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Ureteric stents can be complicated by incrustations, sometimes making it impossible to withdraw or replace the stent over a guide. In this exceptional indication, we report a case in which the use of the Swiss-Lithoclast pneumatic lithotriptor allowed withdrawal of an incrusted double J stent. There was no morbidity related to the use of the Lithoclast. Among the various techniques available for removal of these incrusted double J stents, endoprosthetic lithotripsy appears to be the most effective and the least invasive, in selected cases.

Objectives: Multicentre study of the Transplantation Committee of the Association Française d'Urologie (French Urology Association) concerning the attitudes of various French transplantation centres in relation to renal transplantectomy., Methods: Nine centres participated in this study: Bordeaux, Brest, Grenoble, Marseille, Nantes, Paris-Necker, Paris-La Pitié, Strasbourg and Toulouse. The survey was performed by means of 2 types of forms: study of transplantectomies performed between 1982 and 1992, specific study of transplantectomies performed in 1992., Results: From 1982 to 1992, 731 transplantectomies were performed in these centres, i.e. 15% of all renal transplantations. Rejection represented 80% of the indications and vascular complications represented 15%. The technique used before the 6th week was complete removal of the transplant. After this period, the transplant was removed via a subcapsular approach. The postoperative mortality was 0.7% and the morbidity was 26%. In 1992, 91 transplantectomies were performed in these different centres. Forty-two per cent of the transplants presented with local signs and 38% with general signs. A subcapsular transplantectomy was performed in 84% of cases, for rejection in every case. The morbidity was 16%. Complete removal of the transplant was performed in 16% of cases, essentially for infectious complications. The morbidity was 7%., Conclusion: The renal transplantectomy technique must be adapted to the interval after transplantation: before the 6th week, the transplant must be completely removed; after this period, subcapsular transplantectomy must be performed. This operation therefore no longer carries the mortality and morbidity attributed to it.

Interstitial cystitis, first described one hundred years ago, is difficult to classify in urological pathology. It essentially affects middle-aged women. Two main theories are currently proposed to explain its pathogenesis: the permeable epithelium theory and the mast cell theory. However, other factors are also involved: vascular, neurological, infectious and immune. This disease has a chronic course with no transformation of the nonulcerative form into the ulcerative form. There are no specific histological criteria, even the presence of mast cells in the bladder wall. However, histology is able to exclude other bladder disease, principally carcinoma in situ. The diagnosis is therefore based on clinical examination and endoscopy, after excluding other diseases. The essential complementary investigations are cystoscopy and cystomanometry which must be performed according to rigorous protocols. Conservative treatment is based on vesical hydrodistension, bladder retraining, bladder instillations (DMSO) and systemic treatments (sodium pentosanpolysulfate). Surgery is required in 1 to 5% of cases due to failure of medical treatment and the severity of the symptoms. Electrical or laser coagulation of the ulcers is effective. Partial cystectomy with cystoplasty is reserved for forms sparing the trigone, while cystourethrectomy and urinary diversion may be indicated in other more advanced and refractory cases.

From 1980 to 1991, 236 patients with renal cell carcinoma were treated in our department. We studied the characteristics and the prognostic significance of 74 patients with incidental renal cancer in comparison with those with symptomatic tumors. The mean age of the patients was 59.8 years and the sex ratio 2 males/1 female. The incidence of incidental tumors increased from 14% in 1980 to 48% in 1991. Incidental tumors were discovered mainly during examination for cardiovascular diseases (26%), hepatobiliary diseases (22%) and general health examination (23%). Local tumoral stage and histologic grade were significantly lower for the incidental tumors than for symptomatic ones (p = 0.002 and p = 0.001). In the same way, the rates of the patients with metastases or nodal involvement were lower for those with incidental tumors than for those with symptomatic tumors (p = 0.008 and p = 0.001). The mean tumoral size was 5.7 +/- 3 cm for incidental tumors and 7.6 +/- 3.5 cm for symptomatic tumors (p = 0.0001). The survival was significantly different according to the circumstances of detection of the tumors (p < 0.001); the 5- and 10-year actuarial survival rates was 85% for the patients with incidental tumors and respectively 61 and 44% for the patients with symptomatic tumors. The multivariate analysis by Cox proportional hazard model showed three important and independent prognostic factors: the presence of metastases (relative risk (RR): 6.7), nodal involvement (RR: 4.6) and symptomatic tumors (RR: 1.7). The patients with incidental tumors had a better prognosis than those with symptomatic tumors because of lower tumoral size and local stage. The early diagnosis of renal cell carcinoma improved the prognosis of the patients.

From 1980 to 1991, 109 patients were treated for a tumour of the upper urinary tract. All patients were examined by intravenous urography (IVU) which had a sensitivity of 61%. The combination of IVU + RUP established the diagnosis in 72% of cases. Renal ultrasonography and abdominal computed tomography (CT) were performed in 41 and 67 cases, respectively. The sensitivity of ultrasonography was 40% and that of CT was 72%. CT was more sensitive for tumours of the renal pelvis (78%) than for ureteric tumours (53%) (p < 0.02) and when the tumour diameter exceeded 2 cm (70% vs 45%: p < 0.01). The sensitivity of CT for lymph node extension was 47% with an accuracy of 88%. Preoperative CT staging was compared to pathological staging: CT staging had an accuracy of 56%; in 31% of cases, CT underestimated the parietal extension of the tumour. The sensitivity of CT to assess invasion of the renal parenchyma and of the perirenal fat was 52% and 74%, respectively (p < 0.01). Morphological examinations are able to diagnose a tumour of the upper urinary tract in 3 out of 4 cases. Correct preoperative staging can only be achieved on one half of cases, which constitutes a drawback to the development of conservative treatment techniques.

