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Resume La physiopathologie de la dysfonction erectile (DE) est multifactorielle. La decouverte recente du role precis de l’endothelium caverneux dans la regulation fonctionnelle des cellules musculaires lisses a permis de mieux comprendre les bases physiologiques de l’erection. Le but de cet article est de faire une synthese des connaissances actuelles sur la fonction endotheliale et de permettre une meilleure comprehension des mecanismes physiopathologiques responsables de la DE. L’endothelium est capable d’entrainer un relâchement des fibres musculaires lisses des corps caverneux par deux voies principales : la voie de la NO/GMPc initiee par production d’oxyde nitrique (NO) au niveau des fibres terminales des nerfs caverneux et la voie AC/AMPc qui contourne la voie du NO en utilisant d’autres mediateurs, notamment les prostacylines. Cette action permet l’initiation et le maintient de l’erection. Certains facteurs de risque vasculaires (diabete, HTA, hypercholesterolemie) peuvent aboutir a un dysfonctionnement endothelial caverneux, soit par une augmentation du stress oxydatif et accumulation de radicaux libres, soit par une alteration de la production de NO, soit par une diminution de l’expression de VEGF. Ces memes mecanismes cellulaires peuvent egalement s’observer au cours du vieillissement. La connaissance de ces bases physiopathologiques est un premier pas vers la prise en charge clinique de la DE. Les differentes explorations fonctionnelles qui en decoulent et le mode d’action des traitements actuels seront abordes dans une prochaine synthese.

Resume Avec maintenant plus de 20 ans d’experience pour les equipes pionnieres americaines et europeennes (et plus de dix ans en France), la curietherapie par implantation permanente de grains d’iode 125 s’est imposee en 2008 comme une alternative incontournable a la chirurgie pour les cancers de prostate localises a bas risque. Il existe une tendance actuelle pour elargir les indications de cette curietherapie exclusive vers certains patients strictement selectionnes atteints de cancer localise de pronostic intermediaire. Enfin, pour les cancers de prostate localises a haut risque, l’adjonction d’une curietherapie a l’irradiation externe pourrait permettre une escalade de dose dont pourraient beneficier certains patients. Diverses techniques peuvent etre utilisees : avec ou non preplanification, avec grains libres ou lies, avec injection automatique des grains ou non. Le point capital est ici la parfaite maitrise de la procedure et la capacite de repondre a des contraintes dosimetriques precises recemment reactualisees par le Groupe europeen de curietherapie - European Society for Therapeutic Radiology and Oncology (GEC-ESTRO). L’analyse des resultats a moyen–long terme disponibles dans la litterature indique des taux de survie sans recidive de l’ordre de 90 % a 5–10 ans, d’autant meilleurs que les criteres dosimetriques etaient satisfaisants. En termes de complications, quelques etudes comparatives ont confirme des taux d’incontinence et d’impuissance qui semblent significativement inferieurs a ceux des procedures chirurgicales. En revanche, il existe apres curietherapie un risque de retention urinaire, qui ne devrait pas depasser 3–5 %, et un syndrome irritatif urinaire qui peut etre majeur et durer plusieurs mois. Malgre ces inconvenients, la curietherapie par implants permanents, forte de ses resultats a long terme et de ses taux limites d’incontinence et d’impuissance, devrait voir ses indications se multiplier dans les annees a venir.

RESUME La medecine francaise est entree dans une periode de mutation dont les effets devraient etre maximum en 2015, notamment par l’effet de la decroissance de la demographie medicale alors que la technicite et les couts ne cessent de progresser. Cette situation doit etre saisie comme une opportunite pour refondre en profondeur l’ensemble du systeme a partir d’objectifs prioritaires tenant compte des besoins de la population sur l’ensemble du territoire. L’organisation des soins primaires est la priorite a court terme en regroupant les professionnels de sante afin de faciliter l’acces aux malades et d’etablir une permanence des soins. De la meme facon il faut etablir un maillage hospitalier de premier niveau permettant d’assurer les urgences dans un delai de 3 heures. Cette mutation passe egalement par une profonde reforme des etudes medicales. Le mode de selection actuel est inadapte. La formation des generalistes ne correspond pas au metier exerce, et celle des specialistes manque de souplesse. Enfin il faut engager une reflexion sur les revenus des medecins afin de reduire les inegalites.

