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Ojectives: Surgical management of benign prostatic hyperplasia (BPH) in elderly patients is associated with higher morbidity and mortality rate. This raises the question of benefice and risk balance. We conducted a prospective observational study to evaluate the results of endoscopic surgery for BPH in elderly patients, according to geriatric assessment.We included prospectively 60 patients older than 75 years, with an indwelling catheter for acute or chronic retention, who were candidates to endoscopic surgery for BPH. Patients underwent the brief geriatric assessment (BGA) and the comprehensive geriatric assessment (CGA) to classify them into three groups: "vigorous," "vulnerable," and "sick." Success was defined by the bladder catheter withdrawal after surgery.After geriatric assessment, 33 patients were classified in the "vigorous" group (55%), 25 in the "vulnerable" group (42%), and 2 in the "sick" group (3%). The success rate immediately after surgery was 85% and 41% in the "vigorous patient" group and the "vulnerable and sick" patient group, respectively (p 0.05). The success rate at 3 months after surgery was 94% and 55% (p 0.05). The morbidity was higher for the "vulnerable and sick" group (44%) compared with the "vigorous" group (15%) (p 0.05). The BGA also allowed predicting a higher risk of failure in patients with a score ≥3 immediately after surgery (odds ratio 5.9, confidence interval [95% CI] 1.61, 29.9) and 3 months after surgery (odds ratio 6.9, 95% CI 1.31, 70.8).Geriatric assessment can predict the outcome of endoscopic surgery for BPH for patients in retention older than 75 years. "Vulnerable and sick" patients had a higher risk to keep their indwelling catheter after the surgery compared with "vigorous" patients. The complication rate is also higher. The BGA can although predict a poor result of surgery when its score is equal or above 3/6.

Resume Introduction L’objectif de notre etude etait d’evaluer si le type de drainage postoperatoire par sonde double J (SDJ) ou par sonde ureterale (SU) modifiait les resultats apres ureterorenoscopie souple (URS) pour le traitement des calculs renaux. Materiel et methodes Nous avons analyse retrospectivement 162 premieres procedures d’URS pour calculs renaux entre janvier 2010 et janvier 2013. Nous avons compare les caracteristiques cliniques, les donnees perioperatoires et le taux de succes apres traitement en fonction de la mise en place d’une SU ou d’une SDJ. Resultats Nous avons inclus 162 patients. Une SDJ et une SU ont ete utilisees respectivement dans 117 (72,2 %) et 45 (27,8 %) cas. Les groupes etaient comparables concernant l’âge (p = 0,92), le nombre de calculs (p = 0,68), le diametre cumulatif des calculs (p = 0,342) et la presence preoperatoire d’une SDJ (p = 0,117). Les chirurgiens en debut d’experience mettaient plus frequemment une SDJ (86 % vs 62 % ; p = 0,001). Le temps operatoire etait plus long dans le groupe de patients draines par SDJ (96,2 ± 35 min vs 81,2 ± 5 min ; p = 0,018). La duree d’hospitalisation (p = 0,804), le taux de complications postoperatoires (p = 0,148) et l’absence de calcul residuel (p = 0,116) etaient comparables entre les deux types de drainage. Conclusion Le drainage postoperatoire par SDJ est utilise plus souvent par les urologues au debut de leur experience et est associe a un temps operatoire plus long. Cependant, le type de drainage ne modifie pas les resultats postoperatoires en termes de complications, de duree d’hospitalisation et d’absence de calcul residuel. Niveau de preuve 5.

Resume Objectif Evaluer les resultats des therapies ciblees dans la prise en charge du cancer du rein metastatique (CRm), par l’etude des survies globale (SG) et sans progression (SSP). Patients et methodes Nous avons inclus retrospectivement 78 patients traites par therapie ciblee au centre Paul Papin de l’institut de cancerologie de l’ouest pour un cancer du rein metastatique entre 2004 et 2009. Les SG et SSP en premiere et deuxieme lignes ont ete analyses, ainsi que la reponse au traitement, la survenue d’effets secondaires de grade III et IV. Resultats Au terme d’un suivi median de 33 mois [5–236], 41 patients (52,56 %) sont decedes. La SG mediane etait de 36 mois [IC 95 % de 29–43]. Les patients ont recu en premiere ligne, soit du sunitinib ( n = 27 ; 34,6 %), bevacizumab et interferon (IFN) ( n = 16 ; 20,5 %), IFN seul ( n = 16 ; 20,5 %), sorafenib ( n = 4 ; 5,2 %), temsirolimus ( n = 2 ; 2,6 %), IL-2 ( n = 3 ; 3,8 %), IFN et IL-2 ( n = 6 ; 7,7 %), ou autres molecules ( n = 4 ; 5,1 %). En premiere ligne, les medianes de SSP etaient respectivement de 14 mois [IC 95 % de 6,71–21,29] pour le sunitinib, de 38 mois [IC 95 % de 11,41–64,59] pour le bevacizumab + IFN, et de huit mois [IC 95 % de 0–17,03] pour l’IFN seul. Une reponse partielle a ete observee dans 19,2 %, une stabilisation tumorale dans 47,4 % et une progression dans 25,6 % des cas. En deuxieme ligne, 53 patients ont ete traites par soit sunitinib ( n = 20 ; 37,8 %), bevacizumab et IFN ( n = 7 ; 13,2 %), sorafenib ( n = 17 ; 32,2 %), temsirolimus ( n = 3 ; 5,6 %) ou autres molecules ( n = 6 ; 11,2 %). Les effets grade III ou IV ont ete en evidence dans 14,1 %, 28,3 % et 18,2 % des cas lors des premieres, deuxiemes et troisiemes lignes de traitements. Conclusion L’evaluation des resultats des therapies ciblees dans notre centre a confirme les donnees de la litterature. Les therapies ciblees permettent un gain de survie superieure a l’immunotherapie, mais aux prix d’effets secondaires lourds chez certains patients.

