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Purpose: We assessed the feasibility, reproducibility and morbidity of retroperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction., Materials and Methods: A total of 55 retroperitoneal laparoscopic pyeloplasties were performed at 3 institutions between September 1996 and May 2000 in 33 women and 21 men. Results were analyzed in regard to radiological assessment by excretory urography at 3 months, complications and hospital stay., Results: We performed dismembered pyeloplasty in 48 cases and Fenger plasty in 7 cases. Crossing vessels were noted in 23 patients. The conversion rate was 5.4%. Mean operative time was 185 minutes (range 100 to 260), mean hospital stay was 4.5 days (range 1 to 14) and mean followup was 14.4 months (range 6 to 43.6). The overall complication rate was 12.7%. Complications in 7 patients included hematoma in 3, urinoma in 1, severe pyelonephritis in 1 and anastomotic stricture in 2 requiring open pyeloplasty at 3 weeks and delayed balloon incision at 13 months, respectively. Excretory urography in 50 patients and ultrasound in 4 showed decreased hydronephrosis in 88.9% at 3 months. Normal physical activity and absent pain were reported by 47 patients (87%) 1 month after surgery., Conclusions: Retroperitoneal laparoscopic pyeloplasty seems to be a valuable alternative to open pyeloplasty for ureteropelvic junction obstruction. The long-term outcome must be assessed before this procedure may be definitively validated.

Introduction: The objective of this study was to assess the long-term outcome of AV shunts in renal transplant recipients, to discuss mechanisms affecting their functioning and the surgical strategy designed to optimally preserve the venous capital in the hypothesis of a return to dialysis., Materials and Methods: 160 renal transplant recipients, with a mean age of 47 years, were reviewed. AV shunts were performed at the wrist in 95% of cases and in the cubital fossa in 13% of cases. The AV shunt had been performed an average of 29 months before renal transplantation., Results: 62% of AV shunts were considered to be functional with a mean follow-up of 69 months after transplantation and 95 months after creation. The intraoperative and early and late postoperative thrombosis rates were 6%, 7.5% and 17%, respectively. The AV shunt was subsequently closed in 12 patients (7.5%)., Conclusion: Native distal AV shunts, although not used after renal transplantation, have a prolonged survival. The main risk is thrombosis which can be prevented intraoperative and perioperatively. These results encourage a conservative attitude to all well tolerated AV shunts.

Objective: Renal angiomyolipoma (AML) is a rare benign tumour (2-3%) comprising variable proportions of an adipose component, which is often the most abundant, a smooth muscle contingent and a vascular contingent. The objective of this study is to demonstrate the value of embolization of bleeding angiomyolipomas., Material and Methods: 2 patient, aged 22 and 62 years, presented with perirenal haematoma secondary to bleeding angiomyolipoma and were treated by selective arterial embolization., Results: In one case, partial nephrectomy was subsequently performed because of the size of the angiomyolipoma (10 cm). In the other case, attempted partial nephrectomy at 3 months failed due to the proximity of the renal hilum and nephrectomy was performed., Conclusion: Beyond a diameter of 4 cm, the risk of perirenal haemorrhage is proportional to the size of the tumour. When surgery is required, selective arterial embolization is the first stage of treatment allowing partial nephrectomy in the majority of cases.

Objectives: To determine the feasibility of a conservative (expectant) approach to major blunt renal laceration with urinary extravasation and devitalized renal segments., Patients and Methods: All patients treated conservatively who presented between 1990 and 1999 with major renal laceration (grade 4 and 5) were retrospectively reviewed to determine whether urinary extravasation and devitalized segments adversely affected the outcome. For each patient the data collected included the initial emergency department evaluation, findings on computed tomography, associated injuries, duration of hospital stay, transfusion requirements, complications and follow-up imaging., Results: Of 20 patients who sustained blunt trauma resulting in a major renal laceration (five grade 5 and 15 grade 4) with urinary extravasation, 11 had coexisting devitalized segments. There was a statistically significant difference in the length of hospital stay (16.3 vs 7.3 days), blood transfusions (six vs two patients, P < 0.08) and the need for delayed surgical intervention (nine vs two, P < 0.01) between patients with and with no devitalized segments, respectively. Urinary extravasation spontaneously resolved in two of 11 patients with and in seven of nine with no devitalized segment, respectively (P < 0.05), Conclusions: Urinary extravasation will resolve spontaneously in most patients with blunt renal trauma, and expectant treatment does not adversely affect the outcome or prolong hospitalization. In patients who present with a major renal laceration associated with devascularized segments, conservative management is feasible in those who are clinically stable with blunt trauma. However, the physician must be especially aware of the probable complications within this subset of patients.

A better knowledge of antitumour immunity and the mechanisms allowing the tumour to overcome the host's immune surveillance has led to progress in the understanding of the mechanisms of action of Bacille Calmette-Guérin (BCG), as the local intravesical immune response is intimately related to the interaction of three systems: the host (the patient), the BCG (mycobacteria) and the tumour. This interaction gives rise to a cascade of immunological events, some of which are essential to the protective action of BCG against relapse and tumour progression. The immune response to BCG is currently considered to comprise three phases. First of all, the BCG adheres to the urothelium and is then phagocytosed by antigen-presenting cells. This phase corresponds to early release of so-called inflammatory cytokines (IL1, IL6, IL8). These cytokines could be responsible for certain adverse effects, but could also participate in cytotoxic phenomena. The second phase consists of recognition of bacterial antigens by helper CD4 lymphocytes, which mainly release IL2 and IFNg (Th1 response). This cellular activation leads to the third phase: amplification of cytotoxic populations capable of killing tumour cells: CD8, gd lymphocytes, macrophages, NK, LAK, BAK cells. All these cells also produce cytokines, which participate in regulation of the immune response. The understanding of these mechanisms of action, urinary cytokine assays, a better definition of cytotoxic cells and their role, molecular analysis of the tumour and probably certain genetic characteristics of the host will allow the elaboration of more effective immunization protocols by defining an individualized therapeutic approach.

