Base bibliographique

Dérivation urinaire de Mitrofanoff. Mécanismes physiques et explication urodynamique de la continence
2008
- Réf : Prog Urol, 2008, 2, 18, 120-124


Introduction



Objective

To analyze the urodynamic parameters and the mechanisms of continence of Mitrofanoff urinary diversion.


Material and methods

Urodynamic assessment was performed via the stoma in 11 patients with continent urinary diversion according to the Mitrofanoff principle. The mean age of the patients at the time of the operation was 29 years. The appendix, used as conduit in all cases, was anastomosed to the skin of the right iliac fossa. Ileocystoplasty was performed in 10 patients. The urodynamic assessment was performed after a mean follow-up of seven years (range: five to 12 years).


Results

Reservoir pressures after filling did not exceed 20cm H2 O in nine cases. Uninhibited contractions were recorded in two patients with an enlarged bladder with pressures not exceeding 30cm H2 O. Appendix pressures during filling were always higher than bladder pressures. The mean pressure measured at the end of filling was 75cm H2 O (range: 45 to 90cm H2 O). After the Valsalva maneuver, these pressures were between 80 and 150cm H2 O with good transmission. The mean conduit closing pressure was 70cm H2 O (range: 40 to 90cm H2 O). The mean functional length of the conduit was 5cm (range: 2.6 to 7.2cm).


Conclusion

The Mitrofanoff diversion is mainly characterized by the high intraluminal pressure in the continent conduit. A low bladder pressure is essential to maintain a perfectly continent diversion.

Mots clés:
Urodynamique / Dérivation urinaire / Conduit
Mots-clés:
Urodynamic / continent urinary diversion / Conduit
Élévation du PSA total après instillations endovesicales de BCG : prostatite granulomateuse ou adénocarcinome prostatique ?
2008
- Réf : Prog Urol, 2008, 2, 18, 108-113


Introduction



Objective

The objective of this study was to evaluate the incidence of prostatic carcinoma in patients treated by intravesical BCG-therapy for superficial bladder cancer and presenting granulomatous prostatitis. The authors discuss the problems of interpretation of total PSA and the potential indications for prostatic biopsies in this population.


Material and methods

A retrospective study was performed on the cases of symptomatic granulomatous prostatitis observed among patients treated with intravesical BCG instillations between January 1997 and December 2006. A total of 153 men were treated for high-risk or intermediate-risk superficial bladder cancer according to the usual recommendations. The attenuated Connaught strain of BCG was used at a dose of 81mg. Induction treatment consisted of six weekly instillations and was followed by maintenance treatment for a period of three years.


Results

Six patients developed symptomatic granulomatous prostatitis (4% of cases). On average, this complication occurred after about the 10th intravesical instillation (6–13) of maintenance treatment. The mean total PSA at three months was 8ng/ml (range: 5–11.6). Ultrasound-guided biopsies were indicated in view of the persistently elevated PSA level and confirmed the tuberculoid granulomatous lesion of the prostate in each case and revealed prostatic adenocarcinoma in two patients.


Conclusion

Prostatic carcinoma must be systematically excluded by ultrasound-guided biopsies in all patients with clinical granulomatous prostatitis and persistently elevated PSA three months after intravesical BCG instillations.

Mots clés:
Tumeur superficielle de vessie / instillations endovésicales / BCG / Antigène spécifique de prostate / Prostatite granulomateuse
Mots-clés:
Superficial bladder cancer / Intravesical instillations / BCG / Prostate-specific antigen / Granulomatous prostatitis
Évaluation de l'homme infertile : recommandations AFU 2007
2008
- Réf : Prog Urol, 2008, 2, 18, 95-101