La retencion aguda de orina (RAO) es una urgencia urologica que se caracteriza por la imposibilidad dolorosa de orinar y cuya incidencia aumenta con la edad. Se puede deber a diversos mecanismos que provocan una disfuncion del sistema vesicoesfinteriano. La RAO es una afeccion esencialmente masculina que, en dos tercios de los casos, aparece dentro de un cuadro de hipertrofia benigna de prostata (HBP). La clinica se caracteriza por un deseo imperioso de orinar, con dolor y presencia de un globo vesical. Su tratamiento, que debe ser precoz, consiste en la evacuacion vesical, mejor por cateterismo suprapubico si es posible. La administracion de un α-bloqueante asociado al drenaje aumenta las posibilidades de exito de ablacion de la sonda y disminuye los riesgos de recidiva. Cuando despues de un episodio de RAO esta indicada la cirugia, la intervencion se debe realizar a distancia de dicho episodio para limitar la morbimortalidad perioperatoria.

International audience; IntroductionL’Evidence-Based Medicine (EBM) est indispensable à l’exercice de la médecine. Notre objectif était de connaître quel en était son niveau de connaissance par les étudiants français. Matériel et Méthodes Entre avril et mai 2008, un questionnaire a été envoyé par courriel à 900 étudiants en dernière année du deuxième cycle des études médicales participant à des conférences publiques ou privées d’internat. Résultats Sur les 327 réponses, 297 (91%), 94 (29%) et 85 (26%) étudiants déclaraient savoir lire, écrire et parler l’anglais médical. Quatre-vingt-dix étudiants (28%) lisaient un article d’une revue médicale française, une fois par mois et 43 (13%) lisaient un article d’une revue médicale internationale une fois par mois. Trois cent onze (95%) connaissaient les bases de recherche médicale sur Internet et 219 (67%) les utilisaient. Vingt-quatre (7%) avaient déjà participé à la rédaction d’un article médical, sept (2%) avait été co-auteurs. Deux cent soixante-douze (83%) avait réalisé une présentation orale lors d’un staff médical et trois (1%) lors d’un congrès. Enfin, 237 (73%) comprenaient l’intérêt de l’épreuve d’analyse critique d’article à l’examen national classant (ECN) et 70 (21%) pensaient y être préparés. Conclusion L’insuffisance de l’apprentissage de l’EBM est une des limites du système de formation français. L’introduction de la lecture critique d’article (LCA) à l’ECN est un début de réponse concret à ce problème.

Resume But Evaluer l’efficacite et la morbidite du traitement par radiofrequence (Tuna) de l’hypertrophie benigne de prostate (HBP) chez des patients en echec de traitement medical a travers une serie de 28 cas et une revue de la litterature. Materiel et methodes Entre septembre 2003 et juillet 2007, 31 patients ont ete traites par radiofrequence pour une HBP. Leur statut mictionnel a ete evalue par le score IPSS, le score de qualite de vie, la debitmetrie et le residu postmictionnel (RPM). L’efficacite du traitement a ete evaluee de facon retrospective sur l’evolution de ces parametres apres un suivi moyen de 20 mois (5–47). Afin d’evaluer la morbidite du traitement, les complications precoces et tardives ont ete prises en consideration. Le retentissement sur la fonction erectile et la satisfaction des patients ont ete evalues par questionnaire. Resultats Vingt-huit patients, d’âge moyen 59,5 ans (50–76), ont ete inclus dans l’etude. Avec un recul moyen de 20 mois, une amelioration significative du statut mictionnel a ete trouve pour le score IPSS, le score de QdV, le Qmax ( p p Conclusion La radiofrequence est une technique qui donne des resultats significatifs sur les symptomes urinaires lies a l’HBP. Le principal avantage de cette technique est sa faible morbidite. Cependant, presque un patient sur deux a ete retraite apres 20 mois de suivi moyen. Ce taux de retraitement est particulierement eleve en regard du cout de cette technique. La place du Tuna dans le traitement de l’HBP reste donc a mieux definir.

