Christian Saussine

Botulinum toxin-A (Botox) intradetrusor injections in children with neurogenic detrusor overactivity/neurogenic overactive bladder: a systematic literature review.

OBJECTIVES Describe and discuss the efficacy and safety of botulinum toxin type A (BTX-A) intradetrusor injections in children with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB). METHODS A MEDLINE and EMBASE search for clinical studies involving BTX-A injected into the detrusor of children with NDO or NOAB was performed, prior to data analysis. RESULTS A total of six articles evaluating the efficacy and safety of Botox in patients with NDO and incontinence/NOAB were selected. The underlying neurological disease was myelomeningocele in 93% of patients. Most were over 2 years of age. The most common amount of Botox injected was 10-12 U/kg with a maximal dose of 300 U, usually as 30 injections of 10 U/ml in the bladder (excluding the trigone) under cystoscopic guidance and general anaesthesia. Most of the studies reported a significant improvement in clinical (65-87% became completely dry) as well as urodynamic (in most studies mean maximum detrusor pressure was reduced to <40 cm H(2)O and compliance was increased >20 ml/cm H(2)O) variables, without major adverse events. CONCLUSIONS Botox injections into the detrusor provide a clinically significant improvement and seem to be very well tolerated in children with NDO and incontinence/NOAB refractory to antimuscarinics.

Superselective Endo-Vascular Treatment of Renal Vascular Lesions

Embolization with platinum micro-coils delivered through the Tracker-18 micro-catheter was performed in 6 patients when peripheral selective catheterization with standard angiographic catheters was not possible. The patients had a total of 7 peripheral renal vascular lesions (3 arteriovenous fistulas, 2 false aneurysms, 1 direct vascular trauma and 1 arteriovenous malformation). In all patients we initially used platinum micro-coils as the embolic agent. Two patients required repeat embolization with glue. Endo-vascular treatment was technically successful in all cases and no complications were encountered. There was no renal parenchyma infarction in 3 patients and small peripheral infarctions (10 to 15% of the renal parenchyma) occurred in 3. Super selective endo-vascular treatment with a variable stiffness catheter is safe and useful technique when classical methods of embolization are not possible.

Assessment of painful ureterohydronephrosis during pregnancy by MR urography

The purpose of this study was to assess the value of the fast imaging sequence called RARE (rapid acquisition with relaxation enhancement) MR urography (or RMU) In pregnant women with painful ureterohydronephrosis. A total of 17 pregnant women with an acute flank pain were examined with RMU. Results were compared with those of US, X-rays and the evolution of symptoms. The gold standard techniques used to evaluate the results of MR urography were US when it showed the entire dilated urinary tract and the nature of the obstruction (9 cases), limited intravenous urography (IVU) when performed (3 cases) or endoscopic procedure (5 cases). The accuracy of RMU in the detection of urinary tract dilatation and the localization of the level of obstruction was excellent (sensitivity 100% in our series). The determination of the type of obstruction, intrinsic vs extrinsic, was always exact. The RMU technique alone could not specify the exact nature of the obstruction. The RMU technique is able to differentiate a physiological from a pathological ureterohydronephrosis during pregnancy. It could be considered as the procedure of choice when US failed to establish the differential diagnosis.

Natural History of Residual Renal Stone Fragments after ESWL

Objective: After extracorporeal shock wave lithotripsy (ESWL), residual fragments (RF) 4 mm or less are usually considered as clinically insignificant. We retrospectively reviewed the natural history and clinical significance of 97 noninfected and isolated RF (4 mm or less) observed 3 months after the last ESWL session on renal tomography.Patients and Methods: They represented 83 among 1,216 patients treated by ESWL over a 9–year period (1989–1997). These RF were mostly localized in the inferior calyx (62%). Median follow–up was 40.6 months (range: 7–96 months). Renal tomography was always performed at the end of follow–up.Results: Stone–free status, or a decreased, stable or increased amount of residual stone occurred in 27 (33%), 1 (1%), 24 (29%) and 31 (37%) of the 83 patients, respectively. During this study, 18 patients (22%) were proposed for a complementary treatment related to a size increase of the residual fragments (13 ESWL, 1 retrograde endoscopy, 3 percutaneous nephrolithotomy, and 1 polar inferior nephrectomy).Conclusion: The term clinically insignificant should not be employed to describe RF after ESWL. Efforts should be performed to obtain true stone–free status after ESWL.