Primary adenocarcinoma of the urinary tract are uncommon. But secondary involvement of pyelocalyceal system by metastasis of colorectal origin is rare. We report a case of late rectal metastasis with renal pelvis growth presenting as a pyonephrosis. This study emphasizes the relevance of cytokeratin 7 and 20 immunostaining in such differential diagnosis.

Objective: This rare but aggressive bladder tumour presents the morphological and immunohistochemical characteristic, common to all neuroendocrine tumours observed in other organs. This study analyzed the diagnostic criteria and therapeutic results obtained in 5 consecutive patients over a 3-year period., Materials and Methods: 5 patients (3 men and 2 women) suffering from primary small cell carcinoma of the bladder were evaluated. Histological diagnosis, treatment modalities and outcome were reviewed., Results: The main clinical presentation was macroscopic haematuria. All tumours were invasive at the time of diagnosis. 4 patients were treated by trans urethral resection alone, 2 of whom also received adjuvant radio-chemotherapy. One patient was treated by radical cystectomy. The 4 patients treated by conservative treatment modality had progression and a shorter survival, in contrast with patient treated by radical cystectomy., Conclusion: The urologist must recognize this rare histological entity, which have a poor prognosis and requires multidisciplinary management. Treatment must consist of a combination of neoadjuvant or adjuvant chemotherapy and surgery to achieve the best results.

Objective: Standardized symptom scores have been developed to evaluate voiding disorders. The most widely used in France are the IPSS and Madsen-Iversen. These self-assessment questionnaires are by definition subjective. The objective of this study was to compare the capacities of the IPSS and Madsen-Iversen score to describe the patient's voiding status and to define the patient's level of understanding of these questionnaires., Patients and Methods: One hundred male patients were included in this prospective study. All completed an IPSS and Madsen-Iversen questionnaire. Physical examination, uroflowmetry and post-voiding bladder ultrasonography were also performed., Results: The description of the voiding status was considered to be satisfactory or fairly satisfactory, with a total of 85% for IPSS and 87% for Madsen-Iversen. Understanding of the questionnaire was high with a value of 84% for IPSS and 83% for Madsen-Iversen. Neither the order of completion of the IPSS or Madsen-Iversen questionnaires nor the patient's age influenced these results., Conclusions: No difference was demonstrated between the IPSS score and the MADSEN-IVERSEN questionnaire in terms of description and comprehension. However, one out of five patients experienced difficulties completing these questionnaires.

Adoptive immunotherapy with immune effector cells has proved to be potent for treatment of tumors, however neither the attendant criteria for potential clinical efficacy of the injected cells, nor the method to prepare these cells are presently well established. Our procedure of collecting lymphocytes from biological samples, was based on the use of low IL-2 concentrations (90 to 150 IU/ml) and on the stringent separation of lymphocytes from tumor cells at the very early stages of their outgrowth in culture. When lymphocytes were derived from tumor biopsies (TIL), we observed differences depending on the histological type of tumor. In renal cell carcinoma, natural killer cells were expanded in 4/11 biopsies contrary to what was observed in breast cancer (92 +/- 5% of T lymphocytes from 9 biopsies). The outgrowth of lymphocytes from breast tumors was slower and lower than from renal carcinomas. The autologous tumor cell line was more difficult to obtain from breast carcinoma (23%) than from renal cell carcinoma (61%) biopsies. For ovarian cancer, short-term culture of tumor cells could be obtained for half of the tumor-invaded biological samples. Eight of the 23 tumor-derived cultures contained more than 40% CD8 T. TIL were consistently cytolytic each time they could be evaluated. For ascitic and pleural fluids, data were of similar range. In ascitic-derived cultures, tumor cells and antigen-presenting cells are present and can be supposed to rechallenge T cells with tumor antigens. Lymphocytes derived from lymph nodes could be expanded to a larger number than TIL. However, only 1/18 of these cultures contained more than 40% CD8 T. The presence of few tumor cells in this culture was in favor of significant specific and non-specific cytotoxicity in RCC lymph node cultures and higher percentages of CD8 T in breast cancer lymph nodes. Correlations could not be established between CD8 T percentages and specific in vitro cytotoxicity in our polyclonal populations. Our conclusion is that phenotypic and functional quality of lymphocytes is of interest when the T cells are derived 1) from tumors (RCC, breast or ovarian cancer) and isolated very early to avoid inhibitor factors secreted from tumor cells or 2) from lymph nodes and ascitic and pleural fluids when very few tumor cells are co-cultivated with lymphocytes at initial steps of culture. Final expansion to a number of lymphocytes suitable for therapy (> 109) could be attained in a second step of the procedure by the use of 1,000 IU/ml IL-2 each time it was assayed with 50.106 lymphocytes. In view of these data it appears that phenotypic and functional changes occur during culture depending on the presence of a particular ratio of tumor antigens. This could be artificially reproduced.

