Laurent Yonneau

Evaluation of Tension–Free Vaginal Tape Procedure

Introduction and Objectives: The aim of this study was to evaluate preliminary results of tension–free vaginal tape (TVT), a new surgical procedure, performed during the learning phase for the treatment of stress urinary incontinence. Material and Methods: One–hundred consecutive patients underwent surgery, between June 1998 and December 1999, by six different senior surgeons. Indications were socially annoying urinary stress incontinence which persisted after complete physical therapy education. Preoperative examination included a urodynamic evaluation program. Surgical procedure was performed according to Ulmsten technique under local, regional or general anaesthesia. Results were evaluated by self–evaluation questionnaire and the patients were followed for at least 1 year. Results: Perioperative complications were: 14 bladder injuries and one urethral perforation without sequelae (except prolonged bladder drainage up to 3 days). Postoperative complications were: 13 retentions including 3 persistent after 1 month. During the learning phase (50 first patients) bladder injuries, retention and dysuria were more frequent. Progressively, local anesthesia was abandoned while most of the 50 remaining patients had TVT performed under epidural anesthesia. Functional results were divided into 3 groups according to preoperative urethral closure pressure (UCP) and eventual concomitant prolapse repair (PR): (1) UCP >25 cm H2O no PR (59 patients): 39 were totally dry without any instability, 13 dry with de novo (4) or persistent (7) instability and 5 were moderately improved. (2) UCP <25 cm H2O no PR (25 patients): 11 were dry without instability, 5 dry with instability, 6 were improved and 4 failed. (3) PR (15 patients): 9 were dry, 4 were improved and 2 failed. For 2 patients a bladder erosion due to the tape occurred (7 and 11 months) after the TVT procedure. Conclusions: During the learning phase, bladder perforation (22%) and retention (20%) were much more frequent than previously reported. Nevertheless, our results confirm that TVT appears to be an efficient procedure: 97% of patients were cured or improved when UCP >25 cm H2O, 85% when UCP <25 cm H2O and 87% when a PR was associated.

Prostatic capsule- and seminal-sparing cystectomy for bladder carcinoma: initial results for selected patients.

To evaluate the oncological outcome and functional results of prostate‐sparing cystectomy (PSC), proposed for treating bladder cancer, used since 1999 in our institution in an attempt to preserve male sexuality and to increase continence after cystectomy.

Extracorporeal shock wave therapy in the treatment of Peyronie’s disease: experience with standard lithotriptor (siemens-multiline)

OBJECTIVES To assess in a prospective study whether extracorporeal shock wave therapy (ESWT) using a standard radioscopic location lithotriptor is effective in the treatment of Peyronies disease. METHODS Fifty-four patients were included in this prospective study. Before and after treatment, the angulation was calculated by auto-photography. Pain severity was assessed by a visual analog pain scale. A self-evaluation questionnaire (International Index of Erectile Function) was used. All patients had symptoms (35 had pain during erection and 51 angulation greater than 20 degrees ). The mean disease duration was 16 months. The mean angulation before treatment was 48 degrees (range 10 degrees to 100 degrees ). Twenty-four patients had erectile dysfunction (questionnaire score less than 18). The Multiline Siemens lithotriptor was used. The plaque was located by palpation, and 1 mL of contrast agent was injected. Scopic visualization was used. Each patient received a minimum of one session of ESWT (3000 shock waves, 7 kJ) applied to a flaccid penis. RESULTS All patients completed the protocol. The tolerance and safety were excellent. Of the 35 patients with pain on erection, 31 (91%) noticed relief immediately after ESWT (mean reduction 2.9 on the visual analog pain scale) (P <0.00001). For 29 patients (53.7%), an improvement in angulation (greater than 10 degrees ) was observed, with a mean reduction of 31 degrees (P <0.001). For patients with erectile dysfunction, only 6 (25%) had an increased questionnaire score (greater than 4). Twenty-five patients thought the plaque was smoother. CONCLUSIONS ESWT with a standard lithotriptor (without the mobile arm) in Peyronies disease is a feasible, safe, and effective treatment for pain on erection and significantly improves the penile angle.