Las estenosis ureteroileales constituyen la complicacion mas frecuente de las tecnicas que utilizan el intestino delgado en urologia. Su incidencia segun la literatura varia entre el 2-12%. A menudo se localizan a nivel de la union ureteroileal izquierda y son mas frecuentes tras radioterapia o cirugia complicada con fistula anastomotica. A menudo son poco sintomaticas; su diagnostico se sospecha ante la aparicion de insuficiencia renal o infecciones de repeticion; se confirma mediante pruebas de imagen. La ecografia objetiva una ureterohidronefrosis proximal a la estenosis. La asografia o la pielografia retrograda permiten precisar el grado, la localizacion y la extension de la estenosis. La urotomografia computarizada (uro-TC) posee la ventaja de indicar tambien sus relaciones con los organos adyacentes. Su tratamiento permite eliminar la obstruccion que, segun su grado, puede ser responsable de la formacion de calculos, infecciones y destruccion del rinon. El tratamiento puede ser radical o conservador, en funcion del origen tumoral o benigno de la estenosis, pero tambien de la capacidad funcional del rinon afectado. Los tratamientos endoscopicos, aunque menos eficaces, se utilizan como primera opcion debido a su menor morbimortalidad. Consisten en la colocacion de endoprotesis o en la dilatacion o incision de la estenosis. En su mayoria se realizan por via combinada. El acceso anterogrado permite atravesar la estenosis y el retrogrado, tratarla bajo control visual. Entre estas tecnicas, la incision de la estenosis con hoja fria, con la ayuda de una sonda de globo de tipo Acucise o con laser, es el tratamiento mas eficaz. Su aplicacion debe ser cautelosa debido al riesgo de lesion de la arteria iliaca o del borde mesenterico del injerto y de lesiones digestivas. Las tecnicas a cielo abierto son mas eficaces pero dificiles a causa de las adherencias postoperatorias. Consisten principalmente en la reseccion de la zona estenosada antes de practicar una nueva anastomosis. En caso de recidiva tumoral, el tratamiento esta en funcion principalmente de la posibilidad de control local del tumor; recurre la mayor parte de las veces a tecnicas paliativas por via endourologica.

International audience; IntroductionLe drainage vésical peut, mal pratiqué, être iatrogène en se compliquant notamment d’infections et de traumatismes de l’appareil urinaire. Cette étude a pour objectif de déterminer la capacité des étudiants en médecine de fin de deuxième cycle à pratiquer les différents moyens de drainage des urines. Matériel et méthodes Entre janvier et mars 2007, un questionnaire d’autoévaluation des compétences de drainage urinaire a été envoyé par mail à un échantillon représentatif d’étudiants en médecine en dernière année d’externat, soit deux mois avant l’épreuve de l’examen national classant. Résultats Deux cent soixante-dix-sept réponses ont été reçues et analysées. Soixante-douze étudiants (26%) jugeaient qu’ils maîtrisaient le cathétérisme urétrovésical chez l’homme et 106 étudiants (38,3%) chez la femme à la fin de leur externat. Soixante et onze étudiants sur les 277 (25,5%) avaient effectué un stage en urologie au cours de leur cursus. Parmi eux, 53,5% estimaient acquis le sondage à demeure (SAD) chez l’homme (p < 0,001) et 39 (54,9%) chez la femme (p < 0,001). Soixante-treize étudiants (26,4%) estimaient qu’ils maîtrisaient le sondage minute d’une femme ou d’un homme et un seul considérait la pose de cathéter sus-pubien comme acquis. Conclusion L’apprentissage des gestes de drainage urinaire est enseigné de façon inappropriée au cours des études médicales puisque de jeunes médecins se sentent incapables de les reproduire au terme de leur externat. Cela est critiquable, car le sondage doit pouvoir être réalisé par tous médecins non urologues dans leur pratique quotidienne, notamment en terrain hospitalier. Cette étude doit mener à une réflexion sur l’amélioration de l’enseignement des gestes pratiques médicaux essentiels pendant l’externat.