Resume L'anastomose uretrovesicale est le dernier temps operatoire de la prostatectomie radicale. Quelle que soit la voie d'abord, la prostatectomie radicale est une intervention difficile. Les temps de dissection sont similaires par voie ouverte et par voie laparoscopique. L'anastomose uretrovesicale laparoscopique requiert une gestuelle particuliere. Cette gestuelle doit etre maitrisee par le chirurgien realisant une prostatectomie radicale laparoscopique. Cette technique est codifiee et reproductible. Elle peut etre assimilee sur pelvitrainer avant de commencer a realiser cette intervention par voie laparoscopique. Cet article rapporte les points clefs necessaires a la realisation de l'anastomose uretrovesicale par voie laparoscopique, ainsi que les differentes variations techniques.

According to real-world accident analysis (Lamielle et al. 2006), most of the abdominal injuries sustained by restrained occupants can be attributed to submarining. In frontal crashes, submarining ...

In order to assess the effect of in vitro models on the expression of key genes known to be implicated in the development or progression of cancer, we quantified by real-time quantitative PCR the expression of 28 key genes in three bladder cancer tissue specimens and in their derived cell lines, studied either as one-dimensional single cell suspensions, two-dimensional monolayers or three-dimensional spheroids. Global analysis of gene expression profiles showed that in vitro models had a dramatic impact upon gene expression. Remarkably, quantitative differences in gene expression of 2–63-fold were observed in 24 out of 28 genes among the cell models. In addition, we observed that the in vitro model which most closely mimicked in vivo mRNA phenotype varied with both the gene and the patient. These results provide evidence that mRNA expression databases based on cancer cell lines, which are studied to provide a rationale for selection of therapy on the basis of molecular characteristics of a patient's tumour, must be carefully interpreted. British Journal of Cancer (2002) 86, 1283–1289. DOI: 10.1038/sj/bjc/6600239 www.bjcancer.com © 2002 Cancer Research UK

Item does not contain fulltext INTRODUCTION: In order to be able to influence and monitor future developments for urologists, strategies should be promoted in advance to guarantee the future of the speciality and to accommodate the inevitable changes. Faced with this challenge, the EAU, through its Strategy Planning Office (SPO), has prepared a document which is offered, here, in abbreviated form, to the European and international urological communities for general consideration. MATERIAL AND METHODS: A group of subjects, related to the domains and internal consistency of urology as a speciality, were selected and discussed among the members of the SPO and later submitted to open consultation among distinguished members of the urological community. The topics selected for discussion included: what is urology; urology in the university; sub-specialization in urology; training in urology; does kidney transplantation belong to urology, and others. RESULTS: It is shown that urology is going through an exciting and hazardous transition period. Urology has conflicting problems in its traditional domains due to changes in health care policy, and internal identification problems due to its permanent expansion and sub-specialization options. Weaker points are its relation with primary care medicine (shared care options), the presence and role of urology in institutions such as the university, department of surgery, children's hospitals, administration, etc.; the desegregating effect of the sub-specialities; the increasing encroachment of other specialities, and the increasing outpatient effect of technological progress. CONCLUSION: An action plan is proposed to confront these changes without loosing manpower, internal consistency or social image and improving patient care quality, excellence of training and scientific progress.

Resumen Introduccion Es preciso promover estrategias adelantadas que influencien el futuro del compromiso asistencial cientifico y academico de la Urologia y los urologos, si queremos garantizar el futuro de la especialidad y acomodarnos a los cambios inevitables y previsibles. Para atender a este reto la Asociacion Europea de Urologia (EAU), a traves de su Oficina de Estrategia y Planificacion (SPO) ha elaborado un documento que se presenta a continuacion, en forma abreviada, para la consideracion de las Comunidades Urologicas Europeas e Internacionales, en diferentes idiomas Material y metodos Se eligieron dos grupos de temas, uno relacionado con los compromisos asistenciales de la Urologia y otro con la consistencia interna de nuestra disciplina, como especialidad. Estos temas fueron discutidos entre los miembros de la SPO y las conclusiones sometidas en una consulta abierta, al criterio de distinguidos miembros de la Comunidad Urologica Internacional. Los temas seleccionados para la discusion incluyeron aspectos como; Que es la Urologia; Urologia y Universidad; Subespecializacion en Urologia; Residencia Urologica; Urologia y Trasplante Renal; y otros Resultados Se ha concluido que la Urologia esta atravesando un periodo de transicion excitante y arriesgado. La Urologia tiene problemas conflictivos en sus tradicionales campos asistenciales debido a cambios en la politica Sanitaria general, asi como problemas de identificacion interna debidos a su permanente expansion y subespecializacion. Los puntos de mayor debilidad de nuestra disciplina estan en relacion con aspectos de organizacion sanitaria (relacion con la Medicina Primaria), presencia y compromiso en Instituciones como Universidad, Departamento de Cirugia, hospitales infantiles, administracion, etc. Otros puntos importantes son el efecto disgregador de la subespecializacion, la progresiva competencia profesional con otras especialidades y el incremento de la actividad ambulatoria debido al progreso tecnologico Conclusion Se propone un plan de accion que permita enfrentarse a estos previsibles cambios sin perder actividad profesional, sentido de unidad y solidez de la Especialidad, mejorando la imagen publica de la Urologia, la calidad de la asistencia al enfermo y la excelencia en la formacion y progreso cientifico del urologo

