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OBJECTIVE: To retrospectively evaluate the morbidity of radical prostatectomy, with the exception of sexual complications, based on a recent single-centre series. MATERIAL AND METHOD: From January 1996 to January 1998, the morbidity of 100 consecutive patients undergoing radical retropubic prostatectomy was compared to the morbidity of the first 150 patients operated by the same technique in our department for the period 1983-1993. The perioperative morbidity was studied retrospectively on case files, while continence was evaluated in the last 50 patients by a self-administered questionnaire. Sexual complications could not be evaluated objectively for methodological reasons and were not addressed in this study. RESULTS: The single operative complication was a rectal injury (1%). The transfusion rate was 31%. The early complication rate was 23% with a major complication rate of 5% (four thromboembolic complications and one gastrointestinal haemorrhage). The most frequent minor complications (18%) were wound abscess (5%). The reoperation rate was 3%. The mean duration of vesical catheterization was 7 days (range: 4-30) and the mean hospital stay was 8 days (range: 5-30). With a mean follow-up of 14 months, 73% of patients are perfectly continent, with no incontinence pads, while 15% of the patients required incontinence pads "as a precaution". Incontinence required implantation of an artificial sphincter in 2 patients (2%). Only one patient developed stenosis of the anastomosis requiring internal urethrotomy. The reduction of morbidity in these 100 recently operated patients compared to the first 150 operated patients concerned the transfusion rate (31% versus 65%), the reoperation rate (3% versus 8%) and the minor complication rate (18% versus 32%). The reduction of operative morbidity partly explains the reduction of mean duration of vesical catheterization (7 days versus 15 days), and hospital stay (8 days versus 18 days); the anastomotic stenosis rate was also decreased from 17.3% to 1%. CONCLUSION: This study confirms the reduction of overall morbidity of retropubic radical prostatectomy. This improvement is probably multifactorial: increased operative experience and better postoperative management. These retrospective data must be taken into account in the diagnostic and therapeutic decisions concerning localized prostate cancer.

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Two cases of recurrent macroscopic hematuria in which the diagnosis of left renal vein varices has suggested on CT are described. Bloody efflux was seen from the left ureteric orifice. On CT scans, tubulated contrast-enhanced densities in left perineal fat were seen. Selective renal angiography was normal. Selective left renal phlebography demonstrated intra and perirenal varices. In the two cases, embolization with metallic coli was successfully performed during left renal phlebography, to stop renal varices flux. Diagnostic and therapeutic modalities of renal varices are discussed with predominant place for CT and phlebography.

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OBJECTIVE: To identify patients at high risk of extraprostatic seminal vesicle infiltration, in whom preoperative seminal vesicle biopsies should be performed. MATERIALS AND METHODS: We studied the relationship between extraprostatic seminal vesicle infiltration and the available preoperative data [age, clinical stage, prostate-specific antigen (PSA) level, number and site of positive prostatic sextant biopsies, Gleason score] in a total of 75 patients suffering from clinically localized prostatic adenocarcinoma who were candidates for radical prostatectomy. RESULTS: The chi 2 test showed that the preoperative data most significantly correlated with extraprostatic seminal vesicle infiltration were the presence of positive basal biopsies (p < 0.001). The PSA level did not have any predictive value. The most discriminant preoperative parameter of the state of the seminal vesicles (analysis of variance on a univariate model) was the state of the basal prostatic biopsies. The importance of this parameter was confirmed by cluster analysis. Overall, the risk of extraprostatic seminal vesicle invasion was 0 (0/21 patients) when the 2 basal prostatic biopsies were negative, 10.25% (4/39 patients) when 1 of the 2 basal prostatic biopsies was positive and 73.33% (11/15 patients) when both basal prostatic biopsies were positive. CONCLUSIONS: In a patient with clinically localized prostatic adenocarcinoma who is a candidate for radical prostatectomy, seminal vesicle biopsies are useless when basal prostatic biopsies are negative, regardless of the state of other preoperative parameters. When 1 or 2 basal prostatic biopsies are positive, seminal vesicle biopsies can improve the pretreatment pathological staging.

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Magnetic resonance imaging showed a massive intracranial invasion by an adenoid cystic carcinoma (cylindroma) originating from an ethmoid sinus. The tumor was excised and follow-up radiation therapy was planned because of bone involvement and superficial invasion of the right olfactory tract area.

