuclear grade was correlated with tumor stage (P = 0.0001), synchronous metastases (P = 0.003), lymph node involvement (P = 0.0001), renal vein involvement (P = 0.0001), tumor size (P = 0.0001), and perirenal fat involvement (P = 0.001). No correlation was found between nuclear grade and tumor multicentricity (P = 0.14) and cell type (P = 0.2). Nuclear grade was an effective parameter in predicting development of distant metastases after nephrectomy. Among the 54 patients who presented with Grade I tumors, only one tumor did metastasize during the 5-year follow-up, whereas 17% of the Grade III and 30% of the Grade IV tumors metastasized. The 5-year actuarial survival rates of the patients with Grade I, II, III, and IV tumors was 76%, 72%, 51%, and 35%, respectively. The comparison of the survival curves by grade showed a statistically significant difference between the curves when Grade I and II tumors were compared with Grade III and IV tumors (P = 0.001). CONCLUSION: In this study, nuclear grade was found to have prognostic significance and seems to be an important criterion when considering the outcome of patients with RCC.
From 1980 to 1991, 236 patients with renal cell carcinoma were treated in our department. We studied the characteristics and the prognostic significance of 74 patients with incidental renal cancer in comparison with those with symptomatic tumors. The mean age of the patients was 59.8 years and the sex ratio 2 males/1 female. The incidence of incidental tumors increased from 14% in 1980 to 48% in 1991. Incidental tumors were discovered mainly during examination for cardiovascular diseases (26%), hepatobiliary diseases (22%) and general health examination (23%). Local tumoral stage and histologic grade were significantly lower for the incidental tumors than for symptomatic ones (p = 0.002 and p = 0.001). In the same way, the rates of the patients with metastases or nodal involvement were lower for those with incidental tumors than for those with symptomatic tumors (p = 0.008 and p = 0.001). The mean tumoral size was 5.7 +/- 3 cm for incidental tumors and 7.6 +/- 3.5 cm for symptomatic tumors (p = 0.0001). The survival was significantly different according to the circumstances of detection of the tumors (p < 0.001); the 5- and 10-year actuarial survival rates was 85% for the patients with incidental tumors and respectively 61 and 44% for the patients with symptomatic tumors. The multivariate analysis by Cox proportional hazard model showed three important and independent prognostic factors: the presence of metastases (relative risk (RR): 6.7), nodal involvement (RR: 4.6) and symptomatic tumors (RR: 1.7). The patients with incidental tumors had a better prognosis than those with symptomatic tumors because of lower tumoral size and local stage. The early diagnosis of renal cell carcinoma improved the prognosis of the patients.
OBJECTIVE: Annual national epidemiological evaluation of renal tumours by means of a multicentre survey proposed by the oncology committee of the Association Française d'Urologie. PATIENTS AND METHODS: From April 1, 1993 to March 31, 1994, 970 patients were recruited by 54 centres. A computer form was completed for each patient, including: the patient's age and sex, modalities of discovery of the tumour, complementary investigations (radiological and laboratory tests) performed, treatment performed, TNM staging, histological characteristics of the tumour. RESULTS: The mean age of the patients was 62.1 years with a sex ratio of 2 males to 1 female. The rate of incidental tumours was 40%. Radical nephrectomy was performed in 90% of cases and conservative surgery was performed in 7% of cases. Medical treatment was instituted in 5% of cases. The distribution of tumours by TNM stage was: pT1: 8%, pT2: 53%, pT3a: 21% and pT3b: 18%. Lymph node involvement was detected in 12% of cases, and visceral metastases were identified in 6% of cases. 80% of incidental tumours were intracapsular. The predominant histological type was renal cell carcinoma (66%). The mean tumour size for the entire series of tumours was 6.4 +/- 3.5 cm and was significantly larger in symptomatic patients and in those with poor prognostic factors (adrenal involvement, inferior vena cava invasion, lymph node and/or visceral involvement). Adrenal and inferior vena cava involvement was detected in 4% of cases. 14% of patients had multifocal tumours, which was not correlated with either the size of the tumour or the cell type. The nuclear grade was determined in 66% of cases and was significantly correlated with perirenal fat and lymph node involvement. CONCLUSION: This survey collected approximately 1/5 of all new annual cases of renal cell carcinoma in France and therefore provided a precise evaluation of the current epidemiology of this tumour.
