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Resume L'apport des analogues de la LHRH est immense pour la prise en charge, pratiquement a tous les stades, du cancer de la prostate, premier cancer de l'homme de plus de 50 ans. Ils permettent d'utiliser l'hormonotherapie de maniere fiable, peu morbide et reversible. Leur utilisation peut etre immediate ou differee, continue ou intermittente, associee ou non a un anti-androgene, et associee a la chimiotherapie pour les patients parvenus au stade d'echappement hormonal.

Resume Le rising PSA apres prostatectomie radicale correspond a une recidive biochimique, c'est-a-dire une re-ascension du taux de PSA. Plusieurs definitions de la recidive biochimique existent. Des elements predictifs permettent de differencier la recidive locale de la recidive a distance. Selon les cas, les options therapeutiques possibles pour la prise en charge de ces recidives sont la radiotherapie, l'hormonotherapie et la chimiotherapie.

Intermittent hormone therapy in prostate cancer consists in disrupting treatment after the nadir PSA has been reached, and reinitiating treatment when the PSA increases over a certain threshold. Theoretical advantages of intermittent hormone therapy are to delay the occurrence of hormone-independence and to decrease treatment-related side effects. Some phase II trials have demonstrated the feasibility of intermittent hormone therapy. The percent time without treatment varies between 40 and 50%. Oncologic results of intermittent hormone therapy are, at least, equivalent to those of continuous therapy. Moreover, the side effects of treatment are decreased and the quality of life is improved during off treatment phases. Due to the lack of comparative studies, the superiority of intermittent upon continuous treatment has not been established at long-term follow-up. Prospective comparative trials are ongoing; they will determine the true benefit of intermittent hormone therapy in prostate cancer.

The contribution of LHRH analogs is enormous in prostate cancer management at nearly all stages of the disease, the Leading cancer in males over 50 years of age. They make it possible to use hormone therapy reliably, with Little morbidity, and can be reversed. Their use can be immediate or delayed, continuous or intermittent, whether or not they are associated with an antiandrogen, and can be associated with chemotherapy for patients who have reached the stage of hormone-refractory prostate cancer.

Rising PSA after radical prostatectomy corresponds to a biochemical recurrence, i.e., a new rise in PSA levels. Several definitions of biochemical recurrence exist. Predictive factors can differentiate Local recurrence and distant metastasis. Depending on the case, the therapeutic options for managing these recurrences are radiotherapy, hormone therapy, and chemotherapy.

Intermittent hormone therapy in prostate cancer consists in disrupting treatment after the nadir PSA has been reached, and reinitiating treatment when the PSA increases over a certain threshold. Theoretical advantages of intermittent hormone therapy are to delay the occurrence of hormone-independence and to decrease treatment-related side effects. Some phase II trials have demonstrated the feasibility of intermittent hormone therapy. The percent time without treatment varies between 40 and 50%. Oncologic results of intermittent hormone therapy are, at least, equivalent to those of continuous therapy. Moreover, the side effects of treatment are decreased and the quality of life is improved during off treatment phases. Due to the lack of comparative studies, the superiority of intermittent upon continuous treatment has not been established at long-term follow-up. Prospective comparative trials are ongoing; they will determine the true benefit of intermittent hormone therapy in prostate cancer.

Radiation therapy is commonly used to treat pelvic or retroperitoneal cancers but has some impact on genito-urinary system: short-term side effects are frequent with usually a completed regression. However, the incidence of major complications is about 12% and is probably underestimated due to a long delay between radiation therapy and diagnosis of some adverse events such as ureteral strictures or fistula. Clinical follow-up must absolutely include an early diagnosis and treatment of radiation therapy complications such as renal dysfunction, ureteral stricture, ureteral fistula, chronic bladder injury, bladder fistula, urethral stricture, infertility or erectile dysfunction.

The LDMWH (Promeditech 2000), a hyperthermia apparatus emitting microwaves with a frequency of 915 MHz, has been used since July 1988 in the Urology Department of Hôpital Cochin and the Polyclinic of Montreuil for the treatment of prostatic obstructions. Patients are selected on the basis of objective criteria (flowmetry, post-micturating residue) and subjective criteria (standard clinical history). Only patients with objective obstruction are treated by localized hyperthermia, which constitutes a real alternative to surgery. Treatment is performed as an outpatient procedure without anaesthesia as one one-hour session per week for a period of six weeks. The results are evaluated one and three months after completion of treatment by assessing the same objective and subjective criteria as before treatment. The results of the first 26 patients with sufficient follow-up reveals 45% good objective results and 65% good subjective results.

