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La lithotripsie laser est une méthode clé pour détruire les calculs urinaires, exploitant la chaleur du laser. Toutefois, une gestion inappropriée de cette chaleur peut causer des dommages thermiques significatifs. Ce document explore ces dynamiques thermiques et leurs conséquences.

La lithotripsie laser est une méthode essentielle pour la fragmentation des calculs urinaires, offrant une efficacité élevée mais comportant également des risques de dommages thermiques aux tissus environnants. Cette synthèse se concentre sur les stratégies préventives visant à minimiser ces risques par le biais d’un ajustement optimal des paramètres du laser et de techniques d’irrigation améliorées.

Endocorporeal lithotripsy has progressed thanks to the development of lasers. Two laser sources are currently available: Holmium:YAG (Ho:YAG) and more recently Thulium Fiber Laser (TFL). The settings generally used are dusting, fragmentation, and “pop-corning”. These are the first recommendations on laser use for stone management and their settings. Settings must be modulated and can be changed during the treatment according to the expected and obtained effects, the location and stone type that is treated.

L’urosepsis représente actuellement la moitié des complications post-urétéroscopie souple (URSS), avec une incidence pouvant atteindre 4,3 %. Il représente un quart des épisodes septiques chez l’adulte et 2 % des dépenses hospitalières. L’objectif principal de cette étude était de définir les paramètres cliniques prédictifs qui augmentent le risque d’urosepsis après URSS.

Confrontés à une crise d’une ampleur exceptionnelle liée à la pandémie à coronavirusCOVID-19 responsable d’une saturation selon les régions des urgences et des places en réanimation,le Comité Lithiase de l’Association Française d’Urologie (CLAFU) a élaboré pour la première fois les recommandations de prise en charge des calculs urinaires durant cette crise sanitaire.

Il principale obiettivo formativo di questo articolo è la descrizione delle diverse fasi per eseguire una nefrolitotomia percutanea (NLPC). Vengono inoltre affrontati alcune situazioni specifiche e gli ultimi sviluppi tecnici.

La pose d’une néphrostomie est l’un des gestes élémentaires en urologie. Souvent réalisé dans le cadre de l’urgence pour une indication vitale, ce geste doit être maîtrisé par tout urologue. Au cours des dernières années, cette technique a évolué. L’objectif de cet article didactique est de fournir des détails utiles pour sa réalisation, à travers l’expérience de notre équipe chirurgicale.

El principal objetivo pedagógico de este artículo es describir las diversas etapas de la nefrolitotomía percutánea. También se comentan algunas situaciones particulares, así como los últimos avances técnicos.

L’objectif de cet article est de décrire une nouvelle technique d’installation de patient en position de lithotomie modifiée pour néphrolithotomie percutanée.

Le Comité lithiase de l’Association française d’urologie (CLAFU) a souhaité faire le point sur les connaissances actuelles dans le domaine de la lithiase urinaire en s’appuyant sur le rapport du congrès de l’Association française d’urologie présenté en 2007, sur les dernières recommandations (guidelines) américaines et européennes, ainsi que sur l’expérience de ses membres. Cette mise au point concernant la prise en charge des calculs rénaux et urétéraux de l’adulte est présentée en quatre parties distinctes : 1) généralités ; 2) prise en charge des calculs de l’uretère ; 3) prise en charge des calculs rénaux ; 4) bilan métabolique et prise en charge médicale de la lithiase. Depuis les dernières recommandations françaises en 2004, des progrès techniques importants ont été réalisés et ont permis de faciliter et d’améliorer la prise en charge urologique des calculs urinaires : nouveaux générateurs de lithotritie extra-corporelle, nouveaux urétérorénoscopes souples (fibrés et numériques), utilisation généralisée de l’énergie laser holmium : YAG pour la fragmentation des calculs. La lithotritie extra-corporelle (LEC), l’urétéroscopie (URS) et la néphrolithotomie percutanée (NLPC) représentent toujours les trois principaux traitements chirurgicaux des calculs rénaux et urétéraux de l’adulte. La première partie de cette mise au point aborde la description et la classification des calculs, le bilan préopératoire, la prise en charge post-opératoire et le suivi. Trois principaux critères descriptifs doivent être pris en compte pour la décision thérapeutique : la localisation ou topographie (T), la composition ou nature chimique (N) et la taille du calcul (M). La composition du calcul est déterminée par l’analyse morpho-constitutionnelle avec spectrophotométrie par infrarouge (SPIR) et sa dureté peut être évaluée par la mesure de densité en unité Hounsfield (UH) à la tomodensitométrie (TDM). Le bilan biologique préopératoire doit comporter : une bandelette urinaire et/ou un ECBU, une ou plusieurs mesures du pH urinaire, une créatininémie et un bilan de coagulation. Le bilan radiologique recommandé, avant le traitement urologique programmé d’un calcul, est l’uro-TDMqui doit être réalisée avec une technique d’acquisition rigoureuse en limitant l’irradiation (Low-dose). A distance du traitement chirurgical (4 à 6 semaines), le patient doit être revu pour une évaluation radiologique du résultat (ASP-échographie ou TDM) et pour organiser le bilan étiologique et la prise en charge médicale centrés sur la connaissance de la composition du calcul, du bilan métabolique (bilan biologique sanguin et urinaire) et des habitudes nutritionnelles. Le bilan métabolique est recommandé dès le premier épisode lithiasique. Le succès du traitement chirurgical est défini par l’absence de fragment résiduel (SF) sur l’ASP ou l’échographie à trois mois. Un suivi annuel est recommandé et repose sur le couple ASP–échographie ou sur la TDM basse dose.