Introduction



An infertility evaluation should be performed if a couple has not achieved conception after one year of unprotected intercourse. An evaluation should be performed earlier if male or female infertility risk factors exist and if the couple questions its fertility potential. The initial screening of the male should include a reproductive history and a physical examination performed by a urologist or a specialist in male fertility and two semen analyses. Additional procedures and testing may be used to elucidate problems discovered during the full evaluation. The minimal initial endocrine evaluation should include serum total testosterone and serum follicle-stimulating hormone levels. An endocrine evaluation should be performed if sperm concentration is abnormally low, sexual function is impaired, and when other clinical findings suggest a specific endocrinopathy. A postejaculatory urinalysis should be performed if ejaculate volume is less than 1mL, except in patients with bilateral vasal agenesis or possible hypogonadism. With a diagnosis of retrograde ejaculation, specific management should be considered before advising assisted reproductive technology. Scrotal ultrasonography is indicated when physical examination of the scrotum is difficult or inadequate, or when a testicular mass is suspected. Transrectal ultrasonography (TRUS) is indicated in patients who are azoospermic or have a low ejaculate volume. Specialized testing of semen is not required for routine diagnosis of male infertility. However, some tests may be useful for a few patients to identify a male factor contributing to unexplained infertility, or to select therapy (e.g., assisted reproductive technology). Before performing intracytoplasmic sperm injection, karyotyping and Y-chromosome analysis should be offered to men who have nonobstructive azoospermia and severe oligospermia. Genetic testing for gene mutations of the ABCC7 (ex-CFTR) gene should be offered to male and female partners before proceeding with treatments that use the sperm of men with congenital bilateral absence of the vasa deferentia or congenital unilateral abnormality of the seminal tract. Genetic counseling may be offered when a genetic abnormality is suspected in the male or female partner, and it should be provided when a genetic abnormality is detected. Genetic testing in the female partner, when non symptomatic, should only be advised by a physician from a multidisciplinary team registered by the ministry of health. Evaluation by testis biopsy and deferentography should be performed by a urologist or an andrologist registered for sperm retrieval.

Mots clés:
Infertilité masculine / Azoospermie / Recommandations
Mots-clés:
Male infertility / Azoospermia / guidelines
Évaluation des compétences pratiques en fin de deuxième cycle des études médicales : exemple du drainage du bas appareil urinaire
2008
- Réf : Prog Urol, 2008, 2, 18, 125-131


Introduction



Introduction

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.


Material and methods

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.


Results

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 (p <0.001) versus 39 (54.9%) in females (p <0.001). 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.


Conclusion

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.

Mots clés:
Drainage urinaire / Cathétérisme urétral / Évaluation / Compétence / Étudiants en médecine
Mots-clés:
Urinary catheter / Medical student / Competence assessment / Urinary drainage
Greffe rénale et uropathie obstructive du bas appareil traitée par Botox : à propos d'un cas
2008
- Réf : Prog Urol, 2008, 2, 18, 132-135


Introduction



Introduction

The indications for botulinum toxin have been extended in the field of urology, especially in vesicosphincteric dysfunction with good results. The authors report the use of botulinum toxin in a kidney transplant recipient with urethral hypertonia partly responsible for end-stage chronic kidney disease.


Case report

Mr E.J, 25 years old, was operated for bilateral megaureter with vesicosphincteric dysfunction during childhood. He was managed in our department with serum creatinine of 364mol/l. Ultrasound showed bilateral ureteropelvic dilatation and residual urine of 300ml. Urodynamic assessment demonstrated a normally active bladder with normal compliance and urethral hypertonia. An intrasphincter injection of 300units of Botox was performed in May 2003 with a good result for 11 months. He subsequently received a second intrasphincter injection of 200units with clinical efficacy maintained for at least six months. This patient underwent living-donor kidney transplantation in May 2005. An intrasphincter injection of 100units of Botox was performed nine days after transplantation, then every six months. With a follow-up of 16 months, renal function is stable with negligible residual urine.


Discussion

The use of botulinum toxin in non neurogenic urethral hypertonia has been reported in only a few original articles. Botulinum toxin injection into the striated sphincter of the urethra decreases urethral resistance, improving obstructive symptoms and can be effective in kidney transplant recipients.

