J. Petit

Carcinome in situ vésical et urétral chez un patient transplanté rénal : échec de la BCG thérapie

We report the case of a 67-year-old patient, renal transplanted for two years, taken care for carcinoma in situ in bladder and urethra, and treated by intravesical instillations with bacillus Calmette-Guerin (BCG). After failure of a first treatment by Amétycine, a treatment by BCG is instituted during nine weeks. Two months after the end of the treatment, the patient died after bone and liver metastatic invasion of urothelial carcinoma. Management of urothelial high-risk tumour among renal transplanted patient is not clear. Despite successful treatments of few patients reported in literature, this failure called the question of the effectiveness of the BCG therapy in renal transplant patient and suggested an earlier attempt at diagnosis with systematic detection and aggressive therapeutic among these immunodepressed patients.

Les douleurs périnéo-scrotales après soutènement urétral prothétique type InVance® : étude anatomique sur cadavres☆

OBJECTIVE The authors investigated the anatomical basis for prolonged perineoscrotal pain after InVance bone-anchored male sling for the treatment of urinary incontinence after prostatic surgery in order to propose technical advice to reduce the frequency of this complication. MATERIAL AND METHOD The authors dissected three formalin-preserved male cadavres and reviewed the literature on perineal anatomy and complications of the surgical technique. RESULTS Cadavre dissections demonstrated the origin, course and termination of the perineal nerve, a branch of the pudendal nerve derived from the S2-S3-S4 sacral nerve roots. Its superficial branch, accompanied by its blood supply, ensures sensory innervation of the anterior part of the perineum and posterior surface of the scrotum. This branch is situated in the zone of lateral dissection towards ischiopubic rami. Potential lesions of this nerve could be due to coagulation of the vascular pedicle, stretching during lateral dissection towards ischiopubic rami, or damage to its anastomoses with the scrotal branch of the lateral cutaneous nerve of the thigh during exposure of the sites of implantation of ischiopubic screws. CONCLUSION Trauma to the superficial perineal nerve is probably responsible for perineoscrotal pain after InVance perineal surgery. This operative trauma must therefore be reduced by identifying the bulbourethral muscle before dissecting laterally and by limiting the use of coagulation.

L’IRM permet-elle de distinguer les tumeurs urothéliales vésicales superficielles et infiltrantes ? ☆

OBJECTIVE To determine the sensitivity and specificity of MRI to distinguish between superficial and invasive transitional cell bladder cancer. MATERIAL AND METHODS Sixty patients (52 men and eight women) with a mean age of 66.8 years were assessed by bladder MRI between May 2002 and November 2005 for a primary bladder cancer diagnosed by endoscopy, followed by transurethral resection and histological examination of the bladder cancer. Patients presenting a discordance between MRI findings and histological examination were analysed. RESULTS Imaging and pathology staging was concordant for 49 bladder cancers (40 superficial and nine invasive). Ten tumours considered to be invasive on MRI were superficial on histological examination and six of them relapsed at the resection scar at one or three months. The sensitivity of MRI was 80% for a specificity of 90% and a positive predictive value of 97.5%. CONCLUSION MRI is a reliable examination to confirm the superficial nature of bladder cancer. When MRI and histological examination of a bladder cancer resection specimen are discordant, second look surgery is recommended to treat residual disease, which was present in 60% of cases in the present series.

Apport de l'embolisation curative et préventive pour la prise en charge des angiomyolipomes rénaux

OBJECTIVE The purpose of this study was to present the role of embolization in the treatment of kidney angiomyolipomas (AML), for preventive care or in case of bleeding. METHODS From March 1995 to March 2007, 22 AML in 21 patients (16 women and five men, mean age 38 years) were embolized: five AML were treated for hemorrhagic shock emergency and 16 were preventive embolization. Eight AML were discovered incidentally and nine patients had pain or hematuria. The average size of AML was 70 mm (20 to 130 mm). The embolization was performed with coils or embospheres. RESULTS Three patients have not been embolized because of renal failure catheterization. The embolization was effective in 100% of patients treated in emergency. The six patients cared for gross hematuria and pain were asymptomatic after embolization. The average tumor size reduction was 32% with a mean time of 53.2 months (five to 101 months). Three patients (14%) have benefited from surgery remotely. CONCLUSION Embolization is the best technique for treating bleeding secondary to AML. In preventive treatment or symptomatic, AML embolization is a treatment to offer before considering surgery.