La prostatectomie radicale est le traitement de reference du cancer de prostate localise. Le developpement de la laparoscopie en urologie, d’abord pour la nephrectomie puis pour la prostatectomie, est le signe d’une evolution naturelle vers une chirurgie moins invasive. Les principaux avantages sont evidemment la diminution de la morbidite (diminution du saignement, rapidite de recuperation...) associee a une amelioration de la qualite de la vision. Avec 6 ans de recul, les resultats oncologiques sont comparables a ceux de la chirurgie ouverte et les resultats fonctionnels sont tres encourageants. Un suivi a long terme est indispensable, particulierement sur le plan carcinologique.

Cell therapy for urinary incontinence management has been experienced in animals with encouraging results, but studies in human beings are lacking. Our primary objective was to assess the safety of intrasphincteric injections of autologous muscular cells in patients with postprostatectomy incontinence (PPI). Secondary objectives focused on complications efficacy.We conducted an open, prospective study in a single center on 12 patients presenting PPI. Patients underwent intrasphincteric injections of autologous muscular cells isolated from a biopsy of deltoid muscle. The primary endpoint was the Q(max) variation at the three month visit in order to assess potential bladder outlet obstruction. Secondary endpoints assessed side effects and efficacy parameters based on symptoms, quality of life score, voiding diary, pad-test, and urethral pressure profile at one, two, three, six and 12 months after injection.No immediate complication occurred and no significant variation was noted on Q(max). The only side effects possibly product-related were three cases of urinary tract infection treated by antibiotics. An acceptable safety and tolerability of the procedure whatever the injected dose of muscular cells was demonstrated. Results on efficacy after one year were heterogeneous, with 4/12 patients describing reduced urine leakage episodes, 1/12 patient presenting increased maximal closure pressure, and 8/12 patients showing improvement on pad-test.Cell therapy consisting of intrasphincteric injections of autologous muscular cells in patients with PPI was a feasible and safe procedure. The results point out that some subjects may positively respond to this procedure, but clinical efficacy remains to be confirmed.

Evaluation of the efficiency of wound infiltration of ropivacaine in postoperative pain after extraperitoneal laparoscopic radical prostatectomy.Prospective single institution study included 130 patients treated by extraperitoneal laparoscopic radical prostatectomy from January to March 2007. One hundred and two patients were included and randomised in two groups according to the year of birth (pair or impair). Only patients from the first group (year pair) had wound infiltration at the end of the procedure. The second group (year impair) was the control group. An analogic visual scale (EVA) permitted evaluation of pain at 30 minutes, 1, 6 and 12 hours after the procedure. Use of analgesics after procedure were noted for each patient.In the first group, the median of EVA was 1.44, 1.34, 1.72 and 1.51 respectively at 30 minutes, 1, 6 and 12 hours. In the second group, the median of EVA was 1.28, 1.36, 1.46 and 1.44. We found no statistically significant difference for pain and use of analgesic between the two groups (p=0.71, 0.96, 0.47 and 0.86 respectively at 30 minutes, 1, 6 and 12 hours).Ropivacaine in wound infiltration did not decrease significantly the postoperative pain and must not be used systematically.