Objectifs Les patients atteints de polykystose renale autosomique dominante necessitent parfois la realisation d’une nephrectomie. La voie d’abord cœlioscopique est maintenant proposee par de nombreuses equipes. Le volume important des reins polykystiques necessite une technique d’extraction adaptee, differente d’une nephrectomie cœlioscopique classique. Cette technique n’est actuellement pas bien codifiee. Nous avons mis au point une technique d’extraction standardisee originale. Methodes Dix-sept patients atteints de polykystose renale autosomique dominante ont ete operes en cœlioscopique entre 2012 et 2016. Differentes voies d’abord ont ete utilisees : la voie transperitoneale, la lomboscopie ou la cœlioscopique manuellement assistee. La technique d’extraction a ete progressivement mise au point en s’efforcant de pouvoir extraire le rein par une courte incision, pour ne pas attenuer le benefice parietal de la cœlioscopique, sans dissemination bacterienne ou plus rarement tumorale. Resultats Nous presentons en video les differentes techniques qui ont ete proposees pour extraire les reins polykystiques : l’utilisation d’un « morcellator », l’aspiration-morcellement a l’aide d’une canule d’aspiration metallique biseautee, le morcellement au bistouri ou a la pince a travers une incision iliaque ou de Pfannenstiel, eventuellement protegee par un ecarteur d’Alexis ® . Nous presentons egalement notre technique originale de morcellement manuel dans un sac a grele a travers un GelPort ® en cœlioscopie manuellement assistee. Conclusion Le morcellement manuel dans un sac a grele a travers un GelPort ® en cœlioscopie manuellement assistee permet d’extraire facilement de tres gros reins polykystiques, avec un prejudice parietal faible et un risque de dissemination bacterienne et carcinologique minimal.

Purpose: We examine the relationship of nonsteroidal anti-inflammatory drugs and finasteride on the risk of prostate cancer.Materials and Methods: Participants in this case control study using a prospective collection of data were drawn from consecutive patients who underwent prostate biopsy at 12 different departments of urology from January 1999 to June 2000. Medication use was assessed by self-questionnaire as well as questions about dietary and lifestyle factors that might be relevant for prostate cancer risk.Results: The study included 639 patients with prostate cancer and 659 cancer-free controls. Univariate analysis showed no significant impact of aspirin and finasteride on prostate cancer risk while the nonaspirin nonsteroidal anti-inflammatory drug users had a lower risk (OR 0.80, 95% CI 0.64–0.99). After adjusting for potential confounders, the protective effect of nonaspirin nonsteroidal anti-inflammatory drugs was no longer significant (OR, 0.84, 95% CI 0.66–1.07), while finasteride sh...

To evaluate the outcomes following targeted therapies in the management of metastatic renal cell carcinoma (mRCC), through the study of overall survival (OS) and progression-free (PFS).We retrospectively included 78 patients treated with targeted therapies for mRCC at the Paul Papin Cancer Institute from 2004 to 2009. Overall survival (OS), progression free survival (PFS), response to treatment, occurrence of grade III and IV side effects, were analyzed following first and second line treatments.Median follow-up was 33 months [5-236], and 41 patients died (52.6%). Median OS was 36 months [95% CI 29-43]. The median PFS was 14 months [95% CI 6.71-21.29] for sunitinib, 38 months [95% CI 11.41-64.59] for bevacizumab with interferon (IFN), and 8 months [95% CI 0-17.03] for IFN alone. A partial reduction, stabilization or increase in tumor size was observed for 19.2%, 47.4% and 25.6% of cases. A second line treatment was given for 53 patients. They received either sunitinib (n=20, 37.8%), bevacizumab with IFN (n=7, 13.2%), sorafenib (n=17, 32.2%), temsirolimus (n=3, 5.6%) or other molecules (n=6 11.2%). Grade III or IV side effects were observed for 14.1%, 28.3% and 18.2% of the patients following first, second and third line treatment, respectively.Outcomes of targeted therapies in our center upheld the literature data. These therapies allow a benefit survival versus immunotherapy, with sometimes large side-effect.

Nowadays, evidence-based medicine (EBM) is essential to learn and to practice medicine. The aim of the current study was to investigate the baseline level of knowledge of French students regarding EBM.Between April and May2008, a questionnaire was sent by e-mail to 900students in their last year of medical study.On 327 answers, 297 (91%), 94 (29%) and 85 (26%) students declared they read, write and speak medical English. Ninety (28%) read an article of a French medical review once a month and 43 (13%) read an article of an international medical review once a month. Three hundred and eleven (95%) knew the bases of medical research on the Internet and 219 (67%) used them. Twenty-four (7%) had already participated in a editorial staff of a medical article, 7 (2%) had been co-authors. Two hundred and seventy-two (83%) had made an oral presentation during a medical staff and 3 (1%) during a congress. Finally, 237 (73%) understood the interest of the critical analysis of an article at the ECN and 70 (21%) thought they were prepared.The incapacity of learning EBM is one of the limits of the French medical training system. The introduction of the reading critical of an article at the ECN is the concrete beginning of an answer to this problem.

