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Resume La technique de fermeture du parenchyme apres nephrectomie partielle utilisant des clips Hem-o-lok ® pour appuyer la suture est largement utilisee en chirurgie laparoscopique, robotique et parfois en chirurgie ouverte. Nous presentons ici un cas de migration massive des clips apres nephrectomie partielle ouverte. Nous discutons les caracteristiques de ces clips a l’imagerie : non visibles sur les cliches d’AUSP, faible densite au scanner, avant de revoir les cas decrits dans la litterature.

Radiotherapy combined with androgen-deprivation therapy (ADT) is superior to radiotherapy alone in localised prostate cancer; however, data comparing ADT alone are somewhat limited.To compare 3-yr ADT plus radiotherapy with ADT alone in locally advanced prostate cancer patients.A multicentre randomised open controlled phase 3 trial in 264 histologically confirmed T3-4 or pT3N0M0 prostate cancer patients randomised from March 2000 to December 2003.ADT (11.25mg subcutaneous depot injection of leuprorelin every 3 mo for 3 yr) plus external-beam radiotherapy or ADT alone. Flutamide (750 g/d) was administered for 1 mo.The primary objective was 5 yr progression-free survival (PFS) according to clinical or biologic criteria, using the American Society for Therapeutic Radiology and Oncology (ASTRO) and the newer (Phoenix) definition (nadir plus 2 ng/ml), by intention to treat. Secondary objectives included time to locoregional recurrence and distant metastases, and overall and disease-specific survival. Our Analyses: intent-to-treat analysis, multivariate analyses using a Cox model with a 5% threshold from univariate analysis, and Kaplan-Meier estimates.ADT alone was administered to 130 patients and combined therapy to 133. With a median follow-up of 67 mo, 5-yr PFS was 60.9% for combined therapy versus 8.5% with ADT alone (ASTRO; p0.0001), and 64.7% versus 15.4%, respectively, for Phoenix (p0.0011). Locoregional progression was reported in 9.8% of combined-therapy patients versus 29.2% with ADT alone (p0.0001) and metastatic progression in 3.0% versus 10.8%, respectively (p0.018). Overall survival was 71.4% with combined therapy versus 71.5% with ADT alone; disease-specific survival was 93.2% versus 86.2%. Limitations included the relatively small population and a relatively short follow-up period.Combined therapy strongly favoured improved PFS, locoregional control, and metastasis-free survival. Longer follow-up is needed to assess the potential survival impact.

Among the different options recommended for locally advanced prostate cancer (LAPC), radical prostatectomy (RP) is a relatively infrequent option because its role is still controversial. The results of clinical trials combining an external radiotherapy to a long-term androgen deprivation sustain the principle of a multidisciplinary management of LAPC. Impact of surgery on the risk of progression and local recurrence is important in selected patients with low grade and small tumoral volume. Clinical and histological data associated to the MRI assessment remain essential and enhance the preoperative multidisciplinary decision. Oncological results from recent series show 10-year and 15-year specific survival rates around 85 and 75%, respectively. Moreover, approximately 20 to 30% of patients initially presented with cT3 tumours have finally an organ-confined disease on pathological examination. Morbidity of the procedure is similar to RP for organ-confined tumours despite more erectile dysfunction due to non-sparing RP in most of cases. An enlarged RP with an extended pelvic lymphadenectomy can be considered as a viable alternative to radiotherapy and hormonal therapy in patients with long life expectancy presenting cT3 tumour with a high risk of local progression and a low risk of metastatic disease. Comparative and combined treatments including RP have to be prospectively investigated in clinical trials in terms of oncological outcome and quality of life.