The physiopathology of erectile dysfunction (ED) is multifactorial. The recent discovery of the precise role of cavernosal endothelium in the functional regulation of the smooth muscle cells allowed to understand the physiological bases of erection. The purpose of this article is to make a synthesis of the current knowledge on the endothelial function and to allow a better understanding of the pathological responsible mechanisms of ED. Endothelium provides cavernosal smooth muscle cells relaxation by two main pathways: the NO/cGMP pathway induced by production of neural nitric oxide (NO) in cavernosal nerve terminals, and the AC/cAMP pathway which by-passes the NO route by using other mediators. This action allows the initiation and maintenance of erection. Risk factor-associated cavernosal endothelial alterations (diabetes mellitus, hypertension, hypercholesterolemia) are mostly induced by unifying mechanisms, including oxidative stress and accumulation of reactive oxygen species, alteration of NO production, or decrease of VEGF expression. The same cellular mechanisms can also be observed during aging. To a comprehensive appraisal of physiological bases of viable endothelium in erectile function, it is crucial to understand its biological activities. The hemodynamic evaluation of endothelial function and the current therapeutic implications will be later approached.

With an experience of more than 20 years for the pionneers (and more than 10 years in France), permanent implant brachytherapy using Iodin 125 seeds is now recognized as a valuable alternative therapy for localized low-risk prostate cancer patients. An extension of the indications of exclusive brachytherapy towards selected patients in the intermediate-risk group is presently under study. Moreover, for patients in the high-risk group, brachytherapy, as an addition to external radiotherapy, could represent one of the best way to escalate the dose for some patients. Various permanent implant brachytherapy techniques have been proposed; preplanning or real-time techniques, loose seeds or stranded seeds, manual or automatic injection of the seeds. The main point here is the ability to perfectly master the procedure and to comply with the dosimetric constraints which have been recently redefined by the Groupe européen de curiethérapie--European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) group. Mid- and long-term results which are now available in the literature indicate relapse-free survival of about 90% at 5-10 years, the best results being obtained with satisfactory dosimetric data. Some comparative data have shown that the incontinence and impotence rates after brachytherapy seemed to be significantly inferior to what is currently observed after surgery. However, a risk of about 3-5% of urinary retention is usually reported after brachytherapy, as well as an irritative urinary syndrome which may be significant and last several months. In spite of those drawbacks, with excellent long-term results and low rates of incontinence and impotence, brachytherapy can be expected to be proposed to an increasing number of patients in France in the next future.

The primary goal of robotic-assisted radical prostatectomy (RALP) is to completely remove the cancer and cure the patient of their carcinoma. Secondary goals of definitive therapy for prostate cancer include both the preservation of preoperative continence and potency. The apical dissection is one of the most crucial steps in the RALP. The dissection of the apex is the one part of this procedure in which the oncological outcome as well as the functional outcomes are in jeopardy if done inaccurately or incorrectly. The surgeon must clearly identify the apex of the prostate to avoid inadvertently entering the prostate and creating a positive surgical margin. The nerves are located in close proximity to the urethra and may be injured if not identified. Post-operative continence is also dependent on an accurate apical dissection. The rhabdosphincter should be clearly identified and a maximum functional urethral length should be maintained to prevent damage to these structures and to avoid postoperative incontinence. If the surgeon does not perform a meticulous dissection the “trifecta” of longterm cancer control, along with recovery of continence and sexual function will not be achieved [1].

The determinants of macroscopic and microscopic anatomical variants of the prostate during ageing are poorly defined. The authors evaluated the correlation between specific gene polymorphisms involved in androgen and oestrogen synthesis and gross (prostatic weight) and microscopic anatomy (stroma/epithelium ratio) of the prostate during ageing.The prostatic weight and stromal surface area of an autopsy series of 85 men over the age of 50 were measured, then compared as a function of gene polymorphisms involved in androgen or oestrogen regulation. The following polymorphisms were studied: number of CAG repeats of the androgen receptor (AR), number of TA repeats and the V89L variant of the 5-alpha-reductase gene (SRD5A2) for androgens, and the A1A2 variant of 17-alpha-hydroxylase (CYP17) and number of TTTA repeats of the aromatase (CYP19) for oestrogens.No correlation was observed between the number of TA repeats of the SRD5A2 gene or TTTA repeats of the CYP19 gene and anatomical parameters of the prostate. A statistically significant positive correlation was observed between age and prostate weight (r=0.21, p=0.05) and a statistically significant negative correlation was observed between prostate weight and number of CAG repeats (r=-0.32, p=0.003). The group with less than 20 CAG repeats was associated with a higher prostate weight than the other group. The stromal surface area was greater in the [20-23] CAG repeat group (p=0.02), and in the A2A2 group of CYP17 (p=0.016) than in the other groups.A small number of CAG repeats is associated with a higher prostate weight. The mean number of CAG repeats of the androgen receptor and the A2A2 variant of the CYP17 gene are associated with a larger stromal surface area.

