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The first medical consultation with the urologist is the occasion to explain to the patient the importance of the initial PSA value, the periodic PSA measurements and the need of prostate biopsy for definitive confirmation. The next consults will focus on basic facts concerning the cancer of the prostate in general and the tumor of the patient in particular, and to present to the patient in a clear and objective way the main advantages and drawbacks of the various therapeutic options. These medical consults are key elements for the quality of physician-patient relationships, as each of them will be an opportunity to provide the best possible information to a patient which is often anxious.

Two aspects are considered: the prevention of peri-operative venous thromboembolism, and the management of antiplatelet agents (APA) and anticoagulants during the peri-operative period. Thrombotic and haemorrhagic risk factors linked to the patient and to urological surgical procedures are recalled. A decision whether to initiate preventive therapy for peri-operative venous thromboembolism will be based on analysis of these risk factors and of the risk/benefit ratio. The methods for this preventive treatment are recalled. Practical examples in urology are used to illustrate the application of these principles. Similarly, the indications, and thrombotic and haemorrhagic risk factors related to anti-platelet agents and anticoagulants during the peri-operative period are recalled. A decision whether or not to withdraw these anti-platelet agents or anticoagulants will be based on an analysis of their indications, these risk factors and an assessment of the risk/ benefit ratio. Replacement therapies are reviewed. Practical examples in the urological setting are given regarding application of these principles.

Prostate cancer has become the most frequent cancer and the second cause of cancer mortality in men. This public health problem is becoming increasingly important due to the increasing life expectancy. At the present time, prostate cancer will be discovered in one in every eight men during their lifetime. Prostate cancer represents 25% of all new cases of male cancers. Prostate cancer screening is designed to detect early stage, asymptomatic prostate cancer, as the patient's chances of cure are higher when the cancer is diagnosed at an early stage. The conclusions of the ANAES evaluation in 1998 did not recommend mass screening for prostate cancer. Several international prospective randomized studies based on serum PSA assay, sometimes associated with digital rectal examination, are currently underway. France is participating in the European ERSPC study (European Randomized Study of Screening for Cancer Prostate) and is organizing a national study on high-risk populations. While waiting for the final results of these studies, a recommendation needs to be proposed to inform general practitioners and specialists about optimal use of the currently available tests. Based on the conclusions of its oncology committee (composed of urologists, medical oncologists, radiotherapists, pathologists and radiologists), the Association Française d'Urologie proposes a recommendation concerning prostate cancer screening and defines its modalities, especially concerning the target population, screening tests and the information given to men before screening. The Association Française d'Urologie recommends prostate cancer screening by PSA assay (prostate specific antigen) and digital rectal examination annually between the ages of 50 and 75 years, and from the age of 45 years in men with a family or ethnic risk. If total PSA is above the normal value of the test or if digital rectal examination is abnormal, referral to a urologist is recommended. Information concerning the limits, benefits and risks of screening and the available treatment options must be given before performing these examinations.

This article describes an original technique for transvaginal repair of prolapses concerning the anterior and middle stages of the pelvis. This operative technique uses a polypropylene prosthesis binding the pelvic structures of the anterior and middle stages to the small sacro-sciatic ligaments. The very satisfactory results achieved let us think that this technique will take a great place in the treatment of the genito-urinary prolapses.

Treatment of urinary stones in a caliceal diverticulum may be indicated when they are symptomatic. Operative techniques for the kidney are continuing to improve. After open surgery and percutaneous surgery, laparoscopy occupies an increasingly important place in the urological therapeutic armamentarium over recent years. The authors report the case of a woman with a stone in an inferior caliceal diverticulum, discovered in the context of acute pyelonephritis, and effectively treated by transperitoneal laparoscopy. The details of the operative technique are described and discussed in relation to the techniques reported in the literature.