OBJECTIVES: To evaluate the morbidity of multiple artery renal transplants (> 1 artery) and to assess the value of this parameter as a risk factor for complications of renal transplantation in adults. METHODS: 140 renal transplants derived from brain dead donors with multiple arteries (2 arteries = 123, 3 arteries = 17) were reviewed with a mean follow-up of 3 years (6-120 months). Pedicle restoration was performed in 57 cases (end-to-side reimplantation of a polar artery = 17, composite aortic patch graft = 14, multiple procedures = 10, ligation of a polar artery = 8, arterial wound = 5, "gun barrel" anastomosis of 2 arteries = 4). Arteriography was performed systematically in 57 cases, in the absence of any signs suggestive of a vascular complication. RESULTS: 2 recipients died from a vascular complication. 40% of transplants were functional at 5 years. 10 transplantectomies were performed for a vascular complication. 14 recipients returned to dialysis because of a vascular complication. 7.5% of systematic arteriographies revealed stenosis of the transplant artery. 54 transplants developed a vascular complication: thrombosis = 19, stenosis = 25. Three-artery transplants had a vascular morbidity of 50%. "Gun-barrel" anastomoses and polar reimplantations into the main trunk had a vascular morbidity of 40%. The urological morbidity was 10%. CONCLUSION: Multiple artery renal transplants, especially 3-artery transplants and certain pedicle restorations, are associated with a high risk of vascular complications. Arterial anatomy is a selection criterion for the donor and recipient which must be taken into account in renal transplantation.
Ureteric stents can be complicated by incrustations, sometimes making it impossible to withdraw or replace the stent over a guide. In this exceptional indication, we report a case in which the use of the Swiss-Lithoclast pneumatic lithotriptor allowed withdrawal of an incrusted double J stent. There was no morbidity related to the use of the Lithoclast. Among the various techniques available for removal of these incrusted double J stents, endoprosthetic lithotripsy appears to be the most effective and the least invasive, in selected cases.
OBJECTIVES: This European multicenter study was aimed to assess the clinical reliability of a modified prostatic UroLume Wallstent (American Medical System, Minnetonka, MN) in the treatment of 135 healthy patients with symptomatic benign prostatic hyperplasia. METHODS: Ninety-one patients who were obstructed but still voiding spontaneously and 44 patients who had an indwelling catheter were treated by placement of a modified stent. RESULTS: A significant improvement in mean peak flow rates and residual urine volumes was maintained throughout follow-up. Both obstructive and irritative voiding symptoms were significantly improved after placement of the stent, although a greater amelioration was seen in obstructive symptoms. The rate of patients reporting erections increased after stent insertion. Eighty percent of sexually active patients reported the maintenance of antegrade ejaculation postoperatively. A greater than 80% epithelialization of the stent was seen in 28 patients (100%) examined at the 18-month follow-up. Long-term complications were seen in 51 patients (38%). Twenty-one of these patients had the stent removed due to intractable detrusor instability, stent encrustation, stent migration, or persistence of obstruction due to prominent median lobe, understenting, or severe hyperplasia of the epithelium of the prostatic urethra. In 6 of them another stent was reimplanted while the others were treated surgically. CONCLUSIONS: Although this modified stent was abandoned due to an unacceptable rate of complications, this study demonstrates that bladder outlet obstruction in healthy patients with benign prostatic hyperplasia can be successfully relieved by the placement of a UroLume Wallstent.
From 1980 to 1991, 109 patients were treated for a tumour of the upper urinary tract. All patients were examined by intravenous urography (IVU) which had a sensitivity of 61%. The combination of IVU + RUP established the diagnosis in 72% of cases. Renal ultrasonography and abdominal computed tomography (CT) were performed in 41 and 67 cases, respectively. The sensitivity of ultrasonography was 40% and that of CT was 72%. CT was more sensitive for tumours of the renal pelvis (78%) than for ureteric tumours (53%) (p < 0.02) and when the tumour diameter exceeded 2 cm (70% vs 45%: p < 0.01). The sensitivity of CT for lymph node extension was 47% with an accuracy of 88%. Preoperative CT staging was compared to pathological staging: CT staging had an accuracy of 56%; in 31% of cases, CT underestimated the parietal extension of the tumour. The sensitivity of CT to assess invasion of the renal parenchyma and of the perirenal fat was 52% and 74%, respectively (p < 0.01). Morphological examinations are able to diagnose a tumour of the upper urinary tract in 3 out of 4 cases. Correct preoperative staging can only be achieved on one half of cases, which constitutes a drawback to the development of conservative treatment techniques.