To estimate the efficiency and morbidity of the radiofrequency (Tuna) for treatment of symptomatic benign prostatic hyperplasia (BPH) in patients with medical treatment failure.Between September 2003 and July 2007, 31 patients, mean age 59,5 years (50-76), were treated for BPH with Tuna. Patients had initially received medical treatment, which happened to fail and Tuna was offered as surgical treatment. Available clinical data of 28 patients was retrospectively analyzed. Mictionnel status was estimated with International Prostatic Symptoms Score (IPSS), urinary peak flow (UPF) and post void residual urine (PVR). Quality of life issues were also addressed. Efficiency of treatment was estimated on the evolution of these parameters after an average follow-up of 20 months (5-47). To estimate morbidity of treatment, peroperative and late complications were assessed.Twenty-eight patients were included in the study. At a mean follow-up of 20 months, a significant improvement of the mictionnel status was found for the IPSS, the quality of life, the Qmax (p0,001) and the PVR (p0,005) and quality of life. Morbidity was verified as minimal in the series. At a follow-up period of 20 months, 15 patients (53,6%) had stopped medical treatment, 10 patients (35,7%) pursued medical treatment and three patients (10,7%) had undergone another type of surgical treatment for BPH. The rate of re-treatment in the series was 46,4%. Among the group of patients without any medical treatment (15 patients), 10 patients reported satisfactory quality of life.Tuna is a technique with significant good results for the treatment of LUTS-BPH. The main advantage of this technique is its low morbidity, however, the rate of retreatment was observed as high. Series of patients with long-term follow-up should provide evidence to objectively define the role of Tuna in BPH surgical treatment.

When performed incorrectly, bladder catheterization can cause iatrogenic complications, especially urinary tract infections and trauma. The objective of this study was to determine the capacity of final year medical students to perform the various bladder catheterization techniques.Between January and March 2007, a catheterization self-administered questionnaire was sent by e-mail to a representative sample of final year medical students, two months before the national classifying examination.Two hundred and seventy-seven questionnaires were returned and analysed. Seventy-two students (26%) considered that they were able to perform bladder catheterization in males and 106 (38.3%) in females at the end of their medical training. Seventy-one out of 277 (25.5%) students had completed an urology term during their training and 53.5% of them considered that they had acquired the indwelling catheter technique in males (p0.001) versus 39 (54.9%) in females (p0.001). Seventy-three students (26.4%) considered that they were able to perform intermittent catheterization in males or females and only one student was able to perform suprapubic catheterization.Teaching of catheterization procedures is inappropriate during medical training and young doctors consider themselves unable to perform these techniques at the end of their training. This is unfortunate, as all doctors should be able to perform catheterization as part of their daily practice, especially in hospital. This study indicates the need for improved teaching of essential medical procedures during undergraduate medical training.

We examine the relationship of nonsteroidal anti-inflammatory drugs and finasteride on the risk of prostate cancer.Participants in this case control study using a prospective collection of data were drawn from consecutive patients who underwent prostate biopsy at 12 different departments of urology from January 1999 to June 2000. Medication use was assessed by self-questionnaire as well as questions about dietary and lifestyle factors that might be relevant for prostate cancer risk.The study included 639 patients with prostate cancer and 659 cancer-free controls. Univariate analysis showed no significant impact of aspirin and finasteride on prostate cancer risk while the nonaspirin nonsteroidal anti-inflammatory drug users had a lower risk (OR 0.80, 95% CI 0.64-0.99). After adjusting for potential confounders, the protective effect of nonaspirin nonsteroidal anti-inflammatory drugs was no longer significant (OR, 0.84, 95% CI 0.66-1.07), while finasteride showed a significant protective effect (OR 0.58, 95% CI 0.37-0.92).The results suggest that finasteride could have a chemopreventive role in prostate cancer. While aspirin did not show any impact on prostate cancer risk, the role of nonaspirin nonsteroidal anti-inflammatory drugs warrants further studies.

The aim of this study was to report our experience with endoscopic transanal resection (ETAR) using a urologic resectoscope for palliative treatment of rectal carcinoma.Outcome in patients who underwent ETAR with a urologic resectoscope between October 1992 and March 1999 are reported.The 60 ETAR procedures were performed in 37 patients (19 men and 18 women, median age 82 years). Morbidity was 10% (6 patients) and mortality was 2.7% (1 patient). Median hospital stay for the procedure was 5 days. Symptom control was achieved in 86% of the patients (40% partial control, 46% complete control). Colostomy was performed in 8 patients 7 months after ETAR. At study end, 4 patients were alive. Median survival was 14 months (range 0 - 62). The 1-, 2-, and 5-year survival rates were 54, 32 and 5%, respectively.ETAR is a simple, minimally invasive and economical method for palliative treatment of patients with rectal carcinoma. ETAR is a useful addition to the surgeon's armamentarium.

