François X. Wese

Long-Term Results and Late Recurrence After Endoureteropyelotomy: A Critical Analysis of Prognostic Factors

Of 102 consecutive endoureteropyelotomy cases followed for 1 to 10 years (mean 5) late recurrence was observed in 13% and long-term success was achieved in 73%. Of 67 cases with an available preoperative angiogram a strong association was noted between the existence of a vessel crossing the ureteropelvic junction and high grade hydronephrosis, and final failure and/or recurrence: long-term success rate was 39% when both factors were present and it was 95% when neither factor was present. Therefore, we recommend that the presence of a vessel should be determined preoperatively since it significantly influences the outcome.

ADJUVANT RADIATION THERAPY DOES NOT CAUSE URINARY INCONTINENCE AFTER RADICAL PROSTATECTOMY: RESULTS OF A PROSPECTIVE RANDOMIZED STUDY

PURPOSE We analyzed the potential influence of adjuvant radiotherapy on urinary continence after radical prostatectomy. MATERIALS AND METHODS A total of 100 patients with N0M0 prostate cancer randomized in a prospective study on postoperative radiotherapy for locally advanced disease (positive surgical margin, capsular perforation and/or seminal vesicle infiltration) were studied. Objective pad weighing tests corroborated by direct personal interviews were used to evaluate urinary continence at regular postoperative intervals. RESULTS Of the patients 48 received 60 Gy. external radiotherapy with 18 MV photon beams between 12 and 16 weeks postoperatively, and 52 were followed expectantly. Risk factors were similar in both groups. With a mean followup of 24 months, no difference in complete urinary continence was observed. Of the irradiated group 77% and of the surveillance group 83% were totally dry. The fate of the bladder neck had no significant influence on final continence status, although there was a trend for faster recovery when the bladder neck was preserved. CONCLUSIONS In this prospective randomized study 60 Gy. external radiation therapy administered between 3 and 4 months after radical prostatectomy for pathologically locally advanced prostate cancer had no significant influence on urinary continence.

Free to total prostate-specific antigen (PSA) ratio improves the discrimination between prostate cancer and benign prostatic hyperplasia (BPH) in the diagnostic gray zone of 1.8 to 10 ng/mL total PSA.

OBJECTIVES Improved discrimination between prostate cancer (PC) and benign prostatic hyperplasia (BPH) is clearly needed. Our aim in this study was to evaluate whether the free to total prostate-specific antigen (PSA) ratio would be useful in the gray zone of 1.8-10 ng/mL total PSA range. METHODS In a consecutive series of 435 clinic patients referred for prostate evaluation, 308 had a total PSA < 10 ng/mL (92 had PC and 216 BPH). Free and total PSA were measured, and the free to total PSA ratio calculated. RESULTS Total PSA values were significantly different between the two groups. For the 200 patients with a total PSA < 6 ng/mL, no significant difference in total PSA values were seen (P = 0.411), whereas free to total PSA ratios remained statistically different (P < 0.001). Receiver operating characteristic (ROC) curve analysis comparing the performances of total PSA over the ratio of free to total PSA showed a clear advantage for the ratio at all sensitivity levels. CONCLUSIONS These data demonstrate that in a significant number (n = 308) of prostatic patients in the diagnostic gray zone of 1.8-10 ng/mL total PSA, the routine use of free to total PSA might be advantageous in discriminating between cancer and benign hyperplasia. This advantage remained for total PSA < 4 ng/mL. Further study is warranted to confirm these findings in an unselected population.

Free to total prostate-specific antigen (PSA) ratio is superior to total-PSA in differentiating benign prostate hypertrophy from prostate cancer

Serum prostate‐specific antigen (PSA) exists in different molecular forms, and their respective concentration has been proposed as a useful tool to improve discrimination between benign prostatic hypertrophy (BPH) and prostate cancer (PC).

Laparoscopic nephrolithotomy: the value of intracorporeal sonography and color Doppler.

Laparoscopic nephrolithotomy was used as an alternative to open surgery in a patient who had failed extracorporeal shock-wave lithotripsy and whose anteriorly located stone-bearing calix precluded percutaneous extraction. Endocavitary ultrasonography and color Doppler render the procedure safe and effective; localization of the stone, selection of an optimal nephrotomy site away from large vessels and where cortical thickness is minimal, and control of fragment clearance are greatly facilitated.