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OBJECTIVES: We report the first experimental studies of focused extracorporeal pyrotherapy. METHODS: Focused extracorporeal pyrotherapy has been used to treat superficial bladder tumors in a Phase II protocol in 25 patients. In 5 cases, for technical reasons, pyrotherapy was not used. In 20 patients (10 under general anesthesia and 10 under spinal anesthesia), the mean treated volume was 3 cm3 with an average of 300 shots and a mean skin focused length of 90 mm. Treatment time was 44 minutes; hospital stay was 2 days. Postoperatively, two skin burns and one acute retention were observed. RESULTS: Of 20 patients, 15 (75%) had a normal urinary cytology bladder ultrasonography and cystoscopy at 1 month. In 67% of patients with primary tumor, there was no recurrence at 1 year; 33% had recurrent tumors. No infiltrative tumor or metastases have been observed during this follow-up (3 to 21 months). CONCLUSIONS: These encouraging results show that ablation of superficial bladder tumor is feasible. The technique must be improved to allow treatment of larger tumor volume in a shorter time.

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The advent of extra-corporal shock-wave lithotripsy in the eighties totally changed management strategies for renal and ureteral lithiasis of the upper urinary tract. Currently, approximately 80% of all patients can benefit from lithotripsy with an overall success rate of about 75%. Although classical surgery has a higher success rate of about 90%, extra-corporal shock-wave lithotripsy has many advantages. First there is a very low risk of morbidity (pain, immobilization, complications) for this outpatient treatment. Second, the overall cost, including that of preventive treatment, is low as illustrated by the major reduction in the number of cases of pyonephritis on stones and of corraliform lithiasis. The apparent safety of shock-wave therapy should not mask the risk of unacceptable indications: small stones which may resolve spontaneously or inversely very large stones carrying the risk of residual fragments and renal damage. Long-term morbidity remains to be evaluated, but the management of upper urinary tract lithiasis now relies heavily on shock-wave therapy alongside conventional surgery and percutaneous or endoscopic methods.

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The authors report their experience of the first 10 patients operated by upper urinary tract lumboscopic surgery. Lumboscopy is performed in the lateral supine position and a simple technique for creation of retropneumoritoneum is described. In 4 patients, the planned nephrectomy could be performed because of poor anatomical conditions (peripyelitis and/or perinephritis). Lumboscopy allowed complete renal exploration, two nephrectomies, two resections of the roofs of compressive parapelvic cysts and one lumbar ureterolithotomy. The ease and rapidity of lumboscopic dissection makes it a valuable alternative to laparoscopy.

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The authors have performed a "Mini-Bricker" operation in 24 patients with bladder cancer. This technique consists of urinary diversion in which the size of the intestinal loop is reduced to an average of 4 cm and the ureteroileal anastomosis is performed end-to-end in order to allow subsequent endourological procedures, if necessary. The postoperative course was uneventful in 71% of cases. Seven early complications were reported: 3 infectious, 1 thromboembolic and 2 hernias. In the medium term, one case of disturbances and 2 stenoses of the ureteroileal anastomosis were treated by endoscopic dilatation. The median follow-up is 3 years and 5 patients have died. A retrospective survey of quality of life revealed that 86% of patients were satisfied with their diversion and rapidly acquired autonomy following cystectomy without the need for retraining and without having to get up at night.

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The authors studied the morbidity of retropubic radical prostatectomy in 150 patients operated between December 1983 and March 1993. The perioperative mortality was zero. A rectal injury occurred in 3 cases (2%) and was repaired immediately without colostomy. The median operative blood loss was 1,500 ml. 36.6% of cases developed perioperative complications. 8% of early postoperative complications (< 1 month) required reoperation. Major complications (thromboembolic and septic) were observed in 3.2% of cases. The late postoperative complications included fibrous stenosis of the urethrovesical anastomosis in 12% of cases with a median time to onset of 4 months: 3.6% of patients developed an anastomotic stenosis due to local recurrence. 12.6% of cases developed persistent urinary incontinence (6.6% of minor incontinence, 5.3% of moderate incontinence and 0.7% of severe incontinence). Incontinence was more frequent (p < 0.05) among the first 75 patients of the series. Erectile function was preserved in 19.8% of patients. The incidence of post-operative impotence was significantly lower (p < 0.01) in patients under the age of 60 years (65% vs 94.8%). Radical prostatectomy, considered to be the most appropriate treatment for localised prostatic cancer, can now be performed with acceptable morbidity.