La lymphadénectomie après la récidive biochimique du cancer de prostate localisé reste une opération peu fréquente. Avec l’essor de l’imagerie métabolique surtout du PET/TD-68Ga-PSMA, on identifie plus fréquemment et plus tôt des lésions de récidive, permettant une intervention précoce. Dans cette étude descriptive, on montre les Résultats des patients opérés d’une lymphadénectomie de sauvetage pour des patients, traités initialement par chirurgie radicale, présentant ensuite une récidive biochimique, avec une imagerie métabolique négative au PET-Choline, mais positive au PET/TD-PSMA.

Une enquête de pratique a été menée par internet auprès des urologues membres de l’AFU de septembre à décembre 2011 pour déterminer la prise en charge diagnostique et thérapeutique des calculs et de la lithiase urinaire. Huit questions ont été adressées et 403 urologues ont répondu. Les résultats montrent que la prise en charge des calculs urinaires et de la lithiase sont conformes aux recommandations de bonnes pratiques émises par l’AFU et l’EAU.

La position de décubitus dorsal modifiée devient une technique de plus en plus utilisée à l’échelle mondiale pour la néphrolithotomie percutanée. Pour les urologues qui ne sont pas familiarisés à la création d’un accès rénal sous contrôle échographique ou qui n’ont pas accès à une échographe au bloc opératoire, la ponction des cavités rénales sous contrôle radioscopique en décubitus dorsal pourrait être un problème en l’absence d’une méthodologie bien définie. Nous décrivons une technique standardisée et reproductible basée sur l’inclinaison du bras de l’appareil de scopie vers la tête du patient durant la ponction d’un calice repéré et choisi.

La néphrolitothomie percutanée fait partie des traitements chirurgicaux contemporains de la lithiase urinaire, ses indications sont clairement définies. La technique standard se fait en décubitus ventral. Récemment, une position alternative a été décrite par Valdivia-Uria, offrant un accès antérograde et endoscopique rétrograde aux voies urinaires en position de décubitus dorsal. Cette voie a pour avantage l’installation en une seule étape, ce qui représente une économie non négligeable en temps opératoire. Elle est aussi plus sécurisante et plus facile à gérer sur le plan de l’anesthésie. Le principal inconvénient est la possibilité de collision du néphroscope avec la table opératoire pendant l’exploration des calices antérieurs.

Laparoscopic and robotic-assisted prostatectomy have been proposed as alternatives to traditional open retropubic prostatectomy. In this review, we update the more recent data concerning the results, technical trends and controversies regarding these novel, minimally invasive procedures.

We developed a training model and program aimed at improving the skills of urologists with no previous experience in laparoscopy to perform a running suture urethrovesical anastomosis as is done during laparoscopic radical prostatectomy.

We assess the incidence and location of positive surgical margins in a consecutive series of patients who underwent laparoscopic radical prostatectomy.