Objective: To determine the influence of radiotherapy on the outcome of artificial urinary sphincter implantation., Patients and Methods: A series of 72 men who had an artificial urinary sphincter inserted were reviewed retrospectively, analysing in detail the information from 15 patients with a past history of pelvic radiotherapy., Results: In those who had undergone radiotherapy, the complication rate was higher, both for re-operation (eight of 15) and infection (three); 11 of the 15 patients were continent after surgery, compared with 51 (89%) of the 57 in the unirradiated group., Conclusions: An artificial sphincter can be inserted after pelvic radiotherapy reasonably successfully, but at the cost of a high complication and re-operation rate. Patients with a previous history of radiotherapy should be informed of the higher risk of surgical revision associated with insertion of the prosthesis.

We report a case of nested cell carcinoma, an uncommon transitional tumor. These tumors are composed of regular cuboidal transitional cells forming small nests with minimal cytologic atypia. Despite the benign course, this tumor resembling proliferation of Brunn's nests or inverted papilloma, must be considered as an aggressive transitional tumor. Thus, morphologic criteria are needed to make the diagnosis. Because of its aggressive behaviour, the surgical therapy depends on the tumor's infiltration.

Objective: Several types of enterocystoplasty can be performed after cystoprostatectomy for cancer. The objective of this study was to evaluate our 8-year experience with Studer's technique., Patients and Methods: The medical files of 33 patients were studied retrospectively. The median age was 60 years. Bladder replacement was performed when frozen section histological examination of urethral biopsies was negative. The median follow-up was 41 months. Continence was evaluated by means of a questionnaire. Patients not using any pads or only using pads as a precaution were considered to be diurnally continent, and those using no more than one pad per night were considered to be nocturnally continent., Results: Postoperative surgical morbidity consisted of two pelvic abscesses, two cases of obstructive acute pyelonephritis, one occlusion, and three wound complications. Eight patients developed urethroneovesical stenosis and seven ureters were reimplanted because of stenosis (two right ureters and five left ureters). Diurnal and nocturnal continence rates were 67% and 74% at 12 months, and 80% and 94% at 24 months, respectively. Seven patients developed acute pyelonephritis, renal function deteriorated in one patient (preoperative renal failure) and one patient developed acidosis., Conclusion: Studer's technique is a simple technique providing satisfactory functional results while preserving the upper tract by means of a simple and original antireflux system (ileal ureter) with a median follow-up of 41 months, although it was associated with a considerable stenosis and pyelonephritis rate.

Objective: To determine the value of positive sextant biopsies in assessing the location of prostate tumors within radical prostatectomy specimens and to determine if prostate weight influences the results., Methods: From 1988 to 1996, 166 radical prostatectomies were performed for localized prostate cancer diagnosed by means of ultrasound-guided sextant biopsies. The location of the biopsies was compared with that of tumor tissue within the radical prostatectomy specimen., Results: Of the 996 biopsies, 331 (33%) were positive. The correspondence between the location of the biopsies and that of tumor tissue in the surgical specimen was found to have a sensitivity of 39.4%, a specificity of 81.5%, a positive predictive value of 83.3%, negative predictive value of 36.4% and an accuracy of 52%. For prostates weighing < and >/= 45 g, the sensitivity was 39.9 and 38.9%, the specificity was 88 and 77.2%, the positive predictive value was 90.8 and 76.1%, the negative predictive value was 34.9 and 39.8%, and the accuracy was 52 and 52%, respectively., Conclusion: Negative biopsies do not predict a lack of tumor tissue in the corresponding prostate site after radical prostatectomy, and had less value than positive biopsies for prognostic staging before radical prostatectomy. Results of sextant biopsies are more significant for prognosis before radical prostatectomy when positive. Prostate weight influences the interpretation of the results of sextant biopsies.

Objectives: Complications of the ureterovesical anastomosis after renal transplantation are the most frequent surgical complications, estimated to occur in 3 to 20% of cases, depending on the series. Various techniques have been used to treat anastomotic leaks, stenoses or reflux. We present the results of pyeloureterostomy using the recipient's own ureter., Material and Methods: 520 cadaver kidney renal transplantations were performed between 1988 and 1996. The ureterovesical anastomosis was performed according to the Lich Gregoir technique. Sixteen recipients (3%) developed an anastomotic complication: 9 stenoses (1.7%), 6 leaks (1.1%), 1 reflux (0.2%). The mean age of the donor was 37 years and the mean cold ischaemia time was 30 hours. There were 8 right kidneys and 8 left kidneys, transplanted in the right iliac fossa in 11 cases and left iliac fossa in 5 cases. The mean age of the recipients was 42 years, and they were transplanted for nephropathy in 15 cases and uropathy in 1 case. Surgical revision was performed 1 month after transplantation for anastomotic leaks and after 14 months for stenoses. In every case, the native ureter was identified by a ureteric catheter via a midline incision except for 3 cases of early anastomotic leak (< 3 days). The native ureter was sectioned without associated ipsilateral nephrectomy then anastomosed to the renal pelvis of the transplant, which was then drained by a Gil-Vernet catheter (10 cases) or ureteric stent (6 cases)., Results: One transplant was lost on D1 due to renal vein thrombosis. One nephrostomy was inserted on D2 due to obstruction of the ureteric stent. Follow-up pyelography on D15 was normal in every case. The mean follow-up was 2.5 years (2.9 years for anastomotic leaks, 2.2 for stenoses, 3.6 for reflux). One patient died with a functional renal transplant 3 years after the operation and one transplant was lost due to chronic rejection 4 years later. No complications involving the native kidney ipsilateral to the anastomosis were observed and there were no repeated ureteric complications. Mean creatinine 3 years after the operation was 141 mumol/l., Conclusion: Pyeloureterostomy is a reliable technique in the case of complications of the ureterovesical anastomosis. Pyeloureterostomy via a midline incision allowed one-stage definitive treatment of all anastomotic complications of the ureterovesical anastomosis with a low morbidity.