Vesico-urethral anastomosis is the last step of radical prostatectomy. Whatever the approach, radical prostatectomy remains a difficult surgical intervention. The dissection steps are similar whatever the selected access, open or laparostopic. Laparoscopic anastomosis requires specific skills that must be adequately mastered by the surgeon before starting any laparoscopic radical prostatectomy program. Pelvi-trainers allow training on the anastomosis technique, with reproducible results. This chapter presents the key points for laparoscopic vesico-urethral anastomosis.

We performed a nonrandomized retrospective comparison of 2 techniques for laparoscopic partial nephrectomy, that is without and with clamping the renal vessels.Between December 1997 and February 2002, 28 consecutive patients underwent transperitoneal laparoscopic partial nephrectomy for renal tumor. In group 1 (12 patients) partial nephrectomy was performed with ultrasonic shears and bipolar cautery without clamping the renal vessels, while in group 2 (16 patients) the renal pedicle was clamped before tumor excision. In group 2 patients intracorporeal kidney cooling was achieved by a ureteral catheter connected to 4C solution. Intracorporeal freehand suturing techniques were used to close the collecting system when opened and approximate the renal parenchyma.All procedures were successfully completed laparoscopically. Mean renal ischemia time +/- SD was 27.3 +/- 7 minutes (range 15 to 47) in group 2 patients. Mean laparoscopic operating time was 179.1 +/- 86 minutes (range 90 to 390) in group 1 compared with 121.5 +/- 37 minutes (range 60 to 210) in group 2 (p = 0.004). Mean intraoperative blood loss was significantly higher in group 1 than in group 2 (708.3 +/- 569 versus 270.3 +/- 281 ml., p = 0.014). Three patients in group 1 and 2 in group 2 required blood transfusions. Immediately postoperatively mean creatinine was 1.26 +/- 0.36 and 1.45 +/- 0.61 mg./dl. in groups 1 and 2, respectively (p = 0.075). Surgical margins were negative in all specimens. Pathological examination revealed renal cell cancer in 18 cases (stages pT1 in 17 and pT3a in 1), oncocytoma in 4, angiomyolipoma in 5 and renal adenoma in 1.Laparoscopic partial nephrectomy represents a feasible option for patients with small renal masses. Clamping the renal vessels during tumor resection and suturing the kidney mimics the open technique and seems to be associated with less blood loss and shorter laparoscopic operative time.

To propose a scoring system of difficulties for the most currently performed laparoscopic procedures in urology.Each current laparoscopic procedure has been evaluated according to three different criteria: technical difficulty, operative risk and the attention required. Each criterion is scored from 1 (minimal impact of the criteria) to 7 (maximal impact of the criteria). The sum of the 3 criteria is used to classify each operation according to an increasing level of global difficulty, classified into 6 levels: easy (E: sum of criteria between 3 and 5), slightly difficult (SD: sum of criteria between 6 and 8), fairly difficult (FD: sum of criteria between 9 and 11), difficult (D: sum of criteria between 12 and 14), very difficult (VD: sum of criteria between 15 and 17), extremely difficult (ED: sum of criteria greater than 18).Procedures currently performed by laparoscopy have been selected for evaluation according to the above criteria, and retrospectively validated by European experts in laparoscopic urology according to their experience and the international literature.This proposal of a scoring scale system is a basis for discussion, teaching and learning of urological laparoscopy. By necessity, this scale is evolving and will be regularly reconsidered and updated every 5 years.

In order to be able to influence and monitor future developments for urologists, strategies should be promoted in advance to guarantee the future of the speciality and to accommodate the inevitable changes. Faced with this challenge, the EAU, through its Strategy Planning Office (SPO), has prepared a document which is offered, here, in abbreviated form, to the European and international urological communities for general consideration.A group of subjects, related to the domains and internal consistency of urology as a speciality, were selected and discussed among the members of the SPO and later submitted to open consultation among distinguished members of the urological community. The topics selected for discussion included: what is urology; urology in the university; sub-specialization in urology; training in urology; does kidney transplantation belong to urology, and others.It is shown that urology is going through an exciting and hazardous transition period. Urology has conflicting problems in its traditional domains due to changes in health care policy, and internal identification problems due to its permanent expansion and sub-specialization options. Weaker points are its relation with primary care medicine (shared care options), the presence and role of urology in institutions such as the university, department of surgery, children's hospitals, administration, etc.; the desegregating effect of the sub-specialities; the increasing encroachment of other specialities, and the increasing outpatient effect of technological progress.An action plan is proposed to confront these changes without losing manpower, internal consistency or social image and improving patient care quality, excellence of training and scientific progress.