Place du dosage sérique de l’HCG dans la surveillance des tumeurs testiculaires séminomateuses non sécrétantes

OBJECTIVE Human chorionic gonadotrophin (HCG) is secreted by 10 to 20% of seminomas. The authors evaluated variations of serum total HCG levels in patients with normal baseline levels for the surveillance of treated testicular seminomas in order to determine the value of assay of this tumour marker in the follow-up of testicular seminoma. PATIENTS AND METHODS Retrospective study from January 1988 to March 2007, including 95 cases of operated testicular cancer, including 28 seminomas, 25 of which did not secrete HCG (baseline total HCG less than 15 IU/L). Patients were reviewed periodically: every three months for one year, every six months during the second year, then annually, comprising of clinical examination, CT examination and assay of tumour markers (HCG, LDH and AFP). RESULTS Mean follow-up was 77.5 months (range: 6-120). Twenty-five patients had a total HCG level less than 15 IU/L three months after orchidectomy. Serum HCG remained stable at less than 15 IU/L in all patients with a follow-up of more than three years. Two patients developed non-regional lymph node recurrence with no modification of the serum HCG level. CONCLUSION All treated non-HCG-secreting seminomas with or without recurrence had stable and normal HCG levels throughout follow-up, which raises the question of the value of HCG assay in the follow-up of these patients following histological confirmation of the diagnosis.

Lymphomes non hodgkiniens primitifs du testicule : pronostic à long terme associé au traitement combinant chimiothérapie systémique et intrathécale

OBJECTIVES To evaluate the long-term prognosis of a retrospective series of primitive malignant non-Hodgkins lymphoma (MNHL) of the testicle treated by orchidectomy and combined systemic and intrathecal chemotherapy. PATIENTS AND METHODS From 1992 to 2006, eight consecutive patients were treated for a primitive MNHL of the testicle (stages : IA [n=1], IEA [n=5], IIEA [n=1], IVEA [n=1]) and retrospectively analyzed. All of these tumors were highly malignant. The average age of the patients at the time of diagnosis was 64 years old (46-78). All the patients benefited from an enlarged orchidectomy and received a combination of systemic and intrathecal CHOP and VACP chemotherapy. Six patients finished with some locoregional radiotherapy and three had cerebral radiotherapy. RESULTS Patients were treated over an average period of 90.5 months (12 to 168 months). Five patients (62.5%) responded successfully, one patient had a cerebral relapse stabilized by a second course of chemotherapy. Three patients died, one from septic shock during chemotherapy (IVEA stage), another from mesenteric infarction (IAE stage) and the third from acute coronary thrombosis while in complete remission. CONCLUSION In spite of a reputedly bleak prognosis, primitive MNHL of the testicle treated with a combination of systemic and intrathecal chemotherapy would seem to be associated with a good specific long-term survival. Unfortunately, the rate of mortality linked to chemotherapy is significant (close to 12.5% in our series) and would not appear to entirely protect against cerebral recurrence.

« Big PSA » et prostatectomie totale : survie spécifique et globale à dix ans

INTRODUCTION Radical prostatectomy is not currently a recommended treatment modality for patients with preoperative PSA greater than 40 ng/ml. OBJECTIVES To evaluate the specific and overall long-term survival of patients operated despite a PSA greater than 40 ng/ml and to describe the adjuvant treatments associated with the surgical procedure. MATERIALS From 1988 to 1998, 32 consecutive patients with a mean age of 65 years (range: 46-73) underwent retropubic radical prostatectomy. The preoperative work-up (abdominopelvic CT scan, bone scintigraphy) were all interpreted as being normal. All patients had lymph node dissection. Progression was defined by PSA greater than or equal to 0.2 ng/ml or the appearance of metastases. RESULTS The mean follow-up was 117 months (range: 2-177). Six patients were alive without progression, and five of them had received adjuvant radiotherapy. Twelve patients were alive with biological progression after second- or third-line treatment. Three patients had died from their cancer and 12 had died from another cause. With a mean follow-up of 10 years, the specific survival of patients operated for high PSA was 80% and the overall survival was 56% with a progression-free survival of 18.7%. CONCLUSION In rigorously selected patients, radical prostatectomy for high PSA possibly associated with adjuvant radiotherapy can achieve satisfactory prostate cancer control at 10 years for almost 20% of N0M0 patients.