Objectives: The vaginal approach constitutes a solution for all types of urinary stress incontinence (USI). The type of surgery depends on the position of the bladder neck and urethra, the quality of the sphincter and the severity of genital prolapse. The objective of this study was to evaluate the efficacy of the Bologna procedure in the treatment of urinary stress incontinence (USI) with stage III cystocele., Material and Methods: This procedure can repair genital prolapse and USI via a 2 cm suprapubic incision, with vaginal hysterectomy, and intraoperative cystoscopy. The patient is placed in the lithotomy position and a Crossen T-shaped vaginal incision is made releasing the anterior wall and allowing the creation of 2 pedicled vaginal flaps posterior to the urethral meatus. The flaps, passed through the suprapubic pelvic fascia, support the bladder neck by means of 2 nonresorbable sutures to the rectus abdominis muscles. Fifty-four patients were treated by the Bologna procedure with or without vaginal hysterectomy from 1990 to 1996 and were reviewed with a mean follow-up of 30 months (16 to 46 months). All women (mean age: 63.4 years) underwent a preoperative clinical examination, renal ultrasound, cystoscopy and urodynamic assessment (37 cases)., Results: Twelve patients developed postoperative complications (9 local infections, 3 cases of deep vein thrombosis with one pulmonary embolism). All complications were treated by local drainage and/or removal of the suspension sutures. Continence was excellent in 45 women (83.3%), improved in 4 (7.4%), and unchanged in 5 (9.3%). The anatomical results were excellent with correction of prolapse in 48 patients (89%). Six patients subsequently developed prolapse of the vaginal dome and 5 complained of voiding discomfort., Conclusion: USI and genital prolapse must be treated simultaneously. The vaginal approach is minimally invasive and can treat both diseases during the same operation.

The purpose of this paper is to compare the pathological stage of prostate cancer specimens with preoperative characteristics according to the year of diagnosis. One hundred and seventy five patients underwent radical prostatectomy for localized disease between January 1989 and December 1996. In each year group, the mean preoperative PSA (Prostate Substance Antigen, Hybutech((R)) Assay Nl

Objective: To evaluate indications and long-term results of ureteral reimplantation with psoas hitch bladder., Materials and Methods: Between January 1985 and December 1997, we performed psoas-hitch ureteral reimplantation in 18 patients (13 females and 5 males). Mean age was 48 years old. All ureteral injuries involved a pelvic portion of the ureter. The indication was: ureteral injury during gynecological procedures in 5 cases, stricture following open uretero-lithotomy in 3 cases, avulsion of the ureter during ureteroscopy in 1 case, stricture following prior ureteral reimplantation in 3 cases, prostate cancer involving the distal ureter in 1 case, megaureter in 1 case, radiation therapy in 1 case, pelvic and ureteral endometriosis in 3 cases. Treatment consisted to adequate mobilization of the bladder, fixation of the posterolateral corner of the bladder to psoas and ureteral reimplantation with anti-reflux system. In all cases, psoas-hitch ureteral reimplantation has been performed because of an inability to perform end-to-end uretero-ureterostomy or direct uretero-neocystostomy., Results: No complications were observed. At follow-up of 7 months to 12 years (mean 5.7 years) we noticed 13 success (72.4%), 4 improvements (22.2%) and one patient (5.4%) was lost at follow-up. No nephrectomy was done., Conclusion: Psoas-hitch bladder ureteral reimplantation is simple, effective and a first-line procedure for the replacement of the long defects of the lower ureter.

Objective: The aim of this study is to evaluate the safety and effectiveness of conservative management in stage III renal trauma., Material and Methods: We reviewed the records of 150 patients who presented in our institution with renal trauma between 1986 and 1995., Results: Minor injuries (stage I and II: 100 cases) were treated with expectant management. Only 3 patients required nephrectomy in this group. Stage III injuries were seen in 40 patients. The great majority (85%) were treated conservatively with renal sparing procedures such as endourologic techniques (14 cases), nephrorraphy or partial nephrectomy (20 cases). Total nephrectomy was performed in 15% of the cases and only for severely injured kidney or major associated intraabdominal injuries. In this group, none of the patients suffered from hypertension at follow-up. All patients (10 cases) with pedicle injury (stage IV) required total nephrectomy., Conclusion: Stage III renal trauma with urinary extravasation can safely be treated conservatively.