Objective: To evaluate the safety and long-term efficacy of curative-intent radiation therapy in patients with apparently localized prostate cancer., Method: 48 patients with T < 3 M0 prostate cancer recruited between 1981 and 1985 received regular clinical follow-up for at least ten years or until their death. Radiation therapy was given according to the protocols established by Ray and Bagshaw., Results: Radiation therapy was safe and effective in most patients. The rate of escape phenomenon was less than 10% after two years. Tumor control rates were greater than 80% after five years and 50% after ten years. Unfortunately, local remission, even when prolonged, did not necessarily indicate a complete cure: 20% of local recurrences developed five to 11 years after radiation therapy., Conclusion: Radiation therapy may be the best first-line treatment in men older than 75 years of age and in those whose life expectancy seems shorter than ten years, but should probably not be considered curative.

The prevalence of urinary incontinence increases with age, with a predominance of incontinence due to detrusor instability. The development of incontinence in an elderly person can be explained pathophysiologically by the development of age-related histological and functional alterations of the bladder, by increased nocturnal diuresis at the expense of diurnal diuresis and finally, in women, by a reduction of urethral pressure. The initial assessment is essentially clinical and must comprise evaluation of concomitant diseases and drugs likely to favour the development of incontinence, a voiding diary and assessment of the post-voiding residual volume. Only a test for urinary tract infection by dipsticks or urine culture constitutes an essential first-line complementary investigation, as urodynamic studies can be reserved for more complex situations.

Objectives: To evaluate the frequency of urethral and prostatic lesions on cystectomy specimens for bladder tumour., Material and Methods: This retrospective histological study was based on 260 specimens: radical cystectomies performed in 7 operative sites. The prostate and urethra were analysed in 3 planes (upper, middle and lower thirds). The apex was studied separately. Urethral invasion was identified by continuity of the tumour or by the presence of vesical CIS., Results: Urethral involvement is frequent (30.6% cases) essentially due to contiguous invasion (43/80). CIS is the second pathological association (44 urethral CIS/75 bladder CIS). Prostatic adenocarcinoma was present in 17.8% of cases with a Gleason score > 6 for 30% of lesions., Conclusion: The high frequency of urethral and prostatic involvement does not justify preservation of the prostate during cystectomy. A serial prospective study should define the precise criteria able to minimize the risk of conservative surgery.

From October, 1987, to August, 1990, 47 patients underwent an ileal low pressure bladder replacement using the Hautmann procedure after radical cystoprostatectomy for bladder cancer. The qualities of micturition and continence were evaluated from a questionnaire mailed to the patients and by urodynamic examinations in 44 consecutive patients over a follow-up period of more than 3 (mean 10.7) months. The 44 patients (100%) were perfectly dry during the daytime and voided every 4 (2-6) h with a micturitional volume of 357 (200-500) ml. Forty-two of the 44 patients had no residual urine. Thirty-three of the 44 patients (75%) were perfectly dry at night with a voiding frequency of 1.5 (0-3). Seven of the 44 patients (16%) were occasionally incontinent (spotting less than 2/week). Four of the 44 patients (9%) had night incontinence and used as external device. Only two patients showed high pressure waves of greater than 50 cm H2O. The maximum urethral pressure was 59.07 +/- 13.6 (30-80) cm H2O. The maximum flow rate was 17.2 +/- 9.7 (4.5-35) ml/sec. The different factors responsible for the new micturitional balance were discussed. With its very good functional results and its ease of performance, the ileal neobladder is, for us, the procedure of choice for bladder reconstruction after cystectomy.

Twenty seven patients treated by Hautmann enterocystoplasty completed a detailed questionnaire concerning the quality of their micturition and continence. The mean capacity of the neobladder was 250 cc with a diurnal interval between micturitions of about 3 hours. 79% of patients experienced an urge to micturate. The mean frequency of nocturnal micturition was 1.6. Diurnal continence was perfect in 100% of patients, while nocturnal continence was excellent in 78% of cases and good in 18% of cases, while one patient (4%) suffered from nocturnal incontinence. Hautmann enterocystoplasty is therefore an excellent technique for bladder replacement, ensuring diurnal and nocturnal continence for the great majority of patients.