Resume Introduction Le priapisme veineux est une erection prolongee, douloureuse et persistante malgre l’absence de desir ou de stimulation sexuelle. Il peut s’agir d’un effet indesirable, rare mais redoutable, de certains neuroleptiques. Materiel et methodes Du premier janvier 2000 au 30 septembre 2007, quatre hommes, âges de 25 a 55 ans, soignes par des neuroleptiques (amisulpride, clozapine, levomepromazine, olanzapine, pipotiazine, risperidone ou zuclopenthixol) ont presente un ou plusieurs episodes de priapisme veineux. Aucun autre facteur etiologique n’a ete mis en evidence et tous les episodes de priapisme ont ete traites par ponction-lavage des corps caverneux et injection intracaverneuse d’une drogue alpha-stimulante completees dans un cas par une anastomose cavernospongieuse chirurgicale. Discussion La litterature medicale mentionne de nombreux cas de priapisme veineux chez des patients traites par des neuroleptiques classiques ou atypiques. Environ 30 % des priapismes veineux pourraient etre rapportes a des medicaments dont environ 50 % aux neuroleptiques. Cet effet secondaire est lie aux proprietes alpha1-adrenergiques bloquantes de ces traitements, plus ou moins importantes selon les medicaments de cette classe. Apres son traitement en urgence, ce priapisme pose le probleme de la poursuite du traitement neuroleptique. La substitution d’une molecule par une autre aux proprietes alpha1-bloquantes moins marquees est conseillee. Conclusion Le priapisme veineux est une urgence uro-andrologique. Il constitue un des effets secondaires des neuroleptiques, a ne pas meconnaitre pour eviter des sequelles erectiles. Le patient doit etre informe de cette complication eventuelle.

El tratamiento del cancer de prostata de estadio T3 es complejo, debido a la heterogeneidad de las situaciones anatomopatologicas que definen este estadio tumoral de afectacion extraprostatica. La incidencia actual del estadio T3 ha disminuido desde hace 15 anos, y es de alrededor del 15% en la practica corriente. Es habitual integrar en esta categoria tumoral los clasicos estadios clinicos T3a y T3b, pero tambien los pT3 biopsicos y T3 por resonancia magnetica (RM). Asi mismo, el estadio pT3 tras prostatectomia total se engloba en este grupo, por lo que existen multitud de situaciones clinicas que responden a tratamientos diferentes. La cuestion principal que predomina en este tratamiento es el caracter curable o no del tumor, que sera lo que defina la estrategia terapeutica. Debe destacarse la relevancia de la valoracion tumoral por todos los metodos disponibles para apreciar su extension extraprostatica. Estos tratamientos se centran en la radioterapia asociada al tratamiento hormonal, que sigue siendo el tratamiento de referencia, y en la prostatectomia total (pocas veces aislada) para los «pequenos» tumores T3a con criterios de seleccion muy precisos. Estos tratamientos locales se asocian a la hormonoterapia de duracion determinada y a la quimioterapia sistemica neo o adyuvante en el contexto de protocolos que permitiran definir las mejores estrategias combinadas en el futuro.

Contexte. - La Federation nationale des centres de lutte contre le cancer (FNCLCC) et les Centres regionaux de lutte contre le cancer (CRLCC), en collaboration avec des partenaires des secteurs public (CHU, CHG), prive et certaines societes savantes ont entrepris depuis 1993 d'elaborer des recommandations pour la pratique clinique en cancerologie : les « Standards, Options et Recommandations » (SOR). L'objectif des SOR est d'ameliorer la qualite et l'efficience des soins aux patients atteints de cancer en fournissant aux praticiens une aide a la decision facilement utilisable. La methodologie d'elaboration des SOR repose sur une revue et une analyse critique des donnees de la litterature scientifique par un groupe d'experts pluridisciplinaire, permettant de definir, sur la base du niveau de preuve scientifique et du jugement argumente des experts, des « Standards », des « Options » et des « Recommandations ». Avant publication, les SOR sont revus par des experts independants. Objectifs. - Definir, sur la base d'une revue de la litterature et de l'accord d'experts, des Standards, Options et Recommandations pour l'evaluation de l'effet dose de la radiotherapie externe des patients atteints de cancer de la prostate. Methodes. - Un groupe de travail multidisciplinaire mis en place par la Federation nationale des centres de lutte contre le cancer (FNCLCC) et l'Association francaise d'urologie (AFU) a revu les donnees scientifiques disponibles concernant l'evaluation de l'effet dose de la radiotherapie externe du cancer de prostate. Apres selection des articles, synthese des resultats et redaction des SOR, le document a ete valide par des relecteurs independants. Resultats. - Les principales recommandations sont : 1/ la dose minimale d'irradiation recommandee est de 70 Gy quels que soient les facteurs pronostiques ; 2/ les patients de bon pronostic (T1-T2A et PSA ≤ 10 μG/L et score de Gleason a < 6) ne semblent pas beneficier d'une escalade de la dose au-dela de 70-74 Gy; 3/ les patients de pronostic intermediaire semblent ceux qui beneficient le plus de l'escalade de la dose au-dela de 74 Gy si une irradiation exclusive est realisee; 4/ il est recommande d'inclure les patients dans des etudes randomisees evaluant l'escalade de dose et la place de l'hormonotherapie.

