Eric Fontaine

Renal transplantation in children with augmentation cystoplasty: long-term results.

PURPOSEnWe assessed the long-term results of renal transplantation in children with augmentation cystoplasty.nnnMATERIALS AND METHODSnWe retrospectively reviewed the complications and followup in 14 pediatric renal transplant recipients with augmentation cystoplasty. The etiology of bladder dysfunction included posterior urethral valves in 10 cases, neurogenic bladder in 3 and vesicoureteral reflux in 1. All transplants were cadaver donor kidneys. Mean patient age at transplantation was 12.1 years (range 5 to 18). Augmentation cystoplasty was performed before and after transplantation in 10 and 4 cases, respectively. Detubularized ileum was used in 5 cases, tubular ileum in 4, tubular sigmoid in 4 and stomach in 1.nnnRESULTSnOf the 14 transplanted kidneys 10 (71%) were functioning at a mean followup of 80 months (range 12 to 151). Serum creatinine was less than 1.4 mg./dl. in 9 patients. Four grafts were lost to chronic rejection. The 5 and 10-year graft survival rates were 84 and 73%, respectively. Two patients with a functioning kidney died of causes unrelated to augmentation cystoplasty. Complications included symptomatic urinary infections in 4 patients, hyperchloremic metabolic acidosis in 2, nephrolithiasis in the allograft in 2 and the hematuria-dysuria syndrome in 1. All patients were continent.nnnCONCLUSIONSnAugmentation cystoplasty is a safe and effective method of restoring lower urinary tract function in the pediatric renal transplant population with a small noncompliant bladder.

Posterior urethral valves : Long-term renal function consequences after transplantation

PURPOSEnWe assessed the long-term efficacy of renal transplantation in children with posterior urethral valves.nnnMATERIALS AND METHODSnWe retrospectively compared the outcomes of renal transplantation in 66 children with posterior urethral valves and 116 with malformation uropathies (controls).nnnRESULTSnGraft survival in the posterior urethral valves and control groups was 69 and 72% at 5 years, and 54 and 50% at 10 years, respectively (not statistically significant). A statistically significant increase in serum creatinine was noted at 10 years in children with posterior urethral valves but not in controls (p < 0.05).nnnCONCLUSIONSnRenal transplantation in children with posterior urethral valves is not associated with a high rate of failure. However, long-term deterioration of graft function is likely related to lower urinary tract dysfunction.

ROLE OF THE BLADDER IN DELAYED FAILURE OF KIDNEY TRANSPLANTS IN BOYS WITH POSTERIOR URETHRAL VALVES

PURPOSEnThere is a tendency toward less favorable long-term graft function in patients with posterior urethral valves than in controls. We studied the role of the bladder in boys who underwent transplantation by simultaneously evaluating renal graft and voiding function.nnnMATERIALS AND METHODSnBetween 1972 and 1994, 66 boys with posterior urethral valves underwent kidney transplantation. Of these boys 44 with a mean age of 9.7 years who retained a functional renal graft did not undergo any surgery on the lower urinary tract except for the initial treatment of posterior urethral valves. Long-term evaluation included a voiding questionnaire, radiological assessment and serum creatinine measurement.nnnRESULTSnAverage followup was 9.01 years (range 2.4 to 19.6). There was no voiding dysfunction symptomatology in 23 boys, while 3 (14.2%) and 8 (38.1%) of the remaining 21 had daytime and nighttime frequency, respectively. Dysuria and incontinence were present in 11 (52.4%) and 12 (57.1%) patients, respectively. Urodynamics in 11 cases revealed a mean bladder compliance plus or minus standard deviation of 11.3+/-2.8 ml./cm. water. In boys with a voiding disorder mean serum creatinine increased after 5 years of followup. At 10 years after kidney transplantation mean serum creatinine was 140.3+/-36.0 and 285.7+/-36.2 micromol./l. in asymptomatic boys and those with a voiding disorder, respectively (p<0.01).nnnCONCLUSIONSnValve bladder has a role in the deterioration of renal transplants in boys with posterior urethral valves. In those with a voiding disorder closer followup is needed, including urodynamic and radiological studies. Bladder dysfunction, such as hypocompliance and/or hyperreflexia, requires medical or surgical treatment.