Objectives: Routine sextant biopsies have proven useful in the diagnosis and local staging of prostate cancer. A single positive biopsy is more frequently associated with a smaller tumor and a low risk of positive margins. Nevertheless, the risk of positive margins in patients with 1 positive sextant biopsy remains high (20%). A better assessment of local invasion is therefore needed. In addition to standard sextant biopsies, we routinely obtain 3 additional mid biopsies from the apex to the base of the prostate. The aim of this study is to analyze the contribution of these 3 additional mid biopsies to local staging., Methods: From 1988 to 1996, 177 men underwent sextant biopsies plus 3 additional mid biopsies prior to radical prostatectomy; 59 men had 1 positive sextant biopsy, and 13 also had 1-3 positive mid biopsies. The pathological results of the prostatectomy specimens from these 13 men (group A) were compared with those of the 46 men with only 1 positive sextant biopsy (group B), by means of the Fisher and Mann-Whitney tests., Results: The two groups were similar in terms of age, preoperative prostate-specific antigen, the Gleason score of positive biopsies, the weight of the specimen, the Gleason specimen score, tumor volume and pathological stage. Positive surgical margins were found in 53.8% of group A and 19.4% of group B patients (p = 0.002). The location of the positive additional biopsies matched that of the positive surgical margins., Conclusions: Additional mid biopsies improve the local assessment of prostate cancer in patients with a single positive sextant biopsy, identifying significantly more positive margins when these additional mid biopsies are positive and indicating the location of the positive surgical margins. These informations could be helpful to avoid positive surgical margins during radical prostatectomy.

Objectives: The histological results after radical prostatectomy constitute one of the main prognostic factors. We studied the course of these results over time in order to assess their improvement and to identify the factors responsible., Material and Methods: 175 radical prostatectomies were performed between 1989 and 1996. The preoperative assessment for each patient comprised clinical examination, PSA assay, and histological examination of 6 ultrasound-guided transrectal biopsies. All radical prostatectomy specimens were analysed according to the Stanford technique by the same pathologist: the weight of the prostatectomy specimen, the Gleason score, existence of capsular effraction, seminal vesicle invasion, positive lymph node dissection and the presence of positive surgical margins were studied. The results were studied and compared year by year using Student's test and the Chi-square test., Results: From 1989 to 1996, stages pT1-pT2 increased from 40 to 81.8%, while the positive resection margin rate decreased from 80 to 18.1%. No difference was observed over time for weight and Gleason score. Among the preoperative factors, no difference was observed for age of the patients, number of positive biopsies and Gleason score of these biopsies. Only the mean preoperative PSA level decreased from 52.2 to 12.2 ng/ml (t = 0.0001) and the number of stage T1c tumours increased from 13.3 to 59%., Conclusion: The preoperative PSA level is the main factor explaining improvement of the oncological results, especially as the tumours operated between 1988 and 1996 were identical in terms of aggressiveness (Gleason score). This improvement of the results reflects better patient selection, although this selection is performed case by case without exclusive factors.

Objective: To evaluate the medium-term and long-term impact of radical nephrectomy on renal function and to identify prognostic factors able to help predict deterioration of renal function in patients treated for renal cancer by radical nephrectomy, with a functionally and morphologically healthy remaining kidney., Material and Methods: Between January 1992 and June 1996, 114 patients (72 males, 42 females) with renal cancer were treated by radical nephrectomy. The contralateral kidney was healthy. The mean age of the patients was 64 years (31-85 years). Pre- and postoperative renal function was assessed by serum creatinine assay, in micromol/l., Results: 105 patients were alive (16 with metastases) and 9 had died. The mean follow-up of the survivors was 19.6 months (3-53 months). A slight elevation of mean serum creatinine was observed in this group after nephrectomy compared to preoperative figures (117.9 micromol/l versus 95.6 micromol/l). 37 patients (35.2%) had a postoperative serum creatinine greater than or equal to 121 micromol/l, most of them were elderly, male (81%) and/or hypertensive (43%) and/or diabetic (11%). 6 (5.7%) of these 37 patients had a serum creatinine greater than or equal to 170 micromol/l and all were hypertensive and/or diabetic., Conclusion: This study shows that HT, diabetes, advanced age and male sex constitute risk factors for deterioration of renal function. The indication for conservative surgery for T1 T2 N0 M0 tumours should be discussed in the presence of these factors. In their absence and provided the remaining kidney is healthy, renal function remains relatively stable after radical nephrectomy for cancer.

The better understanding of antitumour immunity has improved our knowledge concerning the mechanisms of action of BCG. There are three phases in the immune response to BCG: first of all, BCG adheres and is then phagocytosed by antigen-presenting cells, but also by urothelial cells. This phase corresponds to the early release of so-called inflammatory cytokines (IL-1, IL-6, IL-8). These cytokines may be responsible for certain adverse effects, but may also participate in the cytotoxic phenomenon. The second phase consists of recognition of bacterial antigens by CD4 lymphocytes, which release mainly IL-2 and IFN-gamma(TH1 response). This cell activation leads to the third phase, which consists of amplification of cytotoxic-populations: CD8, gamma delta lymphocytes, macrophages, NK, LAK, BAK. All these cells also release cytokines which then regulate the response. The identification of these modulations allows rationalization of BCG instillation protocols, but identification of the truly cytotoxic elements would allow the proposal of more effective immunization protocols.