Resumen La enfermedad de La Peyronie se observa con mayor frecuencia entre los 50 y los 55 anos y se caracteriza por la aparicion de una placa fibrosa en la albuginea de los cuerpos cavernosos. En la palpacion, dicha placa, por lo general dorsal y unica, se presenta como un nodulo o una induracion. Con frecuencia, se asocia a la enfermedad de Dupuytren, a diabetes, hipertension arterial y artritis. Investigaciones recientes parecen indicar que la enfermedad de La Peyronie tiene un origen inmunologico. Basicamente, se manifiesta por dolor y curvatura del pene, por lo general dorsal, y que en algunos casos entorpece la penetracion vaginal. Se han propuesto numerosos tratamientos (medicamentos por via oral, inyecciones locales, ultrasonidos, radioterapia e iontoforesis) pero ninguno ha dado pruebas cientificas de eficacia. Solamente la cirugia, indicada despues de varios meses de evolucion, permite corregir una curvatura que entorpece la penetracion vaginal. Cuando la angulacion de la curvatura no supera los 50 o 60°, se debe emplear una tecnica que no actua sobre la placa sino sobre la albuginea opuesta a aquella (intervenciones de Nesbit o similares). Con angulaciones mayores, debe procederse a la exeresis de la placa y a un injerto ulterior. Las protesis peneanas se reservan para pacientes con insuficiencia en la ereccion.

Contexte. - La Federation nationale des centres de lutte contre le cancer (FNCLCC) et les Centres regionaux de lutte contre le cancer (CRLCC), en collaboration avec des partenaires des secteurs public (CHU, CHG), prive et certaines societes savantes ont entrepris depuis 1993 d'elaborer des recommandations pour la pratique clinique en cancerologie: les « Standards, Options et Recommandations » (SOR). L'objectif des SOR est d'ameliorer la qualite et l'efficience des soins aux patients atteints de cancer en fournissant aux praticiens une aide a la decision facilement utilisable. La methodologie d'elaboration des SOR repose sur une revue et une analyse critique des donnees de la litterature scientifique par un groupe d'experts pluridisciplinaire, permettant de definir, sur la base du niveau de preuve scientifique et du jugement argumente des experts, des « Standards », des « Options » et des « Recommandations ». Avant publication, les SOR sont revus par des experts independants. Objectifs. - Definir, sur la base d'une revue de la litterature et de l'accord d'experts, des Standards, Options et Recommandations pour la curietherapie des patients atteints de cancer de la prostate. Methodes. - Un groupe de travail multidisciplinaire mis en place par la Federation nationale des centres de lutte contre le cancer (FNCLCC) et l'Association francaise d'urologie (AFU) a revu les donnees scientifiques disponibles concernant la curietherapie du cancer de prostate. Apres selection des articles, synthese des resultats et redaction des SOR, le document a ete valide par des relecteurs independants. Resultats. - Les principales recommandations sont: 1) la curietherapie prostatique exclusive par implants permanents est une option therapeutique curative pour les patients porteurs de cancer de la prostate ayant les facteurs pronostiques suivants (options): stade clinique T1 ou T2a (TNM 1992), score de Gleason 7 et/ou PSA > 10) par rapport a la curietherapie exclusive; 3) l'association radiotherapie externe et curietherapie peut etre proposee pour les cancers de pronostic intermediaire; 4) le risque infectieux doit etre prevenu par l'administration d'une antibiotherapie adaptee prealable a l'implantation et au decours de celle-ci; 5) Un delai d'au moins deux mois apres resection transuretrale doit etre respecte avant la realisation de la curietherapie; 6) la hauteur de l'uretre recevant plus de 200 % de la dose prescrite doit etre rapportee. La longueur maximale de rectum recevant 100 % et 120 % de la dose prescrite doit etre limitee a 10 et 5 mm respectivement.