Evaluation of the efficacy at 1 year of the Prostatron 2.5 in the treatment of BPH weighing more than 40 grams.46 patients over the age of 50 years presenting with BPH40 grams responsible for a maximum flow rate (MFR)9 ml/s and a mean IPSS score of 18 were prospectively included without randomization, by 5 French Urological Centres. These patients were reviewed at 3, 6 and 12 months. Primary endpoint: MFR; secondary endpoints: Madsen score and IPSS.No major complications were observed. The mean postoperative catheterization time was 10 days, causing discomfort with a mean score of 5 on a visual analogue scale from 0 to 10.. Maximum flow rate waas 13.4 ML/s at 3 months, 13.4 ml/s at 6 months and 14.7 ml/s at 12 months. The IPSS was improved by 75%.Treatment by Prostatron 2.5 improves the MFR and the patient's quality of life, which is maintained for at least 1 year after treatment.

The objective of this work is to describe the profile of prevalent and incident populations suffering from lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO) and to analyse the management of care by 620 general practitioners (GPs) in France in 1997 and 1998. Patient records were extracted from the THALES database. Special attention was given to the use of medical therapy and switch rates (ie change to another or combination with another drug). In real life practice (RLP) French GPs predominantly utilise alpha(1)-adrenoceptor antagonists for the treatment of LUTS. This is in agreement with available evidence from randomised controlled trials (RCTs) with different medical therapies (alpha(1)-adrenoceptor antagonists, finasteride, plant extracts). On the contrary, the relatively high usage of phytotherapy might be explained by traditional and personal preferences. Using purely descriptive statistics, newer alpha(1)-adrenoceptor antagonists, alfuzosin and tamsulosin, seem to be the most frequently prescribed medical therapy for new patients and are, moreover, associated with a low switch rate.Prostate Cancer and Prostatic Diseases (2001) 4, 124-131

To quantify the complications of TUR of prostate occurring during the first three post-operative months.Multicentric cooperative study where skilled urologists, aged between 45 and 55 years old, with various practice settings, compile complications in their consecutive patients undergoing TURP between March and June 1996. 410 patients have been assessed by 17 urologists.Rate of intraoperative complications is low with 10 patients being transfused and 3 TUR syndromes being observed. Two deaths occurred in patients aged 84 and 92 years-old at post-op day 27 and 30 respectively. Twenty four percent of patients experienced at least one complication during the observation period, the most frequent of which was asymptomatic bacteriuria in 8.5%. Urethral--mainly meatal--stenosis was the main cause for the readmission/reintervention rate (6.5%).Early morbidity/mortality of TURP for BPH albeit real, occurs in a small percentage of patients, with a general mild intensity. Alongside with excellent objective and subjective outcome, these rates allow TUR of prostate to remain the gold-standard treatment for BPH.

To retrospectively evaluate the morbidity of radical prostatectomy, with the exception of sexual complications, based on a recent single-centre series.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.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%.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.

To establish human renal cell carcinoma (RCC) xenografts for preclinical studies, 55 renal tumors (33 primary and 22 metastatic lesions) were transplanted subcutaneously into severe combined immunodeficient mice. Twenty of 49 evaluable tumors (40.8%) grew with a median latency period of 89 days (36 to 209 days) from the day of engraftment. Tumor growth was stabilized after the fifth passage with a median time between passages of 38 days (19 to 80 days). Tumorigenicity was correlated with the metastatic phenotype of the tumor (54% success rate, p = 0.007) and with reduced survival of patients. Despite a possible evolution of histological features and tumor grading, established RCC xenografts were comparable to parental tumors, as assessed by karyotype and DNA-ploidy analyses. Molecular cytogenetic analysis also revealed specific genetic alterations characterizing distinct RCC types that were constant in parental and corresponding xenografts. In addition, this xenograft model has permitted the selection of minor tumor subclones with a proliferative advantage and minimal overexpressed chromosomal regions. We conclude that severe combined immunodeficient mice are useful recipients for the establishment of long-term RCC xenografts that can be used as valuable tools to evaluate the activity of new therapeutic approaches and to study biological parameters determining in vivo aggressiveness of human RCC.