Seven patients with renal failure secondary to bilateral ureteric obstruction by pelvic carcinoma underwent palliative urinary diversion. In 3 cases, an autostatic ureteric stent was inserted after endoscopic resection of the trigone invaded by the tumour in the presumed zone of the ureteric meatus, and retrograde catheterisation of the ureter. This method has very limited indications, but may improve the comfort of survival of certain patients.

Thirty patients with traumatic rupture of the urethra were treated in the Urology Department of Cochin Hospital between 1975 and 1985: 11 as an emergency procedure, 7 for an early complication and 12 for a late complication. In the patients treated early, urethrorrhaphy or one-stage urethroplasty gave the best results. Two stage urethroplasty constituted best treatment for patients with a complication of earlier treatment. In patients with late complications, endoscopic urethrotomy is rarely sufficient on its own and two-stage urethroplasty is generally indicated.

Endometriosis, initially believed to be a gynecologic disease, occasionally involves the urinary bladder, and less frequently the ureters. Use of ureteral stents with an appropriate hormonal treatment can obviate the need for open surgery.

Complicated pyelo-ureteral duplication in the adult may be revealed by recurrent pyelonephritis or urinary leakage. The diagnosis can be performed by combined urography and ultrasound scan. The management is rarely conservative. In most cases, it consists in hemonephrectomy. The ureterectomy is partial, extending up to the pelvic brim in the case of a fine ureter. If the ureter is dilated, however, the ureterectomy must be subtotal, in order to avoid postoperative infectious recurrence.

The prone position is often used in urologic surgery: posterior approach for pyeloureteral procedures, repair of vesicovaginal fistulas... Positioning of the patient and intraoperative ventilation are facilitated by use of an antistatic, fitted mattress.

Among one hundred consecutive patients submitted to radical cysto-prostatectomy for invasive transitional cell carcinoma of the bladder, 26 also exhibited adenocarcinoma of the prostate on histological specimens: 17 microscopic foci and 9 larger prostate carcinomas. In 3 cases, the tumor was found in the apex of the prostate gland. Pelvic lymphadenectomy was positive in 4 cases but always corresponded to a urothelial metastasis. Follow-up was never marked by a metastatic development of this adenocarcinoma. This frequency of latent prostatic adenocarcinoma is not different from its observed incidence in the general population on autopsy studies. The high incidence of this association makes removal of the whole prostatic tissue during total cystectomy necessary.

A prospective study was conducted on the sexual function of 70 patients undergoing transurethral (48 cases) or transvesical (22 cases) prostatectomy for benign prostatic hypertrophy. 22 patients with no sexual activity before operation, remained sexually inactive after surgery. Frequency of intercourse and penile erection remained generally unchanged after operation. Retrograde ejaculation was observed in 33 patients (69%). Only one patient complained of total loss of potency after operation. Orgasm was maintained in all other patients; however 25 patients considered it to be "different". 4 of the sexually active operated patients (8%) and 7 of their partners complained of lack of sexual satisfaction after operation.

Sarcomas of the retroperitoneal soft tissues and of the cord are rare and serious tumours. However, a better histological understanding, determination of the histological and prognostic grades and progress in chemotherapy have led to an improvement in the overall prognosis of these tumours.

In order to define the prognosis of pure squamous carcinomas of the bladder, on the one hand (group I), and the possible aggravating role of the presence of squamous tissue in an invasive renal cell tumour, on the other hand (group II), 46 cases files of patients treated between 1975 and 1984 were analysed retrospectively. Group I consisted of 18 cases of pure squamous carcinoma (11 men with a mean age of 71 years and 7 women with a mean age of 74 years). 66% of cases presented with haematuria, but urinary cytology was of little help. The diagnosis was established by transurethral resection with 18 grade 3 tumours: stage A in 4 cases and stage B in 14 cases. 10 patients had unilateral (8 cases) or bilateral (2 cases) complications of the upper urinary tract. The presence of lymph node and/or haematogenous metastases was investigated by bone scan, hepatic ultrasonography, pulmonary tomography and, most importantly, by bipedal lymphography combined with percutaneous cyto-aspiration of suspicious nodes. 4 patients presented with invasion of the obturator lymph nodes (2 cases) and iliac lymph nodes (2 cases). 9 patients were treated by total cysto-prostatectomy, 6 patients by radiotherapy (60 Grays) and 3 patients did not receive any treatment. The overall survival was 12.5% after 2 years. None of the patients treated by radiotherapy were alive after 2 years. 29% of the patients treated by surgery survived for 2 years, but none of them were alive after 5 years, essentially as a result of local recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracorporeal lithotripsy of urinary calculi by pulsed dye laser has recently enriched the urologist's therapeutic arsenal. We recall the in vitro studies and animal experimentations which demonstrated the feasibility of laser lithotripsy and the absence of harmful tissue damage. The ideal indications for intracorporeal lithotripsy are ureteral stones accessible by rigid and, more especially, flexible ureteroscopy. The results of the first published series using this technique are very encouraging.