Objectifs A ce jour, aucune etude n’a evalue l’impact de la chirurgie endoscopique intrarenale sur la fonction renale. Le but de cette etude etait d’evaluer les modifications et de determiner les facteurs associes a une deterioration de la fonction renale apres uretero-renoscopie et vaporisation laser des calculs. Methodes Une analyse retrospective a ete menee dans un centre unique entre janvier 2010 et juin 2013 sur les patients traites par ureteroscopie souple pour des calculs intrarenaux. L’evaluation du debit de filtration glomerulaire (DFG) etait derivee de l’equation du groupe d’etude Modification of Diet in Renal Disease (MDRD). La classification de l’insuffisance renale chronique (IRC) selon la National Kidney Foundation a ete utilisee pour classer les DFG en 5 groupes. Un changement vers un groupe plus ou moins favorable apres ureteroscopie etait considere comme signicatif. Resultats Au total, 163 patients ont ete inclus, 86 hommes (52,8 %) et 77 (47,3 %) femmes. L’âge median etait de 52,8 ± 17 ans. Avant la procedure, 24 (16,6 %), 7 (4,3 %) et 1 (0,6 %) patients avaient respectivement un niveau d’IRC classe 3a,3b et 4. Apres un suivi median de 15,5 ± 11,5 mois, le DFG median n’etait pas significativement different (de 84,3 ± 26,2 a 84,9 ± 24,5 ml/min (p = 0,675)). Une deterioration et une amelioration significatives de la fonction renale ont ete observees chez 8 (4,9 %) et 23 (14,1 %) patients respectivement. En analyse univariee, les procedures multiples (p = 0,023 ; HR : 5,4) et la presence d’ IRC preoperatoire (p = 0,011 ; HR : 6,8) etait associes a une deterioration de la fonction renale. Ces resultats n’etaient pas retrouves en analyse multivariee. Conclusion La prise en charge des calculs renaux par ureteroscopie souple semble avoir une influence favorable sur la fonction renale, cependant, une attention particuliere doit etre portee aux patients subissant plusieurs procedures ainsi qu’a ceux presentant une insuffisance renale pre-existente.

Editorial Comment: Ureteroscopy is now the most commonly performed stone removing procedure in North America and other regions of the world. Flexible ureteroscopy is commonly done in patients with proximal ureteral and renal stones. These instruments are fragile and costs for repairs/ replacements are high. The use of disposable ureteroscopes has been proposed for limiting costs. These investigators used a device composed of a single use multilumen catheter and a reusable optic fiber. Their outcomes for treating patients with proximal ureteral and renal stones were solid. However, they did not perform an economic analysis. The usefulness of disposable flexible endoscopes will need to be carefully assessed based on clinical as well as economic effectiveness.

Retrospective evaluation of the use of the free PSA index before prostatic biopsies.The authors retrospectively studied the values for total PSA, free PSA, and free PSA index (ratio of free PSA over total PSA expressed as a %) in men with a total PSA between 2 and 10 ng/ml, from a population of 391 men prior to prostatic biopsies. They also isolated a subgroup of patients in whom the free PSA index could have been used as a first-line marker to decide whether or not to perform prostatic biopsies.The mean values for total PSA, free PSA, and free PSA index were compared as a function of the diagnosis, age, and ultrasound prostatic volume. The yields of the various cut-off values for the free PSA index for PSA between 2 and 4 ng/ml, 4 and 10 ng/ml, and 2 and 10 ng/ml with a normal digital rectal examination are reported. Between 2 to 10 ng/ml, at a cut-off value of 30%, 94.1% of cancers would have been detected (sensitivity) and 22% of biopsies would have been avoided, 10 of which would have been useless, i.e. a 30.3% economy of useless biopsies not performed (specificity). At the cut-off value of 15%, less than half of cancers would have been detected (47.1%) and 90.9% of useless biopsies would have been avoided. Biases creating difficulties of interpretation were the assay kits, the reference population, age, storage of sera, and prostatic volume.The free PSA index would be a useful first-line parameter in only 12.7% of candidates for prostatic biopsies. The cut-off value of 30%, validated for our assay method, would be able to detect the majority of cancers in men aged 50 to 65 years, while avoiding biopsies in the third of men with no detectable cancer.

The free form of PSA represents an average of 30% of total PSA. The free PSA level, in relation to total PSA, is expressed as a percentage (of free PSA). The percentage of free PSA appears to be relatively independent of benign prostatic hypertrophy, but it is markedly and significantly decreased in the case of prostate cancer and acute prostatitis. A cut-off value for the percentage of free PSA combined with a cut-off value for total PSA can decrease the number of biopsies indicated for the detection of prostate cancer. This approach avoids 20 to 30% of useless biopsies (specificity), but is accompanied by a 5 to 10% reduction of the number of cancers detected (sensitivity of 90 to 95%) compared to the use of total PSA alone. This 5 to 10% risk of missing a cancer of significant volume in a man under the age of 65 years explains why the use of free PSA to guide prostatic biopsies is not routinely recommended. Despite the promising performance of the percentage of free PSA to improve the indication for prostatic biopsies, the methodology of the studies performed to evaluate this test is not sufficient to validate their conclusions. The percentage of free PSA can be prescribed as a second-line test by the urologist, following a first series of negative biopsies in a man with a high clinical and laboratory suspicion of prostatic cancer, in order to propose a second series of biopsies after three months or to define the frequency of clinical and laboratory surveillance. While waiting for the results of prospective studies in the screening setting, recommendations concerning the use of PSA by general practitioners, who are the first to order this test in the context of screening, can be formulated as follows: The value of free PSA assay for first-line cancer screening has not been validated. A consensus has not been reached concerning the use of free PSA as an indication for biopsies and the frequency of assays. Total PSA assay (cut-off value: 4 ng/ml) remains the reference laboratory test for screening and indication of biopsies. A lower normal cut-off value (between 2 and 4 ng/ml) is currently under evaluation.