In a series of 107 patients treated over an 11-year period for upper urinary tract tumours (UTT), 30 had a synchronous or metachronous associated bladder tumour. The bladder tumour preceded the UTT in 10.3% of cases, the bladder tumour was synchronous in 6.5% of cases and the bladder tumour occurred after the UTT in 15% of cases, the incidence of UTT after cystectomy over this 11-year period was 3.3%. The median time to recurrence of the UTT after bladder tumour was 17 months. The median time to recurrence of the bladder tumour after the UTT was 12 months. The risk of bladder recurrence after treatment of the upper tract tumour was studied in relation to site, type of treatment, multifocal nature, stage and grade of the UTT and the presence of a previous or synchronous associated bladder tumour. None of these parameters constituted a predictive factor of bladder recurrence after treatment of an upper tract tumour. Comparison of survival between the UTT + bladder tumour group and the UTT alone group did not reveal any significant difference (p = 0.10). The theory of cellular implantation facilitated by vesicorenal reflux and the multifocal theory are complementary explanations of the multifocal and recurrent nature of urothelial tumours.

The authors report a series of 71 patients (sex ratio: 1F/4M, mean age: 68 years) with stage Ta (n = 20), T1a (n = 32), T1b (n = 14) and Tis (n = 5) bladder tumours treated by endoscopic resection followed by a course of intravesical BCG instillation (120 mg/week for 6 weeks). The mean follow-up was 15 months (3-36 months). The overall recurrence rate was 42%. A recurrence occurred in 50% of Ta (median time to recurrence: 10.1 months), 32% of T1a (median: 5.8 months), 65% of T1b (median: 7.3 months) and 20% of isolated Tis (median: 7 months). Disease progression was observed in 9% of stage T1 tumours. The following risk factors for recurrence were identified: stage T1b (p = 0.05), multifocal tumours (p = 0.05), resistance to previous chemotherapy (mitomycin C) (p = 0.001) and association with Tis for stages T1 (p < 0.02). The following risk factors for disease progression were identified: stage T1b (p < 0.001), grade III for stage T1 (p = 0.05) and association with Tis (p < 0.05). Ten patients (14%) developed transient BCGitis. BCG was found to be effective in the prophylaxis of recurrence of stage Ta, T1 and Tis bladder tumours. This treatment is proposed for recurrent stage Ta grade II and III tumours and stage T1 tumours in the presence of recognised risk factors. The high risk of progression for stage T1b grade III tumours associated with Tis demands rigorous surveillance.

The authors study the ultrasound signs of the adrenal gland based on 5 different types of operated adrenal tumours (a lipoma, an adrenal cortical adenoma, a cyst, a corticoadrenaloma, an adrenal metastasis from a renal cell carcinoma). The ultrasonographic morphological criteria of the normal adrenal gland and each type of tumour are recalled and are illustrated by clinical cases. The value of ultrasonography in the investigation of this organ was evaluated in comparison with other imaging techniques. It constitutes a good first-line diagnostic guiding examination, but needs to be completed by other investigations (computed tomography, magnetic resonance imaging, etc.). Ultrasonography can also reveal asymptomatic adrenal tumours ("adrenal incidentalomas") in which the therapeutic decision (surveillance or surgery) must be based on criteria of size and appearance after a complete laboratory and morphological assessment.

The late urological sequelae of pelvic radiotherapy for cancer sometimes require cutaneous urinary diversion. The local conditions often exclude the use of direct or transileal ureterostomy. Three cases of cutaneous ureterostomy using the transverse colon are presented. There was no operative mortality. A single ureterocolonic stenosis was observed at 12 months and was treated endoscopically. The choice of the transverse colon was based on its position away from the field of irradiation and, consequently, teh absence of radiation lesions, its blood supply which can be used to form pedicles and the possibility of resecting irradiated ureteric segments allowing anastomoses with the proximal ureters. The results reported in the literature show an operative mortality of 0 to 4% and a low morbidity. This technique can be considered to be a technique of choice for cutaneous urinary diversions in urological complications of pelvic radiotherapy.

Ureteric reimplantations into an intestinal segment are frequently followed by early, secondary or late stenoses. In UCN, it is essential to perform atraumatic ureteric dissection followed by reimplantation of a short ureter well vascularized by a single superior pedicle, i.e. the simplest UCN, putting the least strain on the ureter both during creation of the diversion and during subsequent healing. The ileal segment of an ileocaecocystoplasty must extend above the right iliac vessels. It is open on the antimesenteric border and its distal border is stripped of a 3 mm band of mucosa. To reach its homologue, the left ureter passes underneath the common root of the sigmoid mesocolon. Each optimally shortened ureter is placed in and fixed to the start and the end of a longitudinal mucosal tunnel, about 3 cm long. The ileum is sutured as a cuff around the orifice of each ureter. A ureteric stent is left in place for a fortnight. The ileum is sutured to the right laterocaval retroperitoneal tissue. This UCN is simple and rapid to perform.