Résultats des néphrectomies pour tumeurs des reins natifs chez les patients transplantés rénaux

OBJECTIVE Evaluate epidemiology, diagnosis and outcome of de novo renal cell carcinoma in renal transplanted patients. PATIENTS AND METHOD From June 1989 to December 2007, 824 renal transplantations were carried out and followed in annual consultation by an urologist with abdominal echography or tomodensitometry. The suspect renal lesions were treated by a widened nephrectomy. Incidence, diagnosis, treatment, histological type, and outcome of all patients were analysed. RESULTS Thirty-three patients had nephrectomy for suspect renal lesions. Twenty-two de novo tumours of native kidneys among 21 patients were diagnosed (15 renal clear cell carcinoma and seven papillary tumours) with mean time after transplantation of 25,6 months (2.3-105.5). All tumours were classified pT1aN0M0. Only one patient died at 8 months of metastatic dissemination of a papillary tumour classified initially pT1aN0M0. All the other patients are alive with mean follow-up of 34.8 months (2.8-113.9). Specific survival to 5 years was 93.3%. CONCLUSION The increase risk of tumour at the renal transplanted patient led to propose in the event of suspect lesions of the native kidneys, a widened nephrectomy. In our series, 65% of the operated patients carried a cancer. The good forecast of these localized tumours justifies a regular radiological monitoring and an aggressive therapeutic attitude despite of absence of tumours in 35% of the transplanted patients.

La taille tumorale : critère prédictif des variations hémodynamiques peropératoires dans la chirurgie du phéochromocytome surrénalien ☆

OBJECTIVE To evaluate the correlation between tumour diameter and intraoperative haemodynamic variations during adrenalectomy based on a series of 15 operated cases of adrenal phaeochromocytoma. MATERIAL AND METHODS Seventeen adrenalectomies for adrenal phaeochromocytomas were performed between January 1997 and March 2007. Two laparoscopic adrenalectomies were excluded to ensure a homogeneous series. The mean age of the patients was 39 years (range: 29-75). The hypertensive peak was defined according to the recommendations of the European Society of Hypertension (blood pressure greater than 140/90mmHg). Intraoperative blood pressure was measured and recorded every 10minutes during the operation. RESULTS The median diameter of unilateral tumours was 6cm (range: 3-11) and the median diameter of bilateral tumours (two cases) was less than 6cm. The mean operating time was 135minutes (range: 120-170) for tumours greater than or equal to 6cm versus 105minutes (range: 90-145) for tumours less than 6cm. Operating time was increased by an average of 30minutes for tumours greater than or equal to 6cm. Hypertensive peaks were recorded in seven out of eight cases (87.5%) for adrenal phaeochromocytomas greater than or equal to 6cm, and in three out of seven cases (29%) for adrenal phaeochromocytomas less than 6cm (P=0.04). CONCLUSION Tumour diameter is a decisive predictive factor of intraoperative haemodynamic variations in adrenal phaeochromocytoma surgery.

Prostatectomie radicale rétropubienne (PRRP) sans drainage vésical postopératoire : étude de faisabilité à propos de 14 cas☆

OBJECTIVES To report the feasibility of radical retropubic prostatectomy (RRP) without postoperative bladder catheter. MATERIAL & METHODS We report our experience in 14 patients (mean age 62 [48-75]) who underwent radical retropubic prostatectomy for localised prostatic adenocarcinoma from May 2006 to January 2010. The surgical technique was performed as classically described, without bladder neck preservation (tennis-racket closure), with or without nerve sparing (JP). The criteria that led us not to drain were the satisfactory urethral length, a tension-free anastomosis performed on a bladder catheter with separate sutures, and a lack of anastomotic leack after bladder filling with 200cc. RESULTS The mean hospital stay was 4 days (3-8). Ten patients (71.4%) needed intermittent bladder catherism four times (1-11) before starting micturitions, without any technical difficulties. No anastomic leack was reported. Nine patients (64.3%) were continent leaving the hospital. With a mean follow-up of 30 months (5-48), all of 14 patients (100%) were perfectly continent. No anastomotic stricture was reported. CONCLUSION RRP without postoperative bladder catheter was feasible, with no other early or late complication associated. Early and late continence were perfect (100% at 2 years).