After Cystectomy, Is It Justified to Perform a Bladder Replacement for Patients with Lymph Node Positive Bladder Cancer?

PURPOSE After cystectomy for bladder cancer, when pelvic lymph nodes are positive, bladder replacement remains controversial. The aim of this study was to evaluate the outcome of patients who underwent neobladder replacement despite bladder cancer metastasis to the regional lymph nodes. MATERIALS AND METHODS From 1981 to 1997, a total of 504 consecutive cystectomies for bladder cancer were performed at our institution. For 150 patients, pelvic lymphadenectomy were positive, nevertheless 71 patients underwent a neobladder replacement (50 N1 and 21 N2). The distribution of patients by clinical stage, according to the TNM 97 classification, was 4 T1, 14 T2, 32 T3 and 21 T4. No patient showed signs of metastasis on diagnosis. RESULTS Five-year disease specific survival rate of the entire group (71 patients) was 46%. With a mean follow-up of 8.3 years (3.2-20 years), 25 patients (35%) were alive and free of disease (72% with day continence), five patients were alive with recurrence (three bone metastasis, one chest metastasis and one with local recurrence), 41 patients died, (three non-cystectomy related). Of the 46 patients who recurred, a total of eight patients had local recurrence. For five patients, a severe dysfunction of the plasty appeared: two needed definitive bladder drainage until they died, one patient became totally incontinent, one patient needed a conversion of the plasty to Bricker ileal conduit. For the remaining patient the tumor involvement provoked recto-plasty-cutaneous fistula. All these five patients died in the 6 months after the plasty dysfunction appeared. CONCLUSIONS Although prognosis in bladder cancer metastasis to the regional lymph nodes has been reported to be poor, this study demonstrates that after cystectomy, it is justified to propose a neobladder replacement to well selected patients. Local recurrence only occurred in 11% of patients and there was no damage to enteroplasty function for nearly half of the patients, and considering benefit to the quality of life, orthotopic bladder substitution should be considered as the preferential diversion in this patient population.

Apport d’un cocktail d’anticorps anti-(p63 + p504s) dans le diagnostic de cancer de prostate

Resume De nombreuses lesions benignes de la prostate comme l’atrophie, l’hyperplasie adenomateuse atypique ou des foyers de PIN peuvent simuler un cancer et conduire au diagnostic de foyer suspect (ASAP), incitant a effectuer de nouvelles biopsies. Devant de telles lesions, le pathologiste peut avoir recours a une etude immunohistochimique avec l’anticorps anti cytokeratine de haut poids moleculaire CK903 (34bE12) qui en confirmant l’absence de cellules basales, permet de porter le diagnostic de cancer. But de l’etude Evaluer les nouveaux marqueurs des cellules basales (cytokeratine 5/6 et p63), et un marqueur des cellules prostatiques tumorales (p504s) dirige contre l’alpha methylacyl-CoA racemase (AMACR), dans le diagnostic du cancer de prostate. Materiels et methodes Etude retrospective sur 44 prelevements inclus et fixes en paraffine (36 biopsies, 4 resections, 1 adenomectomie et 3 prostatectomies radicales), interessant 20 adenocarcinomes prostatiques (2 cas de carcinome intraductal ; 12 cas Gleason 6(3+3) ; 4 cas Gleason 7(4+3) ; 2 Gleason 8(4+4)) ; 11 foyers suspects ; 9 neoplasies intra epitheliales : 2 bas grade et 7 haut grade dont 1 isolee ; 10 lesions benignes (8 atrophies, 1 hyperplasie adenomateuse atypique et 1 hyperplasie cribriforme a cellules claires). Pour tous les cas, des coupes de tissu fixe inclus en paraffine ont ete testees avec les anticorps anti CK 5/6 et un cocktail associant p63 et p504s, apres restauration antigenique et utilisation de l’automate Ventana. Resultats CK 5/6 et p63 marquent les cellules basales des glandes normales dans respectivement 91,3 et 100 % des cas, quelque soit le mode de fixation (Bouin, Formol). Les adenocarcinomes ont un profil p63 -/p504s +, les neoplasies intra epitheliales et l’hyperplasie adenomateuse atypique sont p63 +/p504s + et les lesions benignes (atrophie, hyperplasie des cellules basales, hyperplasie cribriforme a cellules claires) sont p63 +/p504s –. L’etude des differents anticorps montre un gain en terme de sensibilite CK5/6 (80 %), p63 (90 %), p504s (95 %) p63/p504s (100 %) et de specificite : CK5/6 (87,5 %), p63 (90,5 %), p504s (90,9 %) p63/p504s (90 %). Conclusion Les resultats de cette etude preliminaire permettent de valider la technique d’utilisation d’un cocktail d’anticorps p63/p504s sur l’automate Ventana, et montrent que devant une lesion ambigue, la realisation d’une etude immunohistochimique avec les anticorps anti CK5/6 et un cocktail p63 + p504s permet de proposer un diagnostic dans 82 % des cas.