Evaluate the technical feasibility of laparoscopic radical prostatectomy, its carcinological efficacy and per- and post-operative morbidity.We performed radical prostatectomy using a new laparoscopic technique in 28 patients between February 1 and August 31, 1998.Radical prostatectomy was achieved totally by a laparoscopic approach in 24 patients (86%). No conversion was required in the last 14 patients. In 9 patients (32%) ilio-obturator node resection was also performed as indicated by preoperative extension work-up. Mean operative time was 270 minutes. The only major complication was one rectal wound (patient n degree 8) which had a benign course after suturing under laparoscopy. The bladder catheter was removed a mean 7.7 days after the procedure. Five patients (18%) required transfusions (mean 2.7 units, range 2-3). Rapid discharge on day 3 was possible due to rapid pain relief postoperatively. Tumor classes were pT2 in 26 patients, NO in 9, NX in 17. The surgical border was doubtful at the apex in one case. The last prostate specific antigen assay was below detectable levels (0.1 ng/ml) in 16 patients (89%) among the 18 with levels know prior to the procedure. Continence was assessable in 20 patients after a 1 to 6 month follow-up. Continence was perfect in 18 patients and becoming so in 12. Sexual activity was not assessed in this series due to the short follow-up.Radical prostatectomy can be reasonably performed as a routine laparoscopic procedure by a well-trained team. The cancerological results in this series were equivalent to those with conventional retropubic surgery and morbidity was very low. Improved operative vision was considerable, allowing much more precise dissection. The laparoscopic technique appears to be an important improvement for radical prostatectomy and should help improve functional outcome.

The prognostic significance of seminal vesicle invasion on the radical prostatectomy specimen was evaluated according to the proximal or distal site of this invasion.52 consecutive patients undergoing radical prostatectomy for stage pT3b N0 M0 prostatic cancer were classified into two groups: group A (18 patients): patients with invasion limited to the proximal part of the seminal vesicles (stage T3b limited); group B (34 patients): patients with invasion extending to the free part of the seminal vesicles (stage T3b extensive). The PSA progression-free curves were compared between the two groups. A multivariable regression model was performed to determine independent prognostic factors.Overall, the 5-year PSA progression free rate of the 52 patients was 14.4%. The 5-year PSA progression-free rate of the patients in group A was 45.4 vs. 4.2% at 4 years in group B (p = 0.0004). The stage of seminal vesicle invasion and the Gleason score were the only independent predictive factors of PSA progression (p = 0.02 and p = 0.04, respectively).The prognostic significance of seminal vesicle invasion is not constant and depends on the site of invasion. Preoperative seminal vesicles biopsies can select patients with invasion extending to the free part of seminal vesicles and who have a poor prognosis in terms of PSA progression after radical prostatectomy.

Tumor-infiltrating lymphocytes (TIL) were grown from 23 urothelial carcinomas. Phenotyping analysis showed that the TIL cultures were mainly CD3+. Although CD4+ and CD8+ T-cell sub-sets were grown in culture, CD4+ T-cell sub-sets predominated over CD8+ T cells. Immunohistochemical studies performed on 5 tumor specimens confirmed this observation, and indicated that CD4+ T cells surrounded the tumor islets, whereas CD8+ T lymphocytes were localized among the tumor cells. Five short-term carcinoma cell lines established from these urothelial tumors were used as target cells in cytolysis assays in order to investigate the functional anti-tumor activity of autologous TIL. TIL from 4/5 tumors were lytic and 3 TIL lines displayed MHC-class-I-dependent cytotoxicity directed against autologous tumor cells. CD4+ T-cell-depletion experiments performed on TIL line 07 confirmed that CD8+ MHC-class-I-dependent CTL were the predominant effectors. Finally, experiments performed on 6 allogeneic urothelial-cancer cell lines matched for HLA-class-I molecules showed that TIL07 exhibited selective lytic activity toward tumor 07. These data indicate that CD8+ MHC-class-I-dependent CTL present in urothelial carcinomas are functional and may participate in the anti-tumor immune response.

To allow the diagnosis of pathological stage C prostatic cancer before deciding on treatment.Seminal vesicle biopsy was performed as an outpatient procedure without anaesthesia. An identical antibiotic prophylaxis to that used for prostatic biopsy was performed. Biopsies were performed by longitudinal vision using a transrectal probe. A seminal vesicle needle biopsy was performed lateral to the prostate in the medial third of the seminal vesicle.When seminal vesicle biopsies are positive, the final pathology report after radical prostatectomy confirmed the diagnosis in 100% of cases. When seminal vesicle biopsies were negative, seminal vesicle invasion was detected on the final pathology examination in one third of cases, mostly corresponding to exclusively intraprostatic involvement of the seminal vesicle. Biopsies are useful when at least one of the two prostatic bases is involved. In the series of the last 42 radical prostatectomies performed because of negative seminal vesicle biopsies, we detected only 11% of capsular lesions, almost always less than 1 mm, and 0% of ilio-obturator lymph node invasion.Although the digital rectal examination findings, the PSA level, the Gleason score, and the number of positive biopsies and their length, allow an approach to preoperative staging, only seminal vesicle biopsies can provide a better preoperative staging of prostatic cancer for a given patient and no longer just statistically.

