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The surgical treatment of female stress urinary incontinence has been dramatically changed during the last 5 years, after Ulmsten introduced the tension-free vaginal tape procedure. This technique is based on a series of experimental investigations of the urethral closure mechanisms in women. The procedure is easy to learn, could be performed on an outpatient basis, and is recognized as a minimally invasive surgery. Despite these arguments, the most probable reason for its present success is the reproducibility of the results in the various published series. The success rate is estimated at between 85 and 95% for correction of genuine stress urinary incontinence. However, longer follow-up will be necessary to confirm these preliminary results, and probably to determine what are the most valuable prognostic factors.

Purpose: Mini percutaneous nephrostolithotomy was developed for use in children and in adults with a reduced renal reserve to minimize the morbidity and renal parenchymal damage presumed to occur with traditional percutaneous nephrostolithotomy. We compared the extent of renal injury incurred by different sized nephrostomy tracts in female farm pigs undergoing 11 or 30Fr percutaneous nephrostomy., Materials and Methods: Bilateral percutaneous nephrostomy was attempted via a mid or lower pole calix under fluoroscopic guidance in 6 pigs. In 2 pigs the procedure was unsuccessful on 1 side, leaving 5 successfully established nephrostomy tracts on each side. In each pig the right percutaneous tract was dilated with a 28Fr dilating balloon and a 30Fr Amplatz working sheath (Cook Urological, Spencer, Indiana) was positioned in the collecting system. On the left side an 11Fr sheath (Cook Urological) was placed. The sheaths were removed after 1 hour and nephrostomy tubes (22Fr on the right and 8Fr on the left side) were left in place overnight and then removed. Six weeks later the pigs were sacrificed and the kidneys were harvested. The nephrostomy tracts were identified grossly and examined microscopically, and the fibrotic scar was measured using digital analysis. The volume of scar was estimated using the calculated volume of a cylinder., Results: At kidney harvest all 10 kidneys appeared grossly normal. No intra-abdominal urine collection or perirenal hematoma was noted. Mean estimated scar volume of the 30 and 11Fr tracts was 0.29 and 0.40 cc, which translates into a mean fractional loss of parenchyma of 0.63% and 0.91%, respectively (p not significant)., Conclusions: Renal parenchymal damage resulting from the creation of a nephrostomy tract is small compared to overall renal volume regardless of the size of the nephrostomy tract. Consequently there is no advantage to the use of a small access sheath based on renal scarring alone.

Objectives: Laparoscopic partial nephrectomy (LPN) has generally been reserved for small exophytic lesions because of the limited hemostatic capabilities when excising large segments of renal parenchyma. To overcome this problem, we investigated a technique of laparoscopic reversible, regional hypoperfusion using a cable-tie to minimize blood loss and optimize exposure., Methods: Ten domestic pigs underwent LPN after securing a cable-tie around one pole of the kidney and tightening it until the distal parenchymal surface blanched completely. Eight large amputations involving the collecting system and eight smaller amputations excluding the collecting system were performed using laparoscopic scissors. Fibrin glue was applied to seal the cut surface prior to cable-tie removal. Four pigs (4 large and 4 small amputations) were killed immediately and methylene blue was injected retrograde into the ureter to identify collecting system leaks. The remaining 6 pigs (4 large and 4 small amputations) were killed 4 weeks later and retrograde urograms were performed to assess collecting system integrity., Results: Median cable-tie ischemia time was 15 minutes (range 7 to 48) and median blood loss was 30 mL (range 10 to 300). In each case, hemostasis was attained with fibrin glue. In the survival group, all 4 small amputations healed with a fibrotic scar. In the large amputation group, 1 animal died from urinary extravasation on postoperative day 4. The collecting systems of the remaining 3 pigs sealed completely., Conclusions: In the porcine model, cable-tie-assisted LPN provides an almost bloodless surgical field that facilitates rapid resection of large renal segments and hemostasis during a short ischemic period. We anticipate that this technique will broaden the clinical application of LPN.