Evaluation of RARE-MR urography in the assessment of ureterohydronephrosis

Objective The goal of this prospective study was to evaluate the value of the fast imaging sequence called RARE-MR urography (RMU) for the diagnosis of ureterohydronephrosis. Materials and Methods Sixty-nine patients underwent this procedure. The results were compared with those obtained by intravenous urography (IVU) and ultrasonography (US). Results The accuracy of RMU in the detection of urinary tract dilatation and the localization of the level of obstruction was excellent (100%). The determination of the type of obstruction, intrinsic versus extrinsic, was 80% by IVU and 60% for RMU. The RMU sequence alone could not specify the nature of the obstruction. Functional information about the obstructed collecting system could not be obtained. Conclusion The RMU technique may be considered in the following circumstances: contraindications to IVU (allergy to contrast medium, severe renal failure), impairment of renal excretion, and failure to locate the level of obstruction by US. The absence of ionizing radiations favors the promotion of this procedure to study ureterohydronephrosis during pregnancy.

MR urography in the evaluation of urinary tract obstruction

For a long time, conventional intravenous urography (IVU) has been considered the gold standard for the evaluation of the urinary tract. Over the years, the use of IVU has become somewhat less common as a result of the advent of cross-sectional imaging techniques, but it has remained in general use because of its low cost, availability, and ready acceptance by urologic surgeons. IVU has the disadvantage of requiring iodinated contrast media, which has a small risk and is undesirable in patients with previous reactions. IVU is of little use in patients with renal failure. The use of ionizing radiation may also be an issue, particularly in children, young adults, and obviously during pregnancy. Moreover, the clinical situation for most entities often dictate further imaging. Both ultrasound (US) and computed tomography (CT) have been advocated for evaluating urinary tract obstruction and other abnormalities. The concept of MR urography (MRU) is not new. In the past 10 years, this technique has been performed as a complementary tool to evaluate urinary tract abnormalities [1, 7]. The purpose of this paper is to discuss the technical aspect and the results of MRU and to give its potential applications.

Radical Nephrectomy for Renal Cell Carcinoma 30 MM. or Less: Long-Term Followup Results

PURPOSE We investigated the clinical and pathological features, and long-term followup of patients with radical nephrectomy for renal cell carcinoma of 30 mm. or smaller and a normal contralateral kidney. MATERIALS AND METHODS Between 1973 and 1993, 74 patients 29 to 83 years old (average age 60) underwent radical nephrectomy for renal cell carcinoma of 30 mm. or smaller. Average followup was 101 months (range 10 to 236). Of the 74 tumors 21 were stage pT1, 36 stage pT2 and 12 stage pT3 (all 69 stag N0 to NxM0), while 5 were stages pT1 to 3, N1 or M1. A total of 27 patients died during follow-up. Of 11 patients who died of disease progression 5 had metastatic disease initially. RESULTS Overall survival rates were 73% at 5 years, 55% at 10 years and 38% at 20 years. Cancer-specific survival rates without the 5 patients with stage N1 or M1 disease were 91% at 5 years, and 80% at 10 and 20 years. For the group with nonmultifocal renal cell carcinoma, stage NO to Nx and/or MO, the cancer-specific survival rates were 93% at 5 years, and 81% at 10 and 20 years. For the group with multifocal renal cell carcinoma, stage NO to Nx and/or MO, the cancer-specific survival rate was 75% at 5, 10, and 20 years. There was a significant survival difference between the nonmultifocal and multifocal renal cell carcinoma groups at 5 years (p<0.05) but not at 10 and 20 years. CONCLUSIONS Small renal cell carcinoma is definitively not a benign disease and a tumor of 30 mm. or smaller does not mean there is no risk of metastatic or multifocal disease.