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A total of 100 men with a mean age of 63 years underwent, in the following order, prostate specific antigen (PSA) assay (radioimmunometric assay, normal less than 2.5 ng./ml.), rectal examination, transrectal ultrasonography with a 7 MHz. probe, measurement of the prostatic volume, and 6 ultrasound-guided randomized biopsies and biopsies of any hypoechogenic zones. All men with a suspicious prostate on rectal examination (nodule, induration or firm zone) were excluded from the study. There were 14 prostatic cancers detected: 3 (8.5%) in men less than 60 years old, 4 (11%) in men between 60 and 70 years old and 7 (24%) in men more than 70 years old. No cancer was detected in men with a PSA level of less than 10 ng./ml., 5 (26%) were detected in 19 men with a PSA level of 10 to 19 ng./ml., 4 (40%) were detected in 10 men with a PSA of 20 to 29.9 ng./ml. and 5 (100%) were detected in 5 men with a PSA of 30 or more ng./ml. A total of 66 men (66%) had a PSA level of less than 10 ng./ml. There were 18 (18%) hypoechogenic zones detected: 2 (11%) were positive for cancer but, over-all, the hypoechogenic zones revealed cancer in only 2 of 100 cases (2%). In 12 of the 14 cancers detected (86%) with no clinical suspicion the PSA level was higher than the maximal PSA level related to the prostate weight. We conclude that systematic randomized prostatic biopsies are the best method of early diagnosis, detecting 41% of all prostatic cancers in men with a normal rectal examination when the PSA level is 10 ng./ml. or more. The real question is to determine whether this early diagnosis is useful for the patient, since presently, there is no certainty of the therapeutic benefit in terms of quantity and quality of life.

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The objective of this study was to develop an apparatus allowing the generation of a high temperature (exceeding 80 degrees C) in a precise focus (20 mm x 2 mm) by means of extracorporeal elastic waves. The treatment time at high temperatures is brief and administered in sequences of 4 to 7 seconds. In vitro studies on blocks of polyurethane demonstrated melting of the plastic at the focal point. Studies on plastic spheres introduced into the bladder of the pig demonstrated melting of the sphere without any alteration in the tissues in the wave path. Studies of cellular viability of bladder carcinoma cultures demonstrated a significant difference after 48 hours between the non-treated control group and the group of cells submitted to high temperatures. This technique, called Pyrotherapy, should be promising if the preliminary results are confirmed.

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A new device made of piezoelectric ceramic placed in a semispherical dish and focussed at 320 mm was developed in order to generate heat and cavitation responsible for coagulative necrosis of deep tissues. The target to be treated is located with a central ultrasound probe of 3.5 MHz. In vitro studies with polyurethane phantoms showed that the ultrasound melted a surface of 2 x 12 mm within 1 s. The temperature recorded at the focus was 270 degrees C. In tissue samples (prostate cancer and benign prostate hyperplasia), the temperature rose to 85 degrees C in vitro and a hyperechoic zone appeared at the focus during shots. In vivo 8-mm plastic spheres, introduced surgically into the bladder of pigs, were melted by repeat shots without burning of crossed tissues. These studies were performed in the kidney and the liver. Autopsy performed on day 0 showed congestion, autopsy performed between day 6 and day 11 showed necrosis, whereas at 3 months the focussed area was fibrosed. This technique, which we called 'focussed extracorporeal pyrotherapy', combines phenomena of cavitation and high heat at the focus. Prostate tumors, bladder tumors, kidney tumors and liver metastases are potential indications for pyrotherapy.

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Twenty-five patients with localized prostate cancer underwent seminal vesicle biopsies before radical prostatectomy. A transrectal probe of 7 MHz, a 18-gauge needle and a biopsy gun were used. The preoperative biopsy established the absence of seminal vesicle invasion in 89% of cases. When the seminal vesicles are positive at biopsy, capsular penetration is observed in 100% of the cases and lymph node positivity in 50%. When seminal vesicles are negative at biopsy and the prostate-specific antigen level is less than 20 ng/ml (n less than 2.5), capsular penetration of greater than 1 cm is absent in 100% of cases and lymph nodes are positive in only 7% of cases. Biopsy of the seminal vesicle, as an outpatient procedure, improves the preoperative staging of prostate cancer before radical prostatectomy: negative biopsies are good predictors of the absence of lymph node invasion.