The sliding-clip renorraphy technique using Hem-o-lok(®) clips for parenchymal closure in partial nephrectomy is largely used in laparoscopic, robotic and sometimes open surgery. We present here a case of massive migration of the clips after open partial nephrectomy. We discuss the imaging characteristics of those clips: not visible on plain X-ray, low density on computed tomography, before reviewing previously published cases.

Ischemic (veno-occlusive, low flow) priapism is a painful and persistent penile erection unrelated to sexual desire or stimulation. In some cases, it is an adverse event of antipsychotic medications.Between 1st January 2000 and 30th September 2007, four men (range 25/55 years), treated with antipsychotic agents (amisulpride, clozapine, levomepromazine, olanzapine, pipotiazine, risperidone or zuclopenthixol), presented one or several episodes of ischemic priapism. No other etiological factor was diagnosed. The patients were treated with aspiration and irrigation of the corpa cavernosa with intracavernous injection of sympathomimetic drugs followed in one case by a surgical distal cavernoglanular shunt.Many conventional or atypical antipsychotic agents have been reported to cause priapism. Drug-induced priapism comprised of about 30% of the cases and an estimated 50% of them occurred with antipsychotic agents. The mechanism of priapism associated with antipsychotics agents thought to be related to alpha-adrenergic blocking properties. The decision of whether to restart a patient on a specific antipsychotic agent after an episode of priapism is a difficult clinical decision. An agent with low peripheral alpha-adrenergic blocking affinity would be preferred.Ischemic priapism is an urologic emergency. Clinicians should be familiar with this rare but serious adverse event of antipsychotic agents to avoid long-term sequelae including erectile dysfunction.

The "Standards, Options and Recommendations" (SOR) collaborative project was initiated in 1993 by the Federation of the French Cancer Centres (FNCLCC), with the 20 French Regional Cancer Centres, several French public university and general hospitals, as well as private clinics and medical speciality societies. Its main objective is the development of serviceable clinical practice guidelines in order to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review, followed by critical appraisal by a multidisciplinary group of experts. Draft guidelines are produced, then validated by specialists in cancer care delivery.Produce clinical practice guidelines for the radiotherapy of prostate cancer using the methodology developed by the Standards, Options and Recommendations project.The FNCLCC and the French Urology Association (AFU) designated the multidisciplinary group of experts. Available data were collected by a search of Medline and lists selected by experts in the group. A first draft of the guidelines was written, they validated by independent reviewers.The main recommendations are: 1/ a minimal dose of 70 Gy must be used, whatever the prognostic factors; 2/ it appeared that patients with favourable prognostic indicators (stage T1-2, PSAor = 10 micrograms/L and Gleason scoreor = 6) do not benefit from a dose escalation effect for doses over 70-74 Gy; 3/ patients with intermediate prognosis are the ones who benefit most from the dose escalation effect over 74 Gy, provided they receive exclusive radiation therapy; 4/ whenever possible, patients should be included in controlled trials designed to assess the effects of dose escalation and hormonotherapy.

The "Standards, Options and Recommendations" (SOR) collaborative project was initiated in 1993 by the Federation of the French Cancer Centres (FNCLCC), with the 20 French Regional Cancer Centres, several French public university and general hospitals, as well as private clinics and medical specialty societies. Its main objective is the development of serviceable clinical practice guidelines in order to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review, followed by a critical appraisal by a multidisciplinary group of experts. Draft guidelines are produced, then validated by specialists in cancer care delivery.Produce clinical practice guidelines for the brachytherapy of prostate cancer using the methodology developed by the Standards, Options and Recommendations project.The FNCLCC and the French Urology Association (AFU) first designated the multidisciplinary group of experts. Available data were collected by a search of Medline and lists selected by experts in the group. A first draft of the guidelines was written, they validated by independent reviewers.The main recommendations are: 1/Brachytherapy with permanent seeds alone is a possible curative treatment for prostate cancer patients with the following prognosis factors: tumour stage T1 or T2a (TNM 1992), Gleason scoreor = 6 and PSA10 micrograms/L. 2/Combined treatment with brachytherapy and hormonal therapy could be more efficient than brachytherapy alone for prostate cancer patients with Gleason score7 and/or PSA10.3/Combination of brachytherapy and external beam radiation therapy can be proposed to prostate cancer patients with intermediate prognosis. 4/Before and after seed implantation, risks of infection must be prevented by appropriate antibiotic therapy (recommendation). 5/Brachytherapy must not be performed within 2 months of transurethral prostate resection. 6/The height of the urethra receiving more than 200% of the prescribed dose must be reported. The portion of the rectum receiving 100 and 120% of the prescribed dose must be limited to 10 and 5 mm length, respectively.