In a retrospective analysis of hemorrhagic cystitis subsequent to allogeneic bone marrow transplantation, we focused on patients who underwent subtotal cystectomy with ileocystoplasty because stepwise use of conservative treatments had failed. Severe lasting hemorrhagic cystitis (more than 40 days) led to urinary tract obstruction and sepsis that required subtotal cystectomy in 3 of 1300 bone graft patients. Hematuria did not recur after surgery with a satisfactory functional result (follow-up 10 months to 17 years). Subtotal cystectomy with detubularized ileocystoplasty can be used to control life-threatening hemorrhagic cystitis.

Objective: To compare two techniques of parieto-renal dilatation for percutaneous surgery: Alken dilators and balloon catheter., Material and Methods: This prospective, non-randomized study was conducted between July 1999 and April 2000 in 20 patients undergoing percutaneous renal surgery. 10 patients were dilated with a balloon catheter (NephroMax, Boston Scientific) and the other 10 patients were dilated with Alken metal dilators. Statistical analysis was performed with the Mann-Whitney test., Result: The dilatation time and x-ray exposure time were shorter during balloon catheter dilatation (statistically significant difference) and the two techniques were associated with a comparable morbidity., Conclusion: Balloon catheter parieto-renal dilatation significantly decrease dilatation and x-ray exposure times and very considerably simplifies this operative step, essential to the success of percutaneous surgery.

Extracorporeal shock-wave lithotripsy (ESWL) constitutes the reference treatment for renal and ureteric stones in adults, but its use and development in children have been accompanied by a certain degree of caution and reticence. A large number of paediatric series have been published since 1986, confirming the efficacy and minimally invasive nature of this technique. Modification of the nature of the shock waves and release onto the market of second and third generation apparatuses have simplified the management of urinary stones in children. However, several questions persist concerning the maximum number of impacts, the recommended interval between two sessions and the long-term effects of shock waves on the growing renal parenchyma. The objective of this study was to review the current state of ESWL in children based on a review of the literature, the GEUP report and our own experience.

Laparoscopy offers a safe and efficacious means of ablating symptomatic simple renal cysts while conferring the usual benefits of shorter hospital stay, quicker convalescence, and reduced postoperative pain, although no direct comparison with open surgery has been performed. For indeterminate, complex renal cysts, laparoscopic exploration may spare the patient a morbid open operation to assess a cystic lesion of indeterminant risk. Although laparoscopic removal of kidneys with ADPKD remains a technically challenging exercise, centers of laparoscopic expertise have demonstrated the safety and feasibility of the procedure, thereby expanding the benefits of laparoscopic surgery to patients traditionally relegated to open surgical management.

Nearly 10 years of experience with laparoscopic nephrectomy for benign renal disease has shown that the procedure can be performed safely with a complication rate comparable with open surgery. Improvements in the skill, instrumentation, and technique of the laparoscopist have expanded the indications for the procedure to include larger (polycystic kidneys) and in some cases more complex (xanthogranulomotous pyelonephritis) specimens. Continued demonstration of reduced postoperative pain, shorter hospital stay, and more rapid recovery along with decreasing operative times have made laparoscopy the preferred approach for the surgical removal of benign kidneys., (Copyright 2000 by W.B. Saunders Company)

Objectives: The objective of this study was to evaluate the efficacy and safety of a new prostatic stent (Trestle((R)), Boston Scientific Microvasive) for the treatment of BPH in patients with complete urinary retention and considered to be inoperable., Methods: The efficacy of the stent was evaluated in terms of return of micturition, level of patient satisfaction, uroflowmetry and residual urine. Any stents removed were examined by infrared spectrophotometry for the presence of crystalline encrustations., Results: From December 1997 to April 1999, 20 stents were inserted under local anaesthesia in 17 patients aged 54-90 years. Stents remained in place for an average of 3.5 months. Two migrations were reported. The mean maximum flow rate was 13.7 ml/s and the mean residual urine was 110 ml. The infrared spectrophotometry study revealed a glycoprotein film on stents in place for 1-6 months, accompanied by uric acid crystals on stents in place for 9 months., Conclusion: The Trestle prostatic stent is effective and constitutes a good alternative to surgical treatment in patients with a high operative risk.