We developed and assessed the feasibility of extraperitoneal laparoscopic radical prostatectomy performed using the da Vinci (Intuitive Surgical, Mountain View, California) robotic system.

Background and Purpose: The management of polycystic kidney disease is mostly restricted to conservative measures. However, nephrectomy may be indicated in particular cases, especially when there are infective complications. To decrease the morbidity of the procedure, the laparoscopic approach has become appealing. We present a laparoscopic retroperitoneal approach to complicated polycystic kidney disease in a high-risk patient. Case Report: We performed right retroperitoneal laparoscopic nephrectomy in a 39-year-old man who had autosomal polycystic kidney disease and had undergone heart transplantation. The immunosuppressed patient presented with severe flank pain, generalized signs of infection, and acute renal insufficiency. With the patient in the right lateral decubitus position, the retroperitoneal space was entered by the open technique, and the posterior pararenal space was developed with finger dissection. Five trocars were used. After the renal vessels had been secured and divided, the cysts were successively punctured, gradually shrinking the operative specimen. The kidney was placed in an Endo-catch and removed after morcellation, with no need to enlarge the 2-cm lumbotomy. The operating time was 80 minutes, and the hospital stay was 4 days. Histologic examination revealed a polycystic kidney with Aspergillus infection. Conclusion: The laparoscopic approach is a less-invasive option for removing a polycystic kidney when nephrectomy is indicated. The retroperitoneal route has the advantage of minimizing infection risks because of the absence of peritoneal opening.

Background and Purpose: The management of polycystic kidney disease is mostly restricted to conservative measures. However, nephrectomy may be indicated in particular cases, especially when there are infective complications. To decrease the morbidity of the procedure, the laparoscopic approach has become appealing. We present a laparoscopic retroperitoneal approach to complicated polycystic kidney disease in a high-risk patient.Case Report: We performed right retroperitoneal laparoscopic nephrectomy in a 39-year-old man who had autosomal polycystic kidney disease and had undergone heart transplantation. The immunosuppressed patient presented with severe flank pain, generalized signs of infection, and acute renal insufficiency. With the patient in the right lateral decubitus position, the retroperitoneal space was entered by the open technique, and the posterior pararenal space was developed with finger dissection. Five trocars were used. After the renal vessels had been secured and divided, the cysts were successively punctured, gradually shrinking the operative specimen. The kidney was placed in an Endo-catch and removed after morcellation, with no need to enlarge the 2-cm lumbotomy. The operating time was 80 minutes, and the hospital stay was 4 days. Histologic examination revealed a polycystic kidney with Aspergillusinfection.Conclusion: The laparoscopic approach is a less-invasive option for removing a polycystic kidney when nephrectomy is indicated. The retroperitoneal route has the advantage of minimizing infection risks because of the absence of peritoneal opening.

Interleukin (IL)-2 and interferon-γ are released during T helper 1 lymphocyte responses, while IL-10 is released during T helper 2 responses. We evaluated the prognostic value of urinary IL-2, interferon-γ and IL-10 levels in patients with superficial bladder cancer treated with bacillus Calmette-Guerin (BCG) instillation

We evaluated the sexual function of patients who underwent laparoscopic radical prostatectomy. We assessed the effect of unilateral or bilateral preservation of the neurovascular bundle on the ability to achieve erections and have sexual intercourse postoperatively.

Purpose:Living–donor nephrectomy is performed via a standard flank approach during open surgery in contrast to laparoscopy where kidneys are procured transperitoneally. Being more familiar with retroperitoneal laparoscopy for the surgery of the upper urinary tract, we investigated the feasibility of live donor nephrectomy by this approach. Material and Methods:We performed laparoscopic retroperitoneal left–sided nephrectomy in 3 living donors. The patients were placed in lumbotomy position. The retroperitoneal space was developed with blunt finger dissection, through a 2–cm mini–lumbotomy under the 12th rib in the posterior axillary line. 5 trocars were inserted. After primary access to the renal artery and vein, these were dissected to their junctions with the aorta and inferior vena cava, respectively, before freeing the kidney of its perinephric attachments. The kidney was delivered manually, through the slightly enlarged initial subcostal incision. Results:The average duration of surgery was 83 min; warm ischemia time less than 5 min. Average blood loss was 120 cm3. Donors did not present any postoperative morbidity and were discharged after an average of 2.3 days. Mean analgesic requirement was 5 mg morphine sulphate equivalent (0–15). Average convalescence was 13.3 days (10–18). All 3 kidneys harvested laparoscopically had immediate function with urine production after graft revascularization; serum creatinine levels returned to normal within 1 week. The first patient presented ureteral stenosis 2 months after surgery. He underwent ureteropyeloplasty using his native ureter. Conclusions:Laparoscopic living–related–donor nephrectomy become a new standard for organ harvesting. Our data suggest that retroperitoneal laparoscopic donor nephrectomy may represent a reasonable option in centers in which more extensive experience has been accumulated with retroperitoneal than with transperitoneal laparoscopy for the surgery of the upper urinary tract.