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The first 400 patients treated on an inpatient basis at our center underwent bacteriological follow-up after extracorporeal lithotripsy (ECL) for ureteric or renal stones. 278 patients did not have any urinary tract infection on the urine culture before ECL. They did not receive any antibiotic prophylaxis and 4.8% of the patients developed infectious problems, with significant bacteriuria in only 1.5% of the cases. 89 patients had urinary tract infection on the preoperative cultures. 21.3% developed either fever or significant bacteriuria and this virtually always occurred in patients who were treated for less than 4 days before ECL, with septicemia in 4.5% of the cases. 33 patients with sterile urine received flush antibiotic prophylaxis and none of them developed postoperative infection. Two of these patients had infection at the time of the flush: one of them, who, by error, did not receive antibiotic treatment prior to ECL, developed bacteremia after the procedure. The rational use of antibiotics in conjunction with ECL should ensure effective prevention of urinary tract infections without requiring the excessive use of antibiotics.

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Intravenous urography, systematically performed in 50 consecutive acute pyelonephritis patients, revealed abnormalities in 17 of them: in 12 cases (24%), treatment and follow-up were modified; in the other 5 cases (10%), the anomalies were insignificant. The nephrogram was normal for 33 patients (66%). The frequency of significant abnormalities was higher in patients over 50 years of age (46.2%) than in those under 50 (16.2%) (p less than 0.05), and was also higher in patients remaining febrile for 3 days after the onset of an appropriate antibiotic therapy (66.6%) than in responsive patients (14.4%) (p less than 0.01). Among the significant lesions, 10 were detectable by echography and another by abdominal X-ray. Thus, a population of women under 50 years of age with acute pyelonephritis can be selected for urography, as shown by these results, however, they must be confirmed before changing the systematic practice of urography.

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One hundred and twenty-six patients with renal cell carcinoma were treated by nephrectomy between 1985 and 1988. They were classified into three groups: group A: 47 patients in whom ultrasonography revealed the renal cancer in the absence of any suggestive clinical signs of tumour; group B: 63 patients who presented with clinical urological signs suggestive of the tumour; group C: 16 patients who presented with general signs leading to the diagnosis. In group A, 50% of the tumours measured between 5 and 10 cm, 51% were located at the lower pole of the kidney and 83% were stage T2. Sixty-six percent of cancers in this group were situated on the right side, indicating that left renal cancers are missed in 16% of cases. In group B, 60% of the tumours measured between 5 and 10 cm, 44% were located at the lower pole and 56% were stage T2. In group C, 60% of the tumours measured between 5 and 10 cm, 50% were located at the upper pole of the kidney and only 38% of the tumours were still stage T2. We can conclude that incidental detection reveals renal tumours at a relatively limited stage (83% of T2), with dimensions smaller than those of the other groups. It is therefore essential for radiologists, ultrasonographists and urologists to investigate the left lumbar fossa and the upper pole of both kidneys very carefully during abdominal or vesico-prostatic ultrasound examinations.

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Flushing back stones of the lumbar or iliac ureter towards the renal cavities by means of a catheter is now part of everyday practice. The ureteric flush-back technique is often easily performed when the appropriate equipment is used wisely. We used a 23 Ch cystoscope with a 5 degrees lens to work in the axis of the ureter and a 7 Ch catheter with a single orifice is advanced as far as the stone. In 30% of cases, the stone immediately ascends as far as the renal cavities due to ureteric distension. In the case of failure, rapid injections of physiological saline with a syringe are successful in 40% of cases. In 10% of cases, success depends on progressive hydraulic distension of the ureter above the stone following injection of physiological saline.

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Nine renal stones were separated into 5 fragments of similar weight and size. One fragment was analyzed chemically and the other 4 fragments were submitted to treatment by piezoelectric shock waves according to the following modalities: 3,000 shock waves at firing frequencies of 1.25, 2.5, 5 and 10 shock waves/s. In the case of hard stones, better quality fragmentation was obtained with low frequencies than with high frequencies. With friable stones, using only 800 shock waves, the result was the same regardless of the frequency used. Treatment of hard stones by shock waves for 20 min at various frequencies revealed that a slightly better result was obtained with a frequency of 5 shock waves/s, although the result was not significantly better. In conclusion, slow frequencies of 1.25 or 2.5 shock waves/s allow better fragmentation of hard stones at the cost of a longer mean treatment than at high frequencies. High frequencies do not give significantly better results than low frequencies when the same firing time is used. In the clinical situation, it is therefore preferable to use low frequencies which allow treatment without anesthesia or analgesia and without admission to hospital.

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