Based on a retrospective study of 52 patients with prostatic adenocarcinoma and bone metastases (stage M1b), the authors analysed the following prognostic factors at the time of diagnosis: age, general status, bone pain, haemoglobin, local tumour volume, ureteric repercussions, pre and post-treatment PAP and PSA levels, Gleason score, and metastatic spread on bone scan. This study demonstrated two predominant prognostic factors for the appearance of early or late therapeutic escape: tumour differentiation established by the Gleason score (P = 0.003), stage of the disease, i.e. local tumour volume (p = 0.001) and bone mass invaded on bone scan (p = 0.0002). The other prognostic factors can be deduced from these two parameters. Qualitative analysis of the initial bone scan allowed patients with peripheral bone metastases to be distinguished from those with exclusively axial involvement. The two-year survival was 50% in patients with peripheral metastases versus 93% in patients without peripheral metastases (p < 0.05). Although bone metastasis constitutes a decisive prognostic factor, the detection of peripheral bone metastases appears to be a factor of poor prognosis.
Collections after renal transplantation are represented by lymphoceles, hematomas and urinary leaks. Symptomatic lymphoceles should be treated by external puncture and drainage. Deeper lymphoceles and prolonged lymphorrhea must be surgically marsupialised, in association with epiploplasty. Acute hematoma in the area of transplantation requires surgical exploration and external drainage--this may induce a lymphorrhea. Urinary leaks and urinomas require drainage as well as an ureteral support. The leakage area determines whether surgery is necessary: be it reimplantation, psoïchal bladder or nature ureter. Intraluminal urinary obstructions responds to conventional urologic treatment. Distal parietal obstructions are surgically treated in the case of failure of percutaneous treatment by reimplantation, psoïchal bladder, native ureter, or even ureteroplasty or prosthesis. Stenoses extending over the entire ureter require surgical ureteral reconstruction. The treatment of extrinsic obstructions can be by ureteral drainage, uterolysis or ureteral reconstruction. In case of such complications, percutaneous techniques have reduced frequency and morbidity of open surgery.
Some renal calculi are borderline indications for either extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL). Our purpose was to quantify by single photon emission computed tomography (SPECT) the parenchymal lesions of these two procedures to make the choice easier. The SPECT study was done before and 30 days after the stone treatment. The scan was carried out 10 hours after injection of 99mTc-DMSA using a GE400 rotative gamma camera, which data were reconstructed in three planes. The local uptake and scar of the treated area were evaluated in 22 patients with symptomatic kidney stones without previous treatment or renal failure. Twelve patients (mean stone size 12 x 9 mm) were treated on a piezoelectric (EDAP LT-01) lithotripter (mean shock wave number 3420), and ten patients (mean stone size 24 x 17 mm) were treated by PCNL (32F Amplatz sheath in a lower calix). There were no complications, and the stone-free rate at day 30 was 50% in both groups. In the ESWL group, all of the kidneys demonstrated a loss of local uptake, whereas 7 of the 10 in the PCNL group did so. In the ESWL group, 4 of the 12 kidneys had a local loss exceeding 4% but only 2 of 10 kidneys in the PCNL group. There were 7 scars in the treated area in the ESWL group and 6 in the PCNL group. Extracorporeal lithotripsy does not seem to be a nontraumatic procedure for the kidney. For stones that would require several sessions of ESWL, the use of PCNL must be preferred.