Radiologic Investigation of the Urinary Tract in the Neonate with Myelomeningocele

A significant number of neonates with myelomeningocele are born with potentially damaging abnormalities of the urinary tract. Therefore, it is logical to investigate these patients aggressively and initiate therapy as early as possible to preserve renal function and maintain lower tract integrity for future continence management. Results of excretory urograms and voiding cystourethrograms were reviewed in 68 consecutive neonates with myelomeningocele. They indicate clearly that only a third of the patients with normal excretory urograms had a normal voiding cystourethrogram, which implies that both studies be performed for complete evaluation of the urinary tract. In other words, of these 68 patients 55 (80.9 per cent) had a normal excretory urogram but only 17 (30.9 per cent) had a normal voiding cystourethrogram. Of the 13 patients (19.1 per cent) with an abnormal excretory urogram 12 (92.3 per cent) had an abnormal voiding cystourethrogram. Reflux occurred in 16.2 per cent of patients; 6 of 7 patients with grade II reflux and 1 of 3 patients with grade III reflux had a normal excretory urogram.

Ureteral Entrapment Injury in Blunt Pelvic Trauma: A Case Report

An unusual ureteral injury occurred during blunt pelvic trauma in a 6-year-old boy. Crush injury opened the sacroiliac joint, and the ureter was trapped and obstructed during realignment of the joint. Combined retrograde and anterograde pyelography accurately localized the injury and surgical repair restored renal function, despite total ureteral obstruction lasting more than 3 months. The mechanism, diagnosis and treatment of this injury are discussed. Vascular and ureteral injuries must be ruled out carefully when treating blunt renal injuries conservatively.

Le pronostic fonctionnel et le traitement des séquelles des malformations anorectales chez l’adolescent et l’adulte

RésuméL’incidence des malformations anorectales est de 1/5000 naissances. Il s’agit d’un spectre de malformations, classées en formes basses ou hautes en fonction de leurs caractéristiques anatomiques et du pronostic de continence fécale chez le patient atteint. La prise en charge des malformations anorectales à la naissance inclut un bilan complet à la recherche des anomalies associées (entité VACTERL). La stratégie thérapeutique consiste en une chirurgie en un, deux ou trois temps, en fonction du type anatomique et de la nécessité d’une colostomie de protection. Les séquelles fonctionnelles à long terme et leur prise en charge dépendent du type malformatif: 1) les formes basses ont un bon pronostic en terme de continence fécale, mais peuvent être associées à une constipation sévère et un mégarectum responsable de pertes fécales (pseudo-incontinence par regorgement); 2) le pronostic des formes hautes est moins bon, avec un risque de développement d’une incontinence fécale qu’il est important d’identifier avant l’âge de 5–6 ans de façon à proposer un traitement adéquat visant à assurer une propreté fécale pendant les périodes scolaires (gestion intestinale par lavements évacuateurs rétrogrades). La réalisation de lavements coliques antérogrades par une appendicostomie continente ombilicale permettra ultérieurement d’accroître l’autonomie du patient à l’adolescence.SummaryAnorectal malformations occur with a frequency of 1/5,000 newborns and constitute a pathological spectrum, categorized in low and high defects according to their anatomical characteristics and their specific potential for the affected patients to reach fecal continence. The neonatal management should include a complete work-up for associated anomalies (VACTERL entity). The surgical strategy consists in a one/two/three-step approach, according to the anatomical type of anorectal defect and the need for a protective colostomy. The long-term functional sequelae and their management will depend on the type of anorectal malformation: 1) low defects have a good prognosis in term of fecal continence, but may be associated with severe constipation and megarectum responsible of fecal soiling (overflow pseudoincontinence); 2) the functional prognosis of high defects is worse, with possibility of developing fecal incontinence which should be identified in early childhood (3–5 years) in order to offer adequate management (conservative measures and/or bowel management) allowing school attendance with fecal cleanliness. The autonomy of the adolescent can be improved subsequently by means of self-administered antegrade colonic enemas through an umbilical continent appendicostomy.

Undetectable prostate-specific antigen in aging men.

Undetectable prostate-specific antigen was found in three aging men despite the absence of any prostatic surgery or exogenous hormonal deprivation. Clinical and elementary hormonal workup revealed the presence of secondary hypogonadism. This finding confirms the hormonal dependency of this prostatic marker and may, in some cases, explain the discrepancy between prostatic volume and the value of serum prostate-specific antigen.