Objectives: To determine the efficacy of extracorporeal shock-wave lithotripsy (ESWL) in young children and to evaluate, using renal scintigraphy, any possible adverse effects on renal parenchyma., Patients and Methods: From January 1991 to October 1998, 19 infants (aged 5-24 months) underwent ESWL for kidney urolithiasis using a Sonolith 3000 (14 kV, Technomed Corp, Lyon, France) or a Nova (14-20 kV, Direx Medical Systems, Paris, France) lithotripter. The treatment and its effects were evaluated using a physical examination, conventional imaging (plain abdominal X-ray and ultrasonography) and renal scintigraphy 24 h before ESWL and again at least 6 months after the last session of treatment., Results: Ten children were rendered stone-free by ESWL after one session and 18 after two sessions. At the follow-up (8 months to 8 years, mean 36 months) no hypertension was recorded and no acquired parenchymal damage was detected with conventional imaging. No scars or significant variation of differential function attributable to ESWL were identified on renal scintigraphy., Conclusion: ESWL is clearly effective for treating infant urolithiasis. There were no renal parenchymal lesions associated with ESWL, even in previously damaged kidneys or after the treatment of staghorn calculi. A long-term follow-up (assessing blood pressure) is mandatory and renal scintigraphy before and 6 months after ESWL in infants is recommended to confirm these results in a larger series.

Unlabelled: Bladder neck suspension or colpo-suspension can be performed via retropubic or percutaneous transvaginal approaches. A higher success rate is observed for retropubic procedures. One of the hypotheses proposed, but not yet verified, is that the retropubic approach allows better quality vaginal fixation than the percutaneous approach., Objective: The objective of this study was to compare the biomechanical properties of vaginal fixation according to the Burch procedure and according to a percutaneous technique (Vesica; Boston Scientific)., Material and Methods: We performed bladder neck suspension according to the Burch technique (2 points) on the left and according to the Vesica percutaneous technique on the right, on 6 fresh cadavers (mean age 8-5 years), using the same suture material. Vaginal fixations were subsequently excised. The depth of penetration into the vagina was measured and a computerized traction test (Lloyd Instruments, France) was performed on these fixations. The maximum force of traction before rupture was measured., Results: No significant difference was demonstrated for any of the measurements., Conclusion: Vaginal fixation of bladder neck suspension performed according to the Burch technique or via a percutaneous technique (Vesica) present equivalent biomechanical properties.

Aim: The objectives of the study were to confirm the efficacy of extracorporeal shock wave lithotripsy (ESWL) in infants and children and to evaluate potential long-term renal parenchymal damage by 99m Tc DMSA renal scan., Materials and Methods: Between November 1989 and November 1997, 39 children between 10 months and 17-1/2 years of age (average: 7 years) were treated by extracorporeal shock wave lithotripsy for kidney or ureteral stones with a Sonolith 3000 lithotriptor (Technomed Corp). Forty-six stones were treated. Eight metabolic and 11 urological abnormalities were identified. The evaluation of the treatment and its consequences were based on a clinical examination, conventional imaging and a DMSA renal scan performed 24 h before extracorporeal shock wave lithotripsy and at least 6 months after treatment., Results: Treatment was successful (stone fragmented and eliminated) in 84.6% at 3 months after one to four sessions. Sixty-one sessions were necessary and two patients underwent open surgery for failed extracorporeal shock wave lithotripsy. Three recurrences were also retreated. At long term follow-up (6 months to 8 years) no incidents of high blood pressure were observed, nor parenchymal lesions imputable to extracorporeal shock wave lithotripsy., Conclusions: The efficacy of the extracorporeal shock wave lithotripsy for children is proven. This study also confirms the innocuousness of extracorporeal shock wave lithotripsy for renal parenchyma even in infants. However, long term follow-up and further evaluation with the other categories of lithotriptors are necessary to make definitive conclusions.