Superficial bladder cancer includes T1, Ta, TIS transitional cell carcinomas of the TNM classification. These tumors represent a spectrum disease with different biological behavior. Some tumors may recur on the same mode for years, others have a definite metastatic risk in the short range. The main difficulty in the management of these tumors is to predict their potential aggressiveness based on clinicopathological parameters. Their management is based on the initial endoscopy and histopathological analysis. Molecular markers will reach the clinical level in order to better predict the prognosis and improved the non invasive tools for follow-up. For low risk tumors, transurethral resection (TUR) and surveillance allow an adequate tumor control. For high risk tumors, conservative treatment is based on a complete transurethral resection which need confirmation by a second look TUR and prophylactic endovesical instillations of bacille Calmette Guérin (BCG). The response to the first BCG cycle represent a crucial indicator of tumor behavior. For intermediate risk lesions, the advantage of prophylactic endovesical instillations have been finally established either using BCG or chemotherapy (Mitomycine C). However in this setting, various therapeutic modalities (maintenance therapy, dose, repeat cycles) are proposed and their relative efficacy remain to be established. For this later group of tumor it is more likely that the use of maintenance therapy or repeated courses increase the chance of conservative treatment. Other therapeutic modalities exist (oral interferon inductors, photochemotherapy) but remain second line or investigative therapies. In conclusion, progress in the understanding of the natural history of bladder cancer allow a better management of these tumor in order to optimize the ratio between the oncologic efficacy and quality of life.

Objectives: Prostatic biopsies, a diagnostic tool, are also used as prognostic elements before radical prostatectomy. Their sites within the prostatic gland constitute one of these prognostic criteria. The authors compared the site of positive prostatic biopsies with that of the tumour after radical prostatectomy in order to study the value of this prognostic factor and the way in which it can be improved., Material and Methods: From 1988 to 1996, 166 localized prostatic tumours treated by radical prostatectomy were diagnosed by 6 systematized ultrasound-guided transrectal biopsies and 3 supplementary median biopsies performed from the base to the prostatic apex. The site of positive biopsies was compared to that of the tumour within the prostatic gland., Results: Of the 996 sextant biopsies performed, 331 (33%) were positive, i.e. 1.99 biopsies per prostate. 92 (19%) median biopsies were positive. 331 positive sextant biopsies corresponded to a tumour within the prostate with a specificity of 81.5%, a sensitivity of 39.4%, a positive predictive value (PPV) of 83.3%, a negative predictive value (NPV) of 36.4% and an accuracy of 52%. For 3 median biopsies, the sensitivity was 70.3%, the specificity was 91.6%, the PPV was 61.9%, the NPV was 94%, and the accuracy was 82%. The weight of the prostate (prostates less than and greater than 45 g), influenced these results, as PPV decreased from 90.8% to 76.1% while NPV increased from 32.9% to 37.8%., Conclusion: Negative biopsies in a prostatic zone after 6 randomized biopsies do not exclude the presence of tumour in this zone and cannot be used as a prognostic element before radical prostatectomy for the therapeutic management. The presence of negative biopsies in a prostatic zone must be interpreted by taking the prostatic weight into account. 3 median biopsies are more accurate and less influenced by prostatic weight.

The authors report a case of adrenal metastasis contralateral to a renal cell carcinoma in a 74-year-old patient who had undergone right radical nephrectomy for renal cell carcinoma. Nine months later, computed tomography revealed a hypervascular mass considered to be an aneurysm of the splenic artery. Arteriography led to the diagnosis of hypervascular adrenal tumour. Left adrenalectomy was performed. Histological examination showed a metastasis from renal cell carcinoma. This is an unusual form of renal cancer metastasis. Its treatment and prognosis are discussed.

PSA (Prostate Specific Antigen) has modified the management of prostatic disease. Changes of PSA levels can be observed in many clinical circumstances other than cancer (endoscopic procedures, prostatitis, medications, etc.). Various methods have been proposed to increase the specificity of PSA in prostatic cancer, particularly when the PSA level is between 4 and 10 ng/ml: age-related PSA, PSA density, PSA velocity, freePSA. These methods allow more refined indications for transrectal biopsies of the prostate which provide the histological evidence essential for the diagnosis of cancer.

The use of prostate biopsies was developed in parallel with progress in our knowledge of prostate cancer and the use of prostate-specific antigen (PSA). Prostate biopsies were initially indicated for the diagnosis of cancer, by the perineal approach under general anesthesia. Nowadays prostate biopsies are not only for diagnostic purposes but also to determine the prognosis, particularly before radical prostatectomy. They are performed in patients with elevated PSA levels, by the endorectal approach, sometimes under local anesthesia. The gold standard is the sextant biopsy technique described by Hodge, which is best to diagnose prostate cancer, particularly in case of T1c disease (patients with serum PSA elevation). Patients with a strong suspicion of prostate cancer from a negative series of biopsies can undergo a second series with transition zone biopsy or lateral biopsy. Karakiewicz et al and Uzzo et al proposed that the number of prostate biopsies should depend on prostate volume to improve the positivity rate. After the diagnosis of prostate cancer, initial therapy will depend on several prognostic factors. In the case of radical prostatectomy, the results of sextant biopsy provide a wealth of information. The aim of this report is to present the information given by prostate biopsy in the staging of prostate cancer.