To define the value of plasma prolactin assay in the assessment of erectile insufficiency.Plasma prolactin assay (radioimmunoassay) was performed in 445 patients presenting with erectile insufficiency (mean age 52.5 years).9 patients (2%) presented plasma prolactin levels greater than 25 ng/ml and 4 (0.9%) of them had levels higher than 35 ng/ml. Eight of these 9 patients were taking hyperprolactinaemic drugs. The aetiology remained unclear in 1 patient, but the pituitary gland was normal on CT scan.In the population of men with erectile insufficiency, 2.7% of subjects have plasma prolactin levels greater than 20 or 25 ng/ml. 1.3% have levels greater than 35 or 40 ng/ml and 0.6% present pituitary tumours. In the case of pituitary tumours responsible hyperprolactinaemia and erectile insufficiency: 1) plasma prolactin is greater than 30 ng/ml in 90% of cases and greater than 50 ng/ml in 83% of cases; 2) total plasma testosterone is less than 3 ng/ml in 88% of cases and less than 4 ng/ml in 96% of cases; 3) libido is decreased in 90% of cases.The prevalence of hyperprolactinemia and pituitary tumours in the population of men with erectile insufficiency is low. Moreover, certain criteria are suggestive of hyperprolactinemia, especially when it is secondary to a pituitary tumour. Consequently, routine plasma prolactin assay is not justified. This assay should only be performed when libido is impaired, total plasma testosterone is decreased or when the patient presents certain signs such as headache, gynaecomastia or visual disturbances.

The C.C.A.F.U. reviewed the role of interstitial radiotherapy by analysing 66 references published over the last 10 years, obtained from the Medline database.Various modalities of analysis of the laboratory follow-up after radiotherapy have been reported in the literature. The American Society of Therapeutic Radiation Oncology (ASTRO) defines biochemical progression after irradiation by the existence of three consecutive elevations of PSA above the nadir without taking into account the value of this nadir, but the risk of progression appears to continually increase as a function of the PSA nadir; this definition also makes it difficult to compare radiotherapy and surgery. Consequently, we only analysed series reporting results according to strict laboratory criteria (PSAnor = 1 ng/ml, PSAnor = 0.5 ng/ml) more than 4 years after treatment. For stage T1-T2 and well differentiated tumours, the 5-year results of interstitial radiotherapy were comparable to those of surgery, and superior to those of external radiotherapy for poorly differentiated tumours. For stage T3 tumours, only 192Ir and, to a lesser extent, 103Pd associated with external irradiation gave slightly better results than those of external irradiation. RESULTS IN TERMS OF FOLLOW-UP BIOPSIES: Post-treatment biopsies may become negative after a considerable period of time, which justifies follow-up biopsies beyond the 24th month. The significance of persistence of tumour cells on the follow-up biopsy is unclear. A correlation between the follow-up biopsy and PSA monitoring has been demonstrated.Frequency of early irritating symptoms (45% of cases). Dysuria and retention are frequent late complications, and there is a high risk of incontinence after associated endoscopic resection. The impotence rate is low (25%), but sexual potency decreases with time.Interstitial radiotherapy can be rightfully considered to be a curative treatment for localized prostate cancer. However, this treatment modality requires further evaluation due to the insufficient follow-up of recent series and the absence of comparative studies.