Postoperative adhesions are the first cause of small bowel occlusion in developed countries. Nevertheless no progress was done in prevention and treatment of this disease. The aim of this trial is to report results of 276 small bowel occlusions caused by adhesion recently operated and consecutive between first january 1993 and 31 december 1996. These patients had 400 previous surgical procedures, within 67.4% infra mesocolic or pelvic. 15.1% of previous surgical procedures took place less than one year before and 36% less than 5 years. Thirty five per cent of patients were operated during 24 hours following admission 23.2% of patients had a digestive resection, caused by necrosis or iatrogenic dissection. Operative mortality was 4.3% without resection and 16.6% with resection. Progress are warranted to reduce the rate of redux of occlusion and mortality and morbidity in this benign disease: more peri operative attention and place of laparoscopy should be considered.

Blind dissection of the bladder neck during implantation of an artificial urinary sphincter (AMS 800) may lead to injury of either the bladder, genital tract or even the rectum. Significant bleeding may occur. A posterior approach to the bladder neck allowing visual control of the anatomical structures is described. From November 1995 to February 1998, 8 adolescents (12-19 years old) underwent AMS 800 artificial urinary sphincter implantation for the treatment of severe incontinence associated with neurogen bladder; one patient had had a previous augmentation. Three had a simultaneous ileocystoplasty and another patient had a simultaneous bilateral extravesical ureteric reimplant. The procedure consisted of separation of the bladder from the peritoneum, allowing the development of a dissection plane between the rectum and genital tracts posteriorly and the ureters and bladder neck anteriorly; the dissection is extended to the base of the prostate. The endopelvic fascia is then incised laterally and on both sides the neurovascular bundles are perforated under visual control and the cuff is positioned safely around the bladder neck, above the prostate and in front of the genital tract. The bladder was opened only in the case of associated ileocystoplasty, thus avoiding prolonged bladder drainage. The mean operating time was 2.5 hours and the blood loss never exceeded 300 cc. This route was not found to be convenient in the case of the patient with a previous augmentation; 7 sphincters function normally with a follow-up of 18 to 44 months; one was never activated and the patient is dry under CIC. This route for exposure of the bladder neck allows visual control of the anatomical structures, accurate positioning of the cuff, avoids bladder opening and reduces bleeding. It can be used for other procedures such as bladder neck suspension or Müllerian cavity removal.

Objectives: This study evaluated the long-term effects of extra-corporeal shock-wave lithotripsy (ESWL) on the renal parenchyma of children using DMSA-Tc 99m scintigraphy., Material and Methods: Between November 1989 and April 1997, twenty-three children wee treated for renal stones using a SONOLITH 3000 lithotriptor (Technomed-Corp. Evaluation of treatment and its consequences was based on clinical examination, conventional imaging and comparison with DMSA-TC 99m renal scintigraphy performed the day before and at least 6 months after treatment., Results: The success rate (fragmented and eliminated stones) was 90% at 6 months. Long-term follow-up did not reveal any alteration of blood pressure or renal function. Scintigraphic examinations did not demonstrate any significant parenchymal lesions attributable to treatment., Conclusion: Extracorporeal shock wave lithotripsy is effective in adults and young children. Its safety on the renal parenchyma was demonstrated during this study. However, evaluation of larger series with the use of other lithotriptors is necessary before reaching any definitive conclusions.