Objectives: Two surgical approaches are proposed for radical prostatectomy: the retropubic route and the perineal route. We compared the surgical, oncological and functional aspects of these two approaches and present arguments suggesting that the perineal approach is the preferred approach for radical prostatectomy., Material and Methods: 55 retropubic radical prostatectomies were retrospectively compared to 55 perineal radical prostatectomies and performed between March 1992 to December 1995. The clinical TNM, preoperative PSA, results of 6 systematized intrarectal biopsies, operating time, intraoperative bleeding, number of patients transfused and number of packed cell units per patient transfused, medical and surgical complications, catheterization time and length of hospital stay, incidence of urethrovesical anastomosis leak and stenosis, analysis of the prostatectomy specimen, course of PSA, continence and erection were studied., Results: Statistically significant differences were observed for the retropubic and perineal approaches, respectively: preoperative PSA (24 vs 15 ng/mL), intraoperative bleeding (2664 vs 1071 mL), number of patients transfused (91% vs 28%), number of packed cell units per patient transfused (3.9 vs 2.7), medical and surgical complications (56.9 vs 29.1%), anastomotic leak (24.1 vs 7.2%), anastomotic stenosis (31.5 vs 1.8%), duration of catheterization (18 vs 13 days) and length of hospital stay (14 vs 8 days). At 2 years, PSA remained less than 0.5 ng/mL in both groups., Conclusion: Even taking the learning period into account, the perineal approach provides the same results as the retropubic approach in terms of functional and oncological parameters, with a simpler postoperative course for patient.

Objectives: To describe a method of calculation of prostatic tumour volume allowing spatial representation of the tumour within the prostate gland., Methods: 60 radical prostatectomy specimens were studied. Each specimen was processed according to the Stanford technique, and each prostatic section was also divided into two parts, anterior and posterior, according to a sagittal plane through the urethra. 5 microns thick serial sections were performed every 3 mm. The tumour surface area was calculated under light microscopy on each slide. The tumour volume between two consecutive slides was considered to be the volume of a truncated cone. The overall volume obtained was then equal to the sum of these various partial volumes. Spatial representation was performed according to two axes for each of the anterior and posterior parts of the prostatic sections: x-axis represented the prostate from the base to the apex, and the y-axis represented the tumour surface area in each prostatic section., Results: The tumour volume ranged from 0.01 cm3, from 0.21 cm3 for pT2A to 1.98 cm3 for pT3C. pT3 tumours corresponded to the largest volumes, but some pT3 had a small volume. pT3 tumours were preferentially located close to Denonvilliers fascia : 40% of posterior tumours were pT3 versus 9% of anterior tumours (p = 0.01)., Conclusion: The tumour volume on prostatectomy specimens can be evaluated by routine preparations and represents an additional element allowing better assessment of the TNM classification, as well as the predictive value of the information provided by prostatic biopsies.

Objective: To help define the optimal protocol of Bacille Calmette-Guérin (BCG) treatment for transitional cell carcinoma (TCC) of the bladder by examining cytokine production and antigen presentation to effector cells after instillations of BCG in patients with bladder TCC., Patients and Methods: Sixty-four urine samples from 11 patients were tested for the production of interferon gamma (IFN-gamma) using a modified commercial enzyme-linked immunosorbent assay (ELISA) kit. Urine was collected before and at intervals up to 24 h after the intravesical instillation of BCG. Immunohistological studies were also carried out using a two-step alkaline phosphatase technique to explore the expression of tumour-associated antigens (TAAs) (E7, 19A211, T138), major histocompatibility complex (MHC) molecules and lymphocyte subset infiltrates (CD3, CD4, CD8) in bladder biopsies before and 3 weeks after the completion of treatment in seven patients., Results: IFN-gamma was only detected 4, 6 and 8 h after instillation, with a maximum concentration at 6 h (2.9-34.7 IU/mL in 10 patients). During a 6-week course of BCG, IFN-gamma was barely detectable after the first two instillations, but gradually increased from the third instillation onwards. TAA and MHC II antigens, which were absent or faintly expressed on normal urothelial cells before treatment, were expressed strongly in five patients after treatment. The local recruitment of immunocompetent cells was detected in all patients., Conclusion: These results suggest that the local immune response after the intravesical instillation of BCG can be quantified using simple ELISA tests and could be useful in defining objective criteria for rationalizing treatment (dose and duration), and in determining the relation between the immune response and anti-tumour activity. There is evidence that antigen presentation is enhanced after BCG instillations, suggesting that a T cell-MHC restricted pathway might be involved in the anti-tumour response. This study supports the search for tumour-rejection antigens in bladder cancer.

A fall in the PSA level after stopping antiandrogens has been described at the stage of hormonal escape of prostatic cancer treated by complete androgen inhibition. The authors report a new case. The patient was offtially treated by pulpectomy and nitulamide for N+ prostatic carcinoma (PSA: 165 ng/ml). At the stage of hormonal escape, discontinuation of nitulamide induced a reduction of the PSA. Replacement of nitulamide by cytoproterone acetate was followed by a renewed increase of PSA, which again decreased after stomming cyproterone acetate. Three years later, the PSDA level was 3.5 ng/mg. This syndrome is probably due to mutation of the androgen receptor. In hormonal escape, suspension of all antiandrogens apart from LHRH analogues is recommended and can be followed by a temporary fall of PSA. No other antiandrogen must be administered in the place of the previous drug.

Previous reports have described antigens that are recognized on human melanoma cells by autologous cytolytic T lymphocytes (CTL). The genes coding for a number of these antigens have been identified. Here we report the cloning of a gene that codes for an antigen recognized by autologous CTL on a human renal carcinoma cell line. This antigen is presented by HLA-B7 and is encoded by a new gene that we have named RAGE1. No expression of RAGE1 was found in normal tissues other than retina. RAGE1 expression was found in only one of 57 renal cell carcinoma samples, and also in some sarcomas, infiltrating bladder carcinomas, and melanomas. This represents the first identification of an antigen recognized by autologous CTL on a renal tumor.