We reassessed the use of DNA flow cytometry in bladder cancers on the basis of our research and already published findings. We discuss technical aspects underlying the validity of the results. Currently, the validity of DNA flow cytometry is established by parametric analysis of the DNA content of tumor cells found in the course of multiple biopsies of the tumor. In addition, we examine the results obtained with bladder washings and, in some cases, the results of biopsies of the bladder mucosa which may appear normal under cystoscopy. The complementarity of these examinations appears to be essential. Our experience confirms the results already published, suggesting that the frequency of DNA aneuploidy increases significantly according to the grade and the tumor stage. However, clinical interpretation of DNA flow cytometry results calls for some caution. There is a general consensus not to use these results in the screening of bladder cancers. However, DNA flow cytometry is particularly useful in the follow-up of carcinoma in situ since DNA aneuploidy is almost always present. DNA flow cytometry is also useful in the stratification of superficial grade 2 tumors. Finally, during the follow-up of invasive tumors, the persistence or appearance of DNA aneuploidy may be attributed to therapeutic resistance.

In order to evaluate the prognostic value of the anatomical stage (pTNM 1992) and of the histological factors (Führman's grade, cellular and architectural types), 170 renal cell carcinoma diagnosed between 1971 and 1991 were reviewed. In univariate analysis, the prognosis was correlated with the anatomical stage and Führman's grade: for the 125 patients without metastasis, grades 1 and 2 had a good prognosis, whereas grades 3 and 4 did poorly. The cellular type was not related to survival. Among architectural types, only the pseudo-sarcomatous type was correlated with prognosis. Multivariate analysis revealed that grade and metastasis at diagnosis were two independent predictors of survival; the grade was prognostically superior to metastasis. Führman's grade is essential in determining prognosis; its statistical value is superior to anatomical stage in multivariate analysis.

Palliative treatment for patients with rectal carcinoma affect more than 10% of the 8000 cases diagnosed each year in France. Twenty-four patients underwent endoscopic trans-anal resection using a urological resectoscope. The morbidity rate was 18,5% and there were no postoperative deaths. The median hospital stay for the procedure alone was 4 days. Good palliation was obtained in 89% of cases. This simple, minimally invasive and economic method should join palliative treatment for patients with rectal carcinoma beside laser destruction and external beam radiotherapy.

There exist rare cases in which a prostatic carcinoma invades the perirectal space producing an extrinsic rectal stenosis. Three cases are discussed. Differential diagnosis with a rectal tumor is difficult clinically, but endorectal ultrasound and deep rectal biopsies must provide the correct diagnosis in most cases. Hormonotherapy is recommended, but prognosis is reserved.

Palliative treatment for patients with rectal carcinoma concerns more than 10% of the 8000 cases diagnosed each year in France. Seventeen patients (median age: 83 years) underwent 27 endoscopic transanal resections using a urological resectoscope. The morbidity was 18.5% and there were no postoperative deaths. The median hospital stay for the procedure alone was 4 days. Local control was obtained in 13 (76%) patients with good palliation of obstruction, bleeding and tenesmus. The mean survival time was six months. This simple, minimally invasive and economic method should be part of palliative treatment for patients with rectal carcinoma together with laser destruction and external beam radiotherapy.

The authors report a case of pure small cell carcinoma of the prostate expressing neuroendocrine markers on immunohistochemistry. Treatment consisted of chemotherapy with cisplatin and etoposide combined with regional external beam radiotherapy. The result is encouraging with complete remission 15 months after the diagnosis.