Purpose:To analyze the retroperitoneal approach to laparoscopic radical nephrectomy in terms of feasibility, safety, morbidity, and cancer control.Patients and Methods:We reviewed the records of 50 consecutive patients with renal cancer underwent radical nephrectomy via the retroperitoneal laparoscopic approach from 1995 through 1999.Results:The mean operative time was 139 minutes (range 60-330 minutes) with a mean of 149.78-mL operative blood loss (0-1500 mL). The mean renal size was 100 mm (70-150 mm) with a mean tumor size of 38.6 mm (20-90 mm). The postoperative hospital was 6 days (2-13 days). Three open conversions were necessary: one for laparoscopically uncontrolled bleeding and two because obesity interfered with surgery. We noted two major complication and two minor complications. Two disease progression have been noted to date. One patient with a pT3 grade 2 renal-cell carcinoma had a local recurrence with liver metastasis 9 months after the procedure and died 19.7 months after radical nephrectomy. Another patient with a pT3aN+M+cancer died 23.1 months after the procedure.Conclusion:Retroperitoneal laparoscopic nephrectomy for kidney cancer requires further assessment. It seems to have several advantages over open radical nephrectomy and to be effective and safe for small (<50-mm) renal tumors.

Interleukin (IL)-2 and interferon-γ are released during T helper 1 lymphocyte responses and IL-10 is released during T helper 2 lymphocyte responses. We have previously reported that a T helper 1 lymphocyte urinary cytokine profile is associated with a favorable prognosis after bacillus Calmette-Guerin (BCG) treatment. We evaluated the T helper 1/2 lymphocyte cytokine profiles during courses 1 and 2 of 6 weekly BCG instillations.

Objectives:In an effort to reduce the morbidity associated to radical prostatectomy, we implemented laparoscopic surgery to this advanced ablative and reconstructive procedure. In our study, we describe our operative technique and assess our results in terms of oncologic cure, continence and potency. Methods:200 patients with clinically localized prostate cancer underwent laparoscopic radical prostatectomy. 66 of these patients were either referred, or operated during surgical demonstrations. Thus, complete evaluation is based on a homogenous personal series of 134 patients and was performed by an independent clinical analyst. There were 91 T1 and 43 T2. We did not perform pelvic lymph node excision in 78 patients whose PSA was less than 10 ng/ml and the Gleason score of endorectal biopsies was below 7. The surgical procedure recapitulated the steps of traditional retropubic prostatectomy with one basic difference however: the first step of the technique consisted in a rectoprostatic cleavage, which was done transperitoneally. Except for the first 10 patients, the vesicourethral reconstruction was performed either with two hemi–circumferential or a single circumferential running suture. Results:All interventions were performed as planned, no conversions were necessary, and only 4 patients required blood transfusion. Operating time decreased with growing experience; after the first 20 patients the usual operating time was 3.5 h without and 4 h with lymphadenectomy. The surgical complication rate was 22.5% in the first 40 patients, and 3.2% in the remaining 94 patients. Except for the first 10 patients, the mean hospital stay was 6.1 days and bladder catheterization 4.8 days. Median catheterization time was 4 days. Histological study of the specimen showed pT2 disease in 101 patients and pT3 in 33 patients, the rate of positive margins was 16.8 and 48.8%, respectively. At 1 year, overall erection rate (with or without sexual intercourse) was 56%, the rate of patients without pad was 86.2% during the day and 100% during the night. Conclusions:Laparoscopic environment seems to comply with the oncologic goals of radical prostatectomy. Improved intraoperative visualization and magnification may provide benefits for the preservation of continence and potency by allowing a more precise dissection and vesicourethral reconstruction. Despite longer operative times and the steep learning curve this new technique is currently proliferating due to expectations of decreased postoperative morbidity and better quality of life.