Clinical history and examination are essential in order to correctly guide the sequence of complementary investigations. First-line examinations are urine culture, KUB and ultrasonography, bearing in mind that the two main causes to be investigated are renal stones and tumours. Depending on the results of this first series of examinations, abdominopelvic CT-scan and vesical endoscopy, performed under local anaesthesia as an outpatient procedure, generally establish the aetiological diagnosis. MRI may usefully complete CT data in some cases of renal tumours. Lastly, more invasive techniques such as arteriography, retrograde ureteropyelography and ureteroscopy are much less frequently required for diagnostic purposes.

Human genes MAGE-1 and MAGE-3 code for distinct antigens, which are recognized on melanoma cells by autologous cytolytic T lymphocytes (CTL). These antigens may constitute useful targets for anti-cancer immunotherapy, since no expression of MAGE genes has been observed in normal tissues other than testis. Out of 57 samples of primary transitional-cell carcinomas of the bladder, 12 (21%) expressed MAGE-1 and 20 (35%) expressed MAGE-3. All but one of the tumors expressing MAGE-1 also expressed MAGE-3. Genes MAGE-2 and MAGE-4, which are closely related to MAGE-1 and MAGE-3, were expressed by 30% and 33% of the tumors respectively. MAGE expression was more frequent in advanced tumor stages: 61% of the invasive tumors (stage > or = T2) were positive for expression of at least one of the four genes, whereas only 28% of the superficial tumors (stages Ta and T1) expressed these genes.

Fifty five women with a mean age of 59 years, suffering from urinary stress incontinence (U.S.I.), were treated by endoscopic percutaneous cervicocystopexy (Stamey's operation), 39 patients (71%) suffered from pure U.S.I. and 16 (29%) presented a combination of stress and urge incontinence. Bonney's manoeuvre was positive in every case. With a mean follow-up of 21.5 months, 30 patients (58.8%) were completely continent, 9 (17.6%) presented occasional incontinence with intense effort, 12 (23.5%) were failures and 4 patients were lost to follow-up. The complications were minimal. The results were less favourable in patients with a history of pelvic surgery, particularly for correction of U.S.I., associated urge incontinence, detrusor hyperactivity or low urethral closure pressure, although one half of the patients in this group were nevertheless cured. Stamey's operation is a simple, reliable, easily reproducible technique which gives good results at the cost of low morbidity, short hospital stay and a low cost.

MRI has only recently been described in the evaluation of traumatic rupture of the corpora cavernosa. Our case report emphasises the perfect correlation between the MRI findings and the anatomical lesion. This examination therefore constitutes a valuable aid in the pretreatment assessment of rupture of the corpora cavernosa.

Initial reports focused on purified protein derivative skin test reactivity and granuloma formation in patients treated with intravesical bacillus Calmette-Guérin. Then some investigators using immunohistochemical methods showed that some lymphocyte phenotypes where predominant in such infiltrates and that HLA DR antigens where strongly expressed following BCG therapy. Similar results where obtained in urine using flow cytometric analysis. Additionally some cytokines where found at significant levels in urine after BCG instillations. In this paper we reviewed these studies, we discussed the meaning of these results and the potential value for treatment monitoring.

In an attempt to appreciate urological practices concerning BCG instillations a study was performed with members of university urological centers. Questions concerned instillation modalities, persons performing instillations and criteria for survey. Main differences concerned doses (low doses versus high doses) and duration of treatment. These results suggest the need of development of new parameters for the rationalisation of this treatment.

Local immunotherapy with bacillus Calmette-Guérin (BCG) is an effective treatment to prevent recurrence and progression of superficial bladder cancer, but the antitumor mechanism of action of BCG remains unclear. There are some experimental and clinical data suggesting that BCG antigens are processed not only by immunocompetent cells but also by urothelial cells and tumor cells. The foreign antigen may be presented at the cell surface by major histocompatibility complex (MHC) class II molecules and recognized by CD4 cells. The cytotoxic effect could result from the direct activity of CD4 cells or from the cytotoxic effect of released cytokines and the activation of other cytotoxic cells [cytolytic T-lymphocytes CTLs; CD8 cells), macrophages, natural killer (NK) or lymphokine-activated killer (LAK) cells]. These mechanisms are also involved in tumor rejection, and the identification of some specific tumor rejection antigens presented to specific CTLs could provide new therapeutic approaches.

Local immunotherapy with BCG was first described by Zbar in an experimental model. The clinical use of BCG in human bladder carcinoma was proposed by Morales in 1976. Since then randomised studies have confirmed the value of BCG against recurrence and progression in superficial transitional cell carcinoma of the bladder (Lamm, Herr). However the optimal protocol has not been defined and the mode of action of BCG remains obscure. In this paper, the authors review the clinical results of BCG and its complications then focus on recent immunological data concerning its mode of action. Finally a practical protocol is proposed.

A large body of evidence suggests that intravesical prophylaxis using bacillus Calmette-Guérin can favorably alter the natural history of superficial bladder cancer. The search for prognostic factors impacting the clinical alternative between conservative and radical treatment has been the subject of numerous efforts and remains a major objective in improving the carcinological results and the quality of life patients with superficial bladder cancer. In this regard, information is available on three levels: clinicopathological parameters, quantitative analysis, and biological markers. Recent advances in as well as the limitations and pitfalls of the use of three kinds of information in prognostication are reviewed. The proper use of prognostic factors will modify our attitude toward superficial bladder cancer in the near future.