The Z-shaped ileal neobladder after radical cystectomy: an 18 years experience with 329 patients.

Study Type – Therapy (case series)

Perivesical fat invasion in bladder cancer: implications for prognosis comparing pT2b, pT3a and pT3b stages and consequences for adjuvant chemotherapy indications

Study Type – Therapy (retrospective cohort)

Trends in Renal Function After Radical Cystectomy and Ileal Conduit Diversion: New Insights Regarding Estimated Glomerular Filtration Rate Variations

INTRODUCTION Our objectives were to evaluate the long-term renal function after radical cystectomy (RC) and ileal conduit diversion (ICD) and to analyze year-by-year the estimated glomerular filtration rate (eGFR) and morphologic upper urinary tract changes. PATIENTS AND METHODS We retrospectively identified 226 patients who had undergone RC and ICD from 1980 to 2008, with regular postoperative follow-up visits. The eGFR was calculated using the Modification of Diet in Renal Disease equation at baseline and during follow-up. A decrease in renal function was defined as > 1 mL/min/1.73 m(2) annually. RESULTS The median follow-up period after RC was 91 months (range, 61-235 months). The median eGFR decreased from 66 mL/min/1.73 m(2) (range, 17-139 mL/min/1.73 m(2)) to 59 mL/min/1.73 m(2) (range, 33-102 mL/min/1.73 m(2)). A rapid decline in renal function occurred during the first 2 postoperative years (-9 mL/min/1.73 m(2) and -4 mL/min/1.73 m(2) in the first and second year, respectively), with a moderate to slight decrease in the subsequent years. Urinary obstruction was diagnosed in 51 patients (23%). Among the patients who underwent prompt surgical treatment, we did not find any association with the eGFR decline (P = .8). CONCLUSION Patients with urinary ICD have a lifelong risk of chronic kidney disease. Regular monitoring of renal function and the morphologic upper urinary tract will permit early diagnosis and treatment of modifiable factors, avoiding irreversible kidney damage.

Syndrome des gènes contigus TSC2/PKD1: À propos de deux observations

Resume Les deux principaux genes responsables de la polykystose renale autosomique dominante et de la sclerose tubereuse de Bourneville se situent sur le chromosome 16 (16p13.3), separes seulement de quelques nucleotides. La deletion simultanee de ces deux genes est appelee « syndrome des genes contigus TSC2/PKD1 » et a ete essentiellement decrite chez l’enfant, et plus rarement chez l’adulte. Nous rapportons deux observations francaises survenues chez des adultes, porteurs d’une polykystose autosomique dominante dont le diagnostic a ete realise fortuitement sur l’etude macroscopique et microscopique de la piece de nephrectomie. Ce diagnostic doit etre evoque devant l’association d’une polykystose et de multiples angiomyolipomes. Il necessite la mise en place d’une surveillance specifique afin de depister les complications de chacune de ces deux pathologies.