Purpose:To determine the incidence of trocar site spillage, local recurrence, and metastatic disease associated with retroperitoneal laparoscopic tumor resection.Methods:From 1994 to 1999, 228 retroperitoneal laparoscopic procedures were performed at our institution. Fifty–six procedures (24.6%) were for malignancies and comprised 41 radical nephrectomies and 8 partial nephrectomies for renal tumors, and 7 nephro–ureterectomies for renal pelvis tumors. The pathological stage and the status of surgical margins were noted according to the 1997 TNM classification. Postoperative follow–up data were obtained by means of physical and radiological examinations after 1 and 3 months, and then half–yearly. Trocar site seeding, local recurrence and metastatic disease were recorded. Kaplan–Meier actuarial analysis was used to determine the disease–free survival likelyhood.Results:The mean follow–up was 24.9±13.85 months. All the patients had tumor–free surgical margins. No laparoscopic trocar site recurrences were identified. For laparoscopic radical nephrectomy: one patient had a local recurrence with hepatic metastasis of a pT3G2 tumor after 9 months and died 19.7 months after the procedure. One patient with a pT3aG3M+ tumor died 23.1 months after radical nephrectomy without any sign of local recurrence. For laparoscopic nephro–ureterectomy: one patient with a pT3G3 tumor had a local recurrence 12.1 months after the procedure and died 26.6 months after surgery. One patient with a pT1G2 renal pelvis tumor had bone metastasis at 9 months and died 29 months after the procedure. The Kaplan–Meier actuarial disease–free survival rate was 91% at 54 months for radical nephrectomy, 61% at 30 months for nephro–ureterectomy and 100% at 49 months for partial nephrectomy.Conclusion:Malignancies of the upper urinary tract can be managed by means of retroperitoneal laparoscopy. Short–term results suggest that this procedure is not associated with an increased risk of portsite or local recurrence, and that disease–free survival is equivalent to that obtained with open surgery.

Background:Retropubic and perineal radical prostatectomy are used for curative treatment of localized prostate cancer. More complex urological procedures are now being done with laparoscopy. We present our initial results of transperitoneal laparoscopic radical prostatectomy.Materials and Methods:Twenty laparoscopic radical prostatectomies were performed between May 1998 and May 1999. The mean age at the time of surgery was 64.2 years. There were 14 stage T1c, 5 stage T2a and 1 stage T2b tumors. The preoperative PSA was 9.3 ng/ml (normal <4 ng/ml). The Gleason score for positive specimens in 6 random echo–guided endorectal biopsies was 5.7. Four trocars were used. Insufflation pressure was 15 mmHg. The seminal vesicles were first dissected. The prostate was dissected free from the anterior face of the rectum to the prostate apex. Then the peritoneum was incised to find the apex of the prostate. The puboprostatic ligaments were isolated and cut, and the dorsal vein complex was ligated and cut to expose the urethra. The bladder neck was opened and dissected free from the prostate. The lateral pedicles were coagulated before sectioning the urethra. The radical prostatectomy specimen was left along the sigmoid colon, the bladder neck was reconstructed, and a urethrovesical anastomosis was performed with 6 interrupted sutures. The prostatectomy specimen was removed intact in a sack by enlarging the umbilical trocar port. All the prostatectomy specimens were processed according to the Standford protocol. Prostate weight, tumor weight, the Gleason score, and the tumor status of the capsule, seminal vesicles, lymph nodes and surgical margins were studied.Results:The operating time was 385 min. Two patients were transfused. The mean hospital stay was 7.8 days. The Foley catheter was removed 10.7 days after the operation. Specimen weight was 61 (28–126) g, the Gleason score was 5.9, and tumor volume was 1.4 ml. There were 18 stage pT2, 1 stage pTa (capsular effraction) and 1 stage pT3b (seminal vesicle invasion) tumors. There were four positive surgical margins (2 at the apex and 2 at the bladder neck). All the patients had a postoperative PSA level <0.1 ng/ml at 1 month. The first patient had urethrovesical anastomotic leakage, and required Foley catheterization for 21 days. There was 1 colostomy for rectal injury and 1 urinoma because of urethrovesical anastomotic leakage that required an open surgical procedure. One month after surgery, 15 (75%) patients were fully continent. Six patients had erections, and 5 stated having sexual intercourse.Conclusion:These preliminary results show that radical prostatectomy can be performed laparoscopically. Laparoscopy offered excellent vision of all the anatomical structures of the pelvis, permitting precise dissection. Long–term follow–up and further studies are required to confirm and improve these results.