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.

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.

The aim of this randomized double-blind trial was to compare two 400 mg pefloxacin regimens either once-a-week or once-a-month applied for 48 weeks for the prophylaxis of recurrent urinary tract infection in women.The main outcome measures were symptomatic and bacteriological reinfections during the period of prophylaxis and rates of reinfections during the three months of surveillance following the end of prophylaxis. 361 women of 18 to 51 years of age suffering from recurrent lower urinary tract infection were randomly allocated to receive pefloxacin 400 mg once-a-week (group A: n = 185) or 400 mg once-a-month (groupe B: n = 176) for 48 weeks.Seventeen of the 185 patients in group A (9.1%) and 52/176 patients in group B (29.5%) experienced at least one reinfection during the period of prophylaxis (p0.0001). The rates of reinfection during the three months of surveillance following the end of the treatment were not significantly different between the two groups with 14/101 (13.8%) patients with at least a reinfection in group A and 8/75 patients (10.6%) in group B (p = 0.51). In group A, 49/174 (28.1%) patients reported at least an adverse event compared with 33/169 (19.5%) patients in group B (p = 0.06).Once-a-week treatment with 400 mg of pefloxacin can be considered as a new effective and well tolerated approach for the prophylaxis of recurrent urinary tract infection in women and does not entail excessive emergence of pefloxacin resistant bacteria, even after 48 weeks of treatment.

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.

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 (p0.05) 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 (p0.01) 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.

α 1 -Adrenoceptors (ARs) play an important role in mediating human prostatic smooth muscle contraction. In the present study cDNA fragments covering different domains of 3 α 1 -AR subtypes ( α 1b , α 1c and α 1d ) were generated from human prostate by reverse transcription coupled to the polymerase chain reaction (RT-PCR). The reconstituted partial sequence (349 amino acids) of the human prostatic α 1c-AR PCR products showed 94% identity at the amino acid level with that of the corresponding region of the cloned bovine brain α 1c -AR. Using human α 1 -AR subtype selective cDNA probes in Northern blot analysis, the co-expression of mRNA transcripts corresponding to α 1b -, α 1c - and α 1d -AR subtypes was detected in 4 different regions (apex, base, periurethra and lateral lobe) of the human prostate. Competitive inhibition experiments of [ 3 H]-prazosin binding to membrane preparations of human prostate revealed that the non-selective α 1 -subtype antagonist, alfuzosin, produced a monophasic inhibition curve, whereas oxymetazoline produced a 2-component inhibition curve with pK i values of 8.54 and 5.46. The high-affinity α 1 -AR component of the oxymetazoline inhibition curve was predominant (57%–66%) and showed an affinity for oxymetazoline comparable to that of the α 1 c -AR subtype. As such our results illustrate the expression of different α 1 -AR subtypes in human prostate and importantly that α 1c represents the predominant α 1 -AR subtype present in this tissue.

A simple endourological management of benign renal cyst is described. Percutaneous circular electrosection of the peripheric cyst wall is performed, thereafter the cyst wall is extracted en bloc and an aspirative drainage is placed for 2 days. Five patients with symptomatic renal cyst were treated with this method. No major complications have been observed. All patients are asymptomatic at follow-up and only one patient has residual cyst.

The curative cell carcinoma is surgery and consists of a radical nephrectomy. Pre-operative assessment must be complete. Indications are extensive because nephrectomy allow, even in evaluated forms, a long and comfortable survival. The incidental discovery of renal cell carcinoma is more and more frequent. It allows limited surgery and should be followed by higher survival rates.

We report a case of Stauffer's syndrome, characterized mainly by cholectasis, that occurred in a patient with benign intracystic renal haematoma and subsided after nephrectomy. Stauffer's syndrome was recognized, in 1961, as a paraneoplastic manifestation, usually associated with hypernephroma. This syndrome has been reported in only 2 cases of benign renal disease, which was a pseudotumoral xanthogranulomatous pyelonephritis.

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.