In order to more clearly define the risk of infection of prostatic biopsy, the authors conducted an analysis of the morbidity of each method. The risk of infection, the possible forms of prophylaxis and the best indications are presented for each method.

Several teams over recent years have proposed deep transurethral incision of the prostate as treatment for obstructive symptoms secondary to primary bladder neck sclerosis or to a small prostatic adenoma. We have performed this technique in 16 patients over a period of 9 months: 9 cases of primary bladder neck sclerosis and 7 prostatic adenomas weighing less than 20 grams. There were no post-operative complications. This technique was definitely effective on the dysuria with 93% good results at 6 months. The preservation of post-operative anterograde ejaculation was less certain; 27% of our patients developed post-operative retrograde ejaculation. The indication for TUI amongst the other available surgical techniques depends on a rigorous pre-operative assessment evaluating the size and the nature of the obstruction. It is a remarkably simple technique which effectively cures the dysuria. It also markedly decreases the risk of retrograde ejaculation. As this complication is difficult to predict, the patients should be informed of the risks prior to the operation.

In order to assess the potential benefits of radical cystectomy in bladder cancer associated with pelvic lymph node metastasis, a retrospective study compared 2 groups of patients with T2-T3 N+ bladder cancer: 10 treated by radical cystectomy and 14 treated conservatively once the diagnosis of nodal metastasis had been established by fine needle node aspiration or lymphadenectomy. The survival rates were identical in both groups: 80% of the patients died within 2 years, 60% during the first year after diagnosis, mainly due to distant metastasis. No patient in the conservative arm required salvage cystectomy because of local progression. It is concluded that radical cystectomy is of little benefit in T2-T3 N+ bladder cancer, a disease which is no longer amenable to purely local treatment.

Extracorporeal shock wave lithotripsy (ESWL) as primary treatment for large renal stones has been evaluated in this clinical study of 55 patients. Patients were treated using the Dornier HM-3 lithotripter. Twenty-one (38%) patients presented with a stone burden greater than 4 centimeters. Nineteen patients had "steinstrasse", of which 8 had to undergo a secondary procedure. Sixteen (29%) patients had no residual stone, 5 had clinically non significant stones and 34 had clinically significant stones. Out of the 15 patients who underwent a second ESWL, only 2 were rendered stone-free. In this study, ESWL was not found to be a satisfactory treatment for large renal stones.

One case of intra-abdominal seminoma with persistent müllerian duct syndrome is reported. Literature is reviewed and guidelines for management of such are suggested.

Four patients with solid genito-urinary tumors and HIV 1 infection have been treated in our institution over the last 2 years, including 2 with seminoma, 1 with renal adenocarcinoma and 1 with renal angiosarcoma. All had severely impaired immunity with a low CD4 level. Three had or developed a true AIDS syndrome according to the WHO and CDC criteria (1988). The remaining patient was seropositive and died less than 3 months following the diagnosis of renal angiosarcoma, he is the first reported case of renal sarcoma in a patient infected with HIV 1. Two patients were homosexuals and the other 2 were drug addicts. Along with other reported cases, our cases may underline the association between depression of immunity due to HIV and onset of solid genito-urinary tumors.

The tissue effects of pulsed dye laser (Pulsolith) were studied in 10 dog ureters. The results show the absence of ureteric perforation or damage to adjacent organs by the laser irradiation. The only lesions observed were focal hyperplasia of the urothelium and chorion with extremely limited abrasions of the urothelium. The absence of tissue damage of the pulsed dye laser allows it to be used in human clinical practice.