Objectives:Retrospective studies have shown that pelvic lymph node dissection can be dispensed with in selected men undergoing radical prostatectomy. We prospectively evaluated the influence of nondissection of pelvic lymph nodes on tumor progression in our first 100 perineal prostatectomies. Methods:From October 1992 to February 1998, 100 patients underwent radical perineal prostatectomy for localized prostate cancer. Preoperative PSA, the Gleason score of positive biopsies and age at surgery were noted. Forty–three of the 100 patients (group 1) did not undergo pelvic lymph node dissection because their preoperative PSA level was below 10 ng/ml (Hybritech assay, normal value 4 ng/ml) and the Gleason score of their positive biopsies was below 7. These 43 patients were compared with 25 of the 114 patients operated on during the same period by the retropubic approach and who had pelvic node dissection and the same preoperative criteria (PSA <10 ng/ml and a Gleason score of positive biopsies <7; group 2). All prostatectomy specimens were processed according to the Stanford protocol: prostate weight, Gleason score, capsular, seminal vesicle, lymph node and surgical margin status, and tumor volume were studied. Postoperative followup was based on routine serum PSA assays after 1 and 3 months and then half–yearly. Biological progression was defined as PSA level which was detectable postoperatively (≧0.2 ng/ml). Kaplan–Meier analysis was used to evaluate the likelihood of biochemical recurrence. Results were compared by using Fisher’s test, the Mann–Whitney test and the log–rank test. Differences were considered significant when the p value was <0.05. Results:No differences in preoperative characteristics were observed; in groups 1 and 2, mean age was 65.9 and 64.7 years, PSA was 6.7 and 5.11 ng/ml, and the Gleason biopsy score was 5.7 vs. 5.0, respectively. In groups 1 and 2, specimen weight was 44.5 and 54.3 g (p = 0.04), the Gleason score was 6.2 and 5.6, tumor volume was 0.91 and 0.8 ml, 81.4 and 84% of patients were in stage pT2, 13.9 and 12% had extracapsular disease, 4.6 and 0% had seminal vesicle invasion, and 13.9 and 16% had positive surgical margins, respectively. The mean follow–up was 2.74 years (0.27–5.59 years). The actuarial 5–year recurrence–free rate was 78% in group 1 and 80% in group 2 (p>0.05). Conclusion:The lack of pelvic lymph node dissection does not influence the intermediate term results of perineal radical prostatectomy in selected patients (preoperative PSA <10 ng/ml and Gleason score for positive biopsies <7).

During the past few years, the indications for laparoscopic surgery in urology have extended from simple ablative procedures towards more complex reconstructive and organ-preserving interventions. Among them, transperitoneal and extraperitoneal laparoscopic partial nephrectomy have been successfully performed for both benign and malignant lesions. However, this approach raises specific problems because in contrast to other laparoscopic procedures the techniques and tools used during open surgery can not be simply transposed to laparoscopy. The absence of surface hypothermia, the lack of manual palpation, difficulties of vascular control and reconstruction of the collecting system necessitate new solutions readily adaptable to laparoscopic surgery. However, the available series comprise only a few cases, and there are differences in techniques and instrumentation in almost every operation. In these circumstances, it is too early to consider this new approach as reproducible and ready to be used elsewhere than in specialized centres. Although the feasibility and good results of partial nephrectomy for benign conditions and small exophitic tumours is now well documented, the development of new surgical tools and standardization of methodology are required for more complex cases within the scope of well conceived prospective studies.

We analyze the retroperitoneal approach to laparoscopic radical nephrectomy in regard to feasibility, safety, morbidity and cancer control, and compare results and outcomes in patients who underwent retroperitoneal laparoscopic or open radical nephrectomy from 1995 to 1998.