Long-Term Results of Renal Transplantation in Children With the Prune-Belly Syndrome

PURPOSEnWe assessed the long-term efficacy of renal transplantation in children with the prune-belly syndrome.nnnMATERIALS AND METHODSnWe retrospectively compared the outcomes of renal transplantation in 9 children with the prune-belly syndrome and 100 with malformative uropathy.nnnRESULTSnGraft survival in the prune-belly syndrome and control groups was 50 and 72% at 5 years, and 50 and 47% at 10 years, respectively (not statistically significant). No statistically significant increase in serum creatinine was noted at 10 years in children with the prune-belly syndrome. Two patients with the prune-belly syndrome underwent internal urethrotomy after transplantation. All patients voided well and did not require intermittent catheterization.nnnCONCLUSIONSnRenal transplantation in children with the prune-belly syndrome is not associated with a high rate of failure. However, these patients must be followed with regular urological evaluation since voiding efficiency may deteriorate.

Néphrectomie partielle laparoscopique : courbe d’apprentissage d’un interne en urologie sur un modèle porcin

INTRODUCTIONnSeveral teams have recently confirmed the technical feasibility of laparoscopic partial nephrectomy (LPN). However, this procedure is not widely performed because it is technically difficult and associated with a high rate of bleeding complications, even for experienced teams. The authors studied the LPN learning curve for urology residents using a porcine model based on analysis of the following criteria: operating time, warm ischaemia time and intraoperative and postoperative bleeding.nnnMATERIALS AND METHODSnForty LPN were performed by the same operator. All operations were performed after arterial clamping and heparinisation of the animal. The renal section was always the same, removing 40% of the kidney and always comprised the excretory tract. A continuous running suture on the excretory tract and interrupted sutures on the parenchyma were performed. Operating time and warm ischaemia time were recorded. Animals were monitored for ten days. Intraoperative and postoperative bleeding via drains was recorded and retrograde urography was performed on the 10th day to confirm the absence of excretory tract leaks. Linear regression statistical tests investigated a correlation between these various criteria and the number of cases performed.nnnRESULTSnThe mean total operating time, warm ischaemia time and total bleeding (intraoperative and postoperative) were 108 minutes (70-140 minutes), 38 minutes (22-50 minutes) and 95 ml (10-300 ml), respectively. Linear regression analysis revealed a direct correlation between the number of cases performed and intraoperative bleeding (p<0.001) and warm ischaemia time (p<0.001). These parameters became stable after the 10th operated case. Two cases of urine leaks were observed on D10 out of a series of 40 operations, with no correlation with the number of cases performed.nnnCONCLUSIONnThe operating time and warm ischaemia time are directly correlated with the number of cases performed. Training on a porcine model appears to be a good way to reduce the learning curve in man. Ten operations are necessary to acquire the various steps of the procedure.

L'hormonothérapie de la phase métastatique, néo-adjuvante et adjuvante

Résumé:Depuis plus de 60 ans, le traitement du cancer de prostate métastatique repose sur la déprivation androgénique. En cas de métastases asymptomatiques, la date d’instauration du traitement reste discutée. Il n’existe pas d’argument actuellement en faveur d’une hormonothérapie avant et après prostatectomie radicale. L’association radiothérapie-hormonothérapie, d’une durée de 2 ou 3 ans, semble efficace chez les patients qui présentent un cancer de prostate localisé de haut grade ou localement avancé.Abstract:For more than 60 years, the treatment of metastatic prostate cancer has been based on androgen deprivation. In the case of asymptomatic metastatic disease, the timing of hormonal therapy remains controversial. No evidence of a beneficial effect of neoadjuvant hormonal therapy before radical prostatectomy has been documented. Radical prostatectomy and adjuvant therapy cannot be considered as a standard treatment. There is a general consensus at this time that patients with high-grade localized tumors benefit from hormone therapy (2-3 years) in conjunction with external beam radiation therapy.