Comparative Sensitivities of Functional MRI Sequences in Detection of Local Recurrence of Prostate Carcinoma After Radical Prostatectomy or External-Beam Radiotherapy

OBJECTIVE The aim of this retrospective study was to determine the respective accuracies of three types of functional MRI sequences-diffusion-weighted imaging (DWI), dynamic contrast-enhanced (DCE) MRI, and 3D (1)H-MR spectroscopy (MRS)-in the depiction of local prostate cancer recurrence after two different initial therapy options. MATERIALS AND METHODS From a cohort of 83 patients with suspicion of local recurrence based on prostate-specific antigen (PSA) kinetics who were imaged on a 3-T MRI unit using an identical protocol including the three functional sequences with an endorectal coil, we selected 60 patients (group A, 28 patients who underwent radical prostatectomy; group B, 32 patients who underwent external-beam radiation) who had local recurrence ascertained on the basis of a transrectal ultrasound-guided biopsy results and a reduction in PSA level after salvage therapy. RESULTS All patients presented with a local relapse. Sensitivity with T2-weighted MRI and 3D (1)H-MRS sequences was 57% and 53%, respectively, for group A and 71% and 78%, respectively, for group B. DCE-MRI alone showed a sensitivity of 100% and 96%, respectively, for groups A and B. DWI alone had a higher sensitivity for group B (96%) than for group A (71%). The combination of T2-weighted imaging plus DWI plus DCE-MRI provided a sensitivity as high as 100% in group B. CONCLUSION The performance of functional imaging sequences for detecting recurrence is different after radical prostatectomy and external-beam radiotherapy. DCE-MRI is a valid and efficient tool to detect prostate cancer recurrence in radical prostatectomy as well as in external-beam radiotherapy. The combination of DCE-MRI and DWI is highly efficient after radiation therapy. Three-dimensional (1)H-MRS needs to be improved. Even though it is not accurate enough, T2-weighted imaging remains essential for the morphologic analysis of the area.

Fast imaging MR assessment of ureterohydronephrosis during pregnancy

PURPOSE to assess the value of the fast imaging sequence called RARE-MR-Urography (RMU) for the diagnosis of pathologic ureterohydronephrosis during pregnancy. MATERIALS AND METHODS 15 pregnant women with an acute flank pain were examined with RMU. Results were compared with those of ultrasonography (US), X-rays, and the evolution of symptoms. RESULTS the accuracy of RMU in the detection of urinary tract dilatation and the localization of the level of obstruction was excellent (100%). The determination of the type of obstruction, intrinsic vs. extrinsic, was always exact. RMU alone cannot specify the exact nature of the intrinsic obstruction. Ultrasonography gave less sensitive information in terms of level (60%) and type of obstruction (53%). CONCLUSION RMU is able to differentiate a physiological from a pathologic ureterohydronephrosis during pregnancy. It could be considered as a procedure of choice for special cases when US failed to establish this differential diagnosis.

Single Stones of the Lower Pole of the Kidney

Objective: To assess the effectiveness of extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCN) as a treatment for stones of the lower pole of the kidney and to compare their morbidity according to the stone size. Methods: We retrospectively studied 739 patients treated for a single stone of the lower pole. Group I consisted of 666 patients treated by ESWL and group II consisted of 73 patients treated by PCN. Results: These were assessed at 3 months for 587 ESWL patients (88%) and at day 1 for all PCN patients on renal tomography or ultrasonography. Respectively in groups I and II, 335 patients (57%) and 53 patients (72.6%) were stone-free (p = 0.01). For medium-size (10–20 mm) stone patients, stone-free represented 102 patients (44%) and 29 patients (72.5%) in groups I and II respectively (p = 0.001). For smaller stones (<10 mm), stone-free represented 231 patients (69%) and 21 patients (84%) in groups I and II respectively (p = 0.12). Morbidity rate was less with ESWL than with PCN. Conclusions: PCN achieves better results than ESWL for single stone of the lower pole with statistical significance for middle-size stones but with higher morbidity.