Background: Tinea capitis are usually cured by medical treatment. We present an unusual case which required a surgical treatment., Case Report: A bulky infected kerion ignored for several weeks extended to a large part of the scalp of a 4-year-old girl. Antibiotics and antifungal agents were ineffective so that a total resection was necessary. The loss of substance was covered by a cutaneous graft; the large alopecia was secondarily repaired by a cutaneous expansion. Evolution has been followed for the past 10 years., Conclusion: It is exceptional that surgical treatment should be required for this condition.

Unlabelled: Abnormalities of the aortic arch which are responsible for tracheobronchial compression are well known. This case demonstrates the value of magnetic resonance imaging (MRI) for diagnosis and suggests that recurrent respiratory symptoms should evoke these abnormalities in infancy., Case Report: The authors report a very rare malformation of the aortic arch formed by encircling aortic arch, with left aortic arch, right descending aorta and right ligamentum arteriosum. It was revealed by airway disorders due to the compression of tracheobronchial axis by the ligamentum arteriosum. Section of the ligamentum permitted suppression of obstruction. The diagnosis of these abnormalities is usually established by means of oesophagogram, tracheobronchial endoscopy, angiography and MRI., Conclusion: In this case, MRI gave a better picture than angiography. Sections of the ligamentum arteriosum are sometimes ineffective when compression is due to the aorta itself. Aortic uncrossing, a more complex operation, is then necessary.

Purpose: To evaluate the efficacy of extracorporeal shock-wave lithotripsy (ESWL) in infants (less than 2-years-old) and study the potential long-term renal parenchymal damage by 99 m Tc DMSA renal scan., Materials and Methods: Between November 1993 and February 1998, 12 children underwent ESWL treatment for kidney and ureter urolithiasis with a Sonolith 3,000 lithotriptor (Technomed-Corp). All children were less than 2-years-old. Evaluation of treatment and its consequences was based on clinical examination, conventional imaging (plain abdominal radiography excretory urogram) and a DMSA renal scan performed 24 hours before ESWL and at least 6 months after treatment., Results: Treatment was successful in 84.6% of cases, by achieving stone-free status after one session and 100% after 2 sessions. Long-term follow-up (one month to four years) did not reveal any blood pressure or renal function changes. No acquired parenchymal scar was identified. On DMSA renal scan., Conclusions: The efficacy of ESWL in treating infant urolithiasis is clearly established. Renal parenchymal damage associated with ESWL did not appear in this study, but long-term follow-up mandatory (blood pressure) and each infant should have a DMSA renal scan before and after ESWL to confirm these preliminary results on a larger series.

Cowper's glands are small appendages of the male genital tract, that are sometimes observed on intravenous urography voiding films. They are involved in the immune defence of the genitourinary tract, play a role in fertility, and secrete many glycoproteins, including PSA. They can be visualized in the form of a duct image parallel to the urethra, sometimes associated with opacification of the gland on IVU. This image can be differentiated from a fistula, extravasation of contrast agent, urethral duplication, or an artefactual image, by the course parallel to the urethra, the upper limit not exceeding the urogenital diaphragm, and the position of the orifice. These glands can be affected by neoplastic, infectious, stone and especially cystic disease: syringocele. The physician should think of these glands in patients with unusual genitourinary symptoms in order not to miss disease of these organs, and to prescribe appropriate treatment.

Lesions of the iliac arteries after blunt trauma is uncommon. We observed 5 cases in our unit from 1992 to 1995. This pathology usually is seen in young men and the diagnosis often is made late. A Doppler examination and arteriography should be made in case of clinical doubt. Treatment is exclusively surgical. We present the mechanism of the arterial lesions, the symptomatology caused by the lesions and the therapeutic modalities.

Uretroprostatorectal fistulas occur rarely, often due to trauma or iatrogenic causes. We observed a case caused by a gun wound and present our surgical route for treatment. The deep situation of these fistulae explains the difficulty in surgical access. Several routes have been described. We used the posterior transanosphincter route proposed by York Mason. This technique has the advantage of direct access for the fistula. Success rate is high and morbidity is limited. No fecal incontinence has been reported in the literature.