Primary or secondary nocturnal enuresis in adults (over the age of 15 years) is rare, but is associated with considerable psychosocial repercussions. The aim of this retrospective study was to determine whether urodynamic studies have any predictive value for the efficacy of the treatments proposed in these patients. This study was based on 20 patients (8 females and 12 males) between the ages of 15 and 33 years (mean: 23.75 years), studied between 1982 and 1990 with a mean follow-up of 13.35 months. Enuresis was primary in 12 patients and secondary in 8 patients. 11 patients had already received one or more treatments without success. Patients with clinically obvious neurological disease were excluded from the study. The urodynamic assessment included water cystomanometry, water urethromanometry with a perfused catheter and uroflowmetry. In addition to the investigation of other associated disturbances of micturition, the following complementary investigations were performed: urine culture in every case, IVU and/or cystography (n = 18), cystoscopy (n = 3), renal and vesical ultrasonography (n = 1). The urodynamic assessment was abnormal in 16 out of 20 cases: marked detrusor hyperactivity (n = 15), impaired compliance (n = 6), significant urethral instability (n = 7), isolated premature urge (n = 1). 15 patients presented with diurnal disorders dominated by frequency (n = 13), urgency (n = 9) and urge incontinence (n = 4); detrusor hyperactivity was detected in every case. The abnormalities observed on the urodynamic assessment guided treatment, allowing correction of enuresis in 3/4 of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report two rare cases of neoplastic vesical malakoplakia, one with an enterovesical fistula and the other with extravesical pelvic extension. The symptoms are non-specific and the diagnosis remains histological. Medical treatment, based on the suspected infectious physiopathogenesis of the disease, consists of variable combinations of antibiotics, cholinergics and vitamin C. It must be sufficiently prolonged and conservative in view of its usual efficacy, even in neoplastic forms.

The authors report a case of pelvic lipomatosis in a 62 year old man associated with venous obstruction (third case reported in the literature), diagnosed after bilateral ureteric obstruction, and review of the literature on this subject. The diagnosis was suggested by the radiological triad of hyperlucency of the pelvis on plain abdominal X-ray, "hot air balloon" appearance of the bladder on IVU and a rigid and ascended rectosigmoid on barium enema, and was confirmed by CT and MRI. Treatment combining corticosteroids and urinary tract disinfection was partially effective. A double J ureteric stent resolved the problem of persistent right ureteric obstruction.

296 solid renal tumors were studied retrospectively, i.e. the total number of renal tumours diagnosed in the Indre-et-Loire region between 1980 and 1987 inclusive. The crude incidence rate increased from 5.4 per 100,000 in 1980 to 8 per 100,000 in 1987. The standardised rates were 6.7 per 100,000 for men and 3.2 per 100,000 for women. These figures being quite high for France. The mean age at the time of diagnosis, 67 years for women and 65 years for men, decreased during the study, especially for women. Patients in whom the renal cancer was discovered accidentally, tended to be older than those in whom the tumour was symptomatic. The percentage of tumours discovered at stage I rose from 29 to 49% the percentage of tumours at stage IV fell from 45 to 23.5%. In parallel, the percentage of nephrectomies rose from 40 to 70%. The overall 5 year survival rate was 43.5%, rising to 71% for stage I tumours. It appeared that patients who consulted in the private sector tended to be younger and were therefore at an earlier stage in the natural history of the disease. From an epidemiological viewpoint, the introduction of ultrasonography in the Indre-et-Loire region and its more widespread use did not produce any change in the means of diagnosis of renal cancer.

Urethrectomy followed by terminoterminal urethrorraphy is one of the oldest surgical techniques for treating short urethral stenoses, regardless of their location. Eighteen patients managed by this technique were followed-up for at least ten years. Results were satisfactory in four out of every five cases and success was nearly immediate. No delayed deteriorations were seen. These limitations are mainly related to the length of the lesion.

Metastatic cancer of the kidney kills one half of the patients concerned within one year and there are no survivors two years later. All of the treatments used up until the present time have been disappointing. Nephrectomy does not prolong survival, does not induce regression of metastases and does not modify the mode of metastatic dissemination. It only has a palliative role. Lymphadenectomy associated with nephrectomy only has a prognostic value. Hormone therapy and chemotherapy are ineffective. Resection of a single metastasis is justified by 5-year survival rates of 30 to 50% in certain series. At the present time, the hopes for effective treatment are raised by the use of recombinant alpha interferon. Therapeutic trials obtain an overall complete response rate of 2.5% (disappearance of all signs of tumour for 4 weeks) and a partial response rate of 14% (decrease in the neoplastic lesions by at least 50%). The combination of interferon with vinblastine ensures much better results with complete and partial response rates of up to 43%. The characteristics of responder patients are discussed in terms of the natural history of renal cancer and the respective results of other treatments. There is a sub-population of patients with metastatic renal cancer suitable for this combination of interferon-vinblastine: they are young patients, in good general condition, previously nephrectomised and preferably suffering from lung metastases. The essential limiting factor of this treatment is the high cost of interferon.

A further case is reported of urinary tract lithiasis developing around a metallic clip used to suture an ileal fragt during Bricker's operation. Although the calculus developed without provoking complications and was evacuated spontaneously through the stoma, the question is asked, after a literature review, whether it is justified to use mechanical suturing for transintestinal cutaneous anterostomies. The moderate gain in time (15 to 20 min) seems counterbalanced by the increased cost and definite risk (2 to 4%) of lithiasis on metallic clips.