Abstract The suspensory system of the penis acquires clinical importance in reparative surgery, traumatology and through its role in erection. The aim of this study was to identify the different anatomic structures constituting the suspensory ligament by dissection and by magnetic resonance imaging (MRI). Ten unembalmed male subjects were used for dissection of the region of the base of the penis. Ten volunteer patients underwent MRI of the penis before and after the injection of prostaglandin (PGE1). The suspensory apparatus consisted of separate ligamentous structures: the fundiform ligament, which is lateral, superficial and not adherent to the tunica albuginea of the corpora cavernosa; the suspensory ligament properly so-called, further back, stretching between the pubis and the tunica albuginea of the corpora cavernosa and consisting of two lateral, circumferential, and one median bundles, which circumscribed the dorsal vein of the penis. These structures were identifiable in MRI and their supporting role was evidenced during tests of erection. The suspensory ligament seemed to maintain the base of the penis in front of the pubis and to behave as a major point of support for the mobile portion of the penis during erection.

PurposeRetroperitoneal laparoscopy, by providing direct access to the retroperitoneal cavity, is a useful approach to urological surgery. We applied this technique to nephroureterectomy in patients with tumors of the renal pelvis.Materials and MethodsBetween January 1995 and March 1997 we performed 4 retroperitoneal laparoscopic nephroureterectomies in patients with tumors of the renal pelvis. The patients were placed in the lateral decubitus position. Five trocars were used. Balloon dilation was not contributory. Radical nephrectomy was performed and the kidney was left in the retroperitoneal space. Via an iliac incision ureterectomy with a bladder cuff was performed in the specimen was removed (kidney and ureter) en bloc via this incision without opening the urinary tract.ResultsOne right and 3 left nephroureterectomies were performed with an average operating time of 220 minutes (range 160 to 300). Average kidney size was 110 mm. (range 100 to 120). Average hospital stay was 5.7 days (range 5 to 7). Blood loss was minimal and postoperative analgesic requirements were moderate. Conversion to open surgery was never necessary. The morbidity rate was zero. The pathological stages were pT2 G2, pT3 G2, pT3G3 and pT3 G2-G3 N +. A local recurrence was observed in a patient with a pT3 G3 tumor.ConclusionsNephroureterectomy can be performed by retroperitoneal laparoscopy. The perioperative morbidity and hospital stay are reduced. Further followup is required to evaluate long-term results in terms of cancer outcome.

Advances in reproductive medicine require the periodic revision of therapeutic methods. The emergence of assisted reproductive techniques has resulted in a new turn in the therapeutic aims of andrology. Therefore, in contrast with previous attempts to achieve a higher sperm count and better sperm motility, individual spermatozoa and their de-novo utilization have gained significance. Accordingly, reassessment of the role of artificial and alloplastic spermatocele, offering an alternative solution for the management of obliterative azoospermia, is topical.

There is controversy regarding the value of biologic markers as prognostic indicators independent of clinicopathologic parameters in transitional cell carcinoma (TCC) of the bladder. The authors examined the prognostic value of p53 tumor suppressor gene expression and the proliferative marker MIB-1 in TCC of the bladder. Fresh frozen samples from 114 TCCs of the bladder and 13 normal bladders were studied by immunohistochemistry, using monoclonal antibodies MIB-1 for proliferation and PAb 1801 for p53 nuclear overexpression. Scores were determined in each case by counting at least 500 nuclei per slide in 3-5 selected regions. Patients were stratified for both markers into two groups for time-event analysis, according to the median number of nuclei stained. Patients with nuclear staining below the median value of the score were considered negative in the statistical analysis. Quantitative immunostaining was analyzed in relation to the time to recurrence, progression, and cancer death, and compared with clinical and pathologic parameters for prognostic significance in univariate and multivariate analysis (stepwise logistic regression). Median nuclear overexpression of p53 was 22% and that of MIB-1 28%. There was a strong association between proliferation and p53 nuclear overexpression (P &lt; 0.0001). Progression free and disease specific survival rate estimates (log rank test) were significantly lower in patients with p53 or MIB-1 scores above 22% and 28%, respectively. Multivariate analysis indicated that stage as well as p53 and MIB-1 immunostaining provided independent prognostic information. Quantitative immunohistochemical evaluation of nuclear p53 and MIB-1 immunostaining inexpensively provides prognostic indicators in cases of TCC of the bladder. Cancer 1997; 80:1472-81. © 1997 American Cancer Society.