Clinical stage T3 prostate cancer is ambiguous both in terms of its definition and its place in the natural history of the disease, and there is no consensus concerning its treatment. In a review of the literature, 148 articles were selected and analysed from the Medline database over a 14-year period (1983-1997). Single-agent therapy: Radiotherapy and radical prostatectomy: it is unlikely that these treatments can cure clinical stage T3 prostatic cancer, except perhaps for a small minority of patients actually presenting with overstaged pT2 disease or certain forms of low-grade pT3. Neither treatment appears to have any advantage over the other-Endocrine therapy: it has been proposed as exclusive treatment at this stage. Few studies have been reported. However, many authors consider this choice to be legitimate, because one-half of patients already have lymph node involvement. Combination therapy: Radiotherapy and endocrine therapy: recent studies comparing exclusive external beram radiotherapy with endocrine therapy show an advantage in favour of combination therapy. Total prostatectomy and endocrine therapy: neoadjuvant endocrine therapy does not provide any advantage. Adjuvant endocrine therapy improves local control and progression-free survival. Adjuvant radiotherapy and radical prostatectomy provides no advantage for T3. The choice of treatment for stage T3, N0, M0 obviously depends on the patient's general state and life expectancy. If the option of a curative treatment in a young subject can be reasonably considered, combination therapy should be preferred.

4505 Background: In locally advanced disease, the combination of RT with ADT is superior to RT or ADT alone. Clear results with an LHRH analog are still pending. We report a phase III trial in loca...

Anuria complicating urethrocystopexy is generally an obstructive uropathy. No urinary tract dilatation had been observed in these two following cases. The rupture of the collecting system, with urinary extravasation, is due to acute ureteral obstruction and furosemide associated. The first exam to be done is the ultrasonography. However, this exploration can fail to demonstrate obstruction. Urgent percutaneous nephrostomy appears to be the best curative method. Surgical liberation of the trapped ureters is almost necessary.

1. La PRL doit etre prelevee dans des conditions precises et controlee en cas d’elevation. 2. La prevalence des HPRL, et des tumeurs hypophysaires dans la population des insuffisants erectiles est faible. 3. Le dosage de la PRL est justifle si la libido est emoussee, la testosteronemie totale

Resume Un cas de septicemie a Lactobacillus acidophilus associe a une pyelonephrite est rapporte chez un malade de 65 ans sans antecedent d'infection urinaire connu. Les auteurs discutent la signification de la presence de Lactobacillus dans les urines.

The authors report two cases of pregnant women suffering from exstrophy of the bladder. One of the patients had been operated on in childhood for reconstruction of the bladder, and the other had undergone Coffey's operation, so that both were able to lead practically normal lives in adulthood. Three children were born by prophylactic cesarean. Exstrophy of the bladder is often associated with other urological, genital or, on occasion, orthopedic, malformations. This article analyzes the consequences of these malformations on the course of pregnancy and delivery, and the consequences of pregnancy on the urinary tract or on the different types of surgical reconstruction. The indications for the type of delivery (natural passages or cesarean section) are discussed in the light of the author's personal experience and a review of the literature.

Blood flow measurement in arterio-venous fistulae can be performed with a duplex ultrasound system which combines echography and C. W. Doppler. This method is very useful to follow up the patency of the fistulae and his consequence on the cardiac function. The exploration consists in two steps: a qualitative study of the Doppler spectrum to detect a possible decrease of the arterial diastole flow which traduce a severe stenosis; the evaluation of the blood flow in ml/min. The blood flow in ml/mn is a good parameter for the follow-up of the fistulae; moreover in case of high blood flow values, it is very useful to guide the surgical therapy.

One case of renal hemangioma is reported. Exact diagnosis was dependent on histopathologic findings. This hemangioma had a calcified mass feature, so, several radiological diagnosis are debated. The relevant literature is reviewed.

Ultrasound and histological sections were taken of 34 prostate units removed from fresh cadavers. Ultrasonography seems to raise more problems than it solves; only 73% of the normal prostates were homogeneous under ultrasound. Ultrasonography visualized nodular structures requiring biopsy in 71% of the cases of prostatic adenoma. There were too few cases of malignant tumors in the sample to warrant a conclusion. They were highly evolved. Ultrasonography gave strong grounds for suspicion, but they could be easily diagnosed clinically.

In 1995 the crude incidence of prostate cancer in France was estimated to be 260–300 out of 100 000 for men aged between 60 and 70 years and over 500 out of 100 000 for men over 70 years of age. The majority of men (73%) are diagnosed when they are over 70 years old. The standardised incidence increased from 51.8 to 87.1 between 1985 and 1995. It has been estimated that in 1995, 26 474 new cases were diagnosed in France. The use of diagnostic tests has contributed to an increase in the number of patients detected with local or locoregional disease. The crude mortality rate for prostate cancer in France was 32.8 out of 100 000 in 1995, and remains stable.