Ninety-six men considered unfit for prostatic surgery underwent the insertion of a permanently implanted super alloy mesh stent (Urolume) at 5 European centres. Ninety were able to void immediately, 2 required a second stent to enable them to void and 4 voided after a period of suprapubic catheter drainage. Seven patients required the subsequent insertion of a further stent to cover the prostatic urethra completely and in 8 cases the stent was removed. Objective and symptomatic evidence of relief of bladder outflow obstruction was shown throughout the period of study. Severe irritative symptoms were seen in the majority of patients for periods of up to 3 months and resulted in removal of the stent in 3. At 12 months, 15 of 27 patients who underwent cystoscopy had complete epithelialisation of the stent and in 11 cases there was more than 70% epithelialisation. Fourteen patients developed encrustation on exposed parts of the stent during follow-up. This was associated with the development of a urinary infection in 9. The positioning of the stent in subsequent studies has been altered to overcome this problem.
Prosthetic surgery for impotence has been transformed by the development of inflatable prostheses in the place of older semirigid models. Despite the popularity of this new technique, it raises certain questions concerning the functional results and complications of this surgery, which have only occasionally been studied concomitantly in the literature. The sexuality of patients has generally been evaluated on the basis of answers to a questionnaire sent to the patients. This study reports our experience, compared to the data in the literature, based on 58 insertions of inflatable prosthesis between October 1987 and October 1991. After rigorous patient selection and a mean follow-up of 30 months, the surgeon evaluated the objective results (mechanical functioning of the prosthesis, complications) and subjective results (sexuality) in 51 patients. 69.4% of patients presented an anomaly of prosthesis function, 10.3% developed an infection of the prosthesis, 34.5% required removal of the prosthesis, 59% declared that they were satisfied sexually and sexual activity was restored in 55%. This study therefore appears to contradict the optimistic data reported in the literature.
In a series of 107 patients treated over an 11-year period for upper urinary tract tumours (UTT), 30 had a synchronous or metachronous associated bladder tumour. The bladder tumour preceded the UTT in 10.3% of cases, the bladder tumour was synchronous in 6.5% of cases and the bladder tumour occurred after the UTT in 15% of cases, the incidence of UTT after cystectomy over this 11-year period was 3.3%. The median time to recurrence of the UTT after bladder tumour was 17 months. The median time to recurrence of the bladder tumour after the UTT was 12 months. The risk of bladder recurrence after treatment of the upper tract tumour was studied in relation to site, type of treatment, multifocal nature, stage and grade of the UTT and the presence of a previous or synchronous associated bladder tumour. None of these parameters constituted a predictive factor of bladder recurrence after treatment of an upper tract tumour. Comparison of survival between the UTT + bladder tumour group and the UTT alone group did not reveal any significant difference (p = 0.10). The theory of cellular implantation facilitated by vesicorenal reflux and the multifocal theory are complementary explanations of the multifocal and recurrent nature of urothelial tumours.
The authors study the ultrasound signs of the adrenal gland based on 5 different types of operated adrenal tumours (a lipoma, an adrenal cortical adenoma, a cyst, a corticoadrenaloma, an adrenal metastasis from a renal cell carcinoma). The ultrasonographic morphological criteria of the normal adrenal gland and each type of tumour are recalled and are illustrated by clinical cases. The value of ultrasonography in the investigation of this organ was evaluated in comparison with other imaging techniques. It constitutes a good first-line diagnostic guiding examination, but needs to be completed by other investigations (computed tomography, magnetic resonance imaging, etc.). Ultrasonography can also reveal asymptomatic adrenal tumours ("adrenal incidentalomas") in which the therapeutic decision (surveillance or surgery) must be based on criteria of size and appearance after a complete laboratory and morphological assessment.
The late urological sequelae of pelvic radiotherapy for cancer sometimes require cutaneous urinary diversion. The local conditions often exclude the use of direct or transileal ureterostomy. Three cases of cutaneous ureterostomy using the transverse colon are presented. There was no operative mortality. A single ureterocolonic stenosis was observed at 12 months and was treated endoscopically. The choice of the transverse colon was based on its position away from the field of irradiation and, consequently, teh absence of radiation lesions, its blood supply which can be used to form pedicles and the possibility of resecting irradiated ureteric segments allowing anastomoses with the proximal ureters. The results reported in the literature show an operative mortality of 0 to 4% and a low morbidity. This technique can be considered to be a technique of choice for cutaneous urinary diversions in urological complications of pelvic radiotherapy.