The scrotal skin is vascularized in part by means of the superficial perineal branch of the internal pudendal artery. This nutrient pedicle, together with the scrotal skin dependent on it, can be isolated. The urethra is approached via the perineum. The stricture is incised longitudinally right down to the healthy area. The scrotal flap and pedicle are mobilized, and then anastomosed along the edges of the urethra. From March 1983 through April 1987, sixteen patients have been operated. Postoperative results: the mean follow-up for the 16 patients is 60 months with extremes of 24 and 66 months. 13/16 patients show good results (81%). 3/16 patients show poor results with recurrence of the stricture localized at the junction of the flap and healthy urethra. Such recurrences have yielded to treatment, in two cases, by optical urethrotomy and, in the other case, by means of a new scrotal flap.

A double-blind, placebo-controlled, randomized, multicenter study was undertaken to investigate the effects of Zoladex plus flutamide vs. Zoladex plus placebo in patients with advanced prostatic cancer. Interim analysis has revealed no differences between the 2 groups in objective or subjective responses at 6 months' follow-up or in overall survival and time to disease progression at 15 months' follow-up.

Twenty-four patients with invasive bladder cancer underwent Hautmann enterocystoplasty. A study of the urinary continence revealed 100 per cent of good results during the day and 87.5 per cent of good results at night. Urodynamic investigation after 3 months revealed that only one patient presented with peristaltic waves and that the postmicturating residual urine volume was always less than 100 cc. There was no mortality in this series. The only uncertainty concerns the long-term outcome of these patients because of the risk of incomplete emptying and distension of the neobladder.

Radioimmunoassay (RIA) of prostatic acid phosphatases (PAP) using the Gammadab (R) PAP pack supplied by Clinical Assays in an effective method for determining extension of prostatic cancer. In patients with lymph node or metastatic invasion serum assay values are almost always elevated (sensitivity = 94%), especially with well differentiated cancer. Elevated levels of this variable are practically pathognomonic of external extension (specificity = 94%). This is of importance in therapy since the degree of invasion determines the choice between palliative and curative treatment. Strategy leading to this therapeutic choice can be greatly simplified and thus modified by RIA of PAP.

The authors investigated the effect of giving a single injection of the antibiotic gentamycin one hour before endoscopic resection of the prostate, by random case selection in a group of 47 cases. The untreated and the treated cases were considered quite comparable. The presence of bacteriurea greater than 10(5) per ml during the first 15 postoperative days was significantly greater in the untreated group than in the preoperatively treated group. The results showed 44% for the untreated group and 14% for the treated group. After 15 days the results were identical for the two groups.

The authors report a quite exceptional case of isolated angiomyolipoma of one kidney in the absence of any manifestation of phakomatosis. Discovery of the tumour led to special investigations which confirmed the solid and hypervascularised nature of the tumour. A doubt remained with regard to its precise nature, and hence an extended nephrectomy, though without damage to the vessels at the time of section. The kidney was cooled and preserved by perfusion which allowed time for adequate histological study. The diagnosis of angiomyolipoma being confirmed, without the slightest risk of dissemination if by chance it had not been a benign tumour, the kidney was transplanted into the lumbar fossa via its own vessels with an excellent result. The authors discuss two problems on the basis of this case: 1) That of preoperative diagnostic difficulties: the scanner provides valuable information when it reveals the presence of intra-tumoral fatty tissue. 2) Difficulties in management when the benign nature of the lesion cannot be confirmed before histological examination. The solution adopted: routine extended nephrectomy with ex-vivo perfusion of the kidney making it possible to obey the basic rules of oncology. Frozen section biopsy confirms the diagnosis of angiomyolipoma. It is then possible to auto-transplant the kidney after tumorectomy.

Placing female patients in prone position with widely spread legs provides very good exposure of the anterior vaginal wall and makes it possible to use the vaginal route alone for the surgical treatment of lower urinary tract lesions, such as vesico-vaginal fistulas.