Mots clés:
Hypertonie sphinctérienne / Toxine botulique de type A / Transplantation rénale
Mots-clés:
Botulinum Toxin Type A / Kidney transplantation / Sphincter hypertonia
L'anesthésie sans anesthésiste ?
2008
- Réf : Prog Urol, 2008, 2, 18, 77-84


Ce sont vers les données fournies par l’Ordre des médecins qu’il faut se tourner pour expliquer le choix d’une telle discussion. Depuis quelques années, les médias tirent la sonnette d’alarme et annoncent la disparition programmée de l’anesthésie-réanimation.


The continuing decline in the number of anaesthetists-intensive care physicians means that certain operations need to be performed under the responsibility of urologists alone. These procedures can be performed perfectly safely in selected patients, provided the urologist is aware of the inherent risks of each local and regional anaesthesia or sedation technique.

Mots clés:
Anesthésiste / Technique d’anesthésie / Sédation
Mots-clés:
Regional anesthesia / Local anesthesia / Penile block / Prostatic block / Nitrous oxide
La prise en charge des pyélonéphrites emphysémateuses. À propos de 21 cas
2008
- Réf : Prog Urol, 2008, 2, 18, 102-107


Introduction



Objective

To define the clinical, laboratory and morphological features of emphysematous pyelonephritis, as well as the treatment modalities, with particular emphasis on the need for urgent treatment.


Material and methods

Between 1987 and 2004, 21 patients were treated for emphysematous pyelonephritis. Epidemiological, clinical, laboratory and radiological data, treatments and clinical outcome were retrospectively collected for all patients.


Results

This series comprised 15 women and six men with a mean age of 54.6 years. All were diabetic. Upper urinary tract obstruction was demonstrated in 47.6% of cases. The left kidney was affected in 14 patients and the right kidney was affected in six patients. Only one patient had bilateral pyelonephritis. The diagnosis was established by CT in every case. All patients received appropriate intensive care. Treatment was purely medical in one case. Emergency nephrectomy was performed in 12 patients, emergency surgical drainage was performed in three patients, percutaneous drainage was performed in two cases and ureteric catheter drainage was performed in three patients. The mortality rate in this series was 23.8%.


Conclusion

Emphysematous pyelonephritis is a serious infection. Early diagnosis is essential, particularly in diabetic patients. The positive diagnosis is based on computed tomography and treatment is now increasingly conservative.

Mots clés:
Pyélonéphrites / Emphysème / Chirurgie / Drainage / Traitement
Mots-clés:
pyelonephritis / Emphysema / Surgery / Drainage / treatment
Prise en charge d'une incontinence urinaire masculine après prostatectomie radicale (CTMH AFU 2006 – 4/5) : place de l'injection intra-urétrale de macroplastique, du sphincter urinaire artificiel et des thérapies cellulaires
2008
- Réf : Prog Urol, 2008, 2, 18, 85-88


Introduction



The management of moderate urinary incontinence after radical prostatectomy may require the use of an artificial sphincter, which remains the reference technique although it requires implantation of material, sometimes involving redo operations. Submucosal macroplastique injections have been proposed, but the results do not appear to be maintained over time. Cell therapy, consisting of the injection of stem cells into or close to the sphincter, probably represents the approach of the future, but in 2006, studies were still only at the evaluation phase.

Mots clés:
Incontinence / prostatectomie radicale / Incidence / Sphincter artificiel / Thérapie cellulaire
Mots-clés:
Incontinence / radical prostatectomy / Incidence / artificial sphincter / Cell therapy
Prise en charge d'une incontinence urinaire masculine après prostatectomie radicale (CTMH AFU 2006 – 5/5) : Prévention de l'incontinence et recommandations du CTMH
2008
- Réf : Prog Urol, 2008, 2, 18, 89-94


Introduction



Preservation of continence essentially depends on the operator and the quality of the operative procedure. The number of publications on this subject reflects the desire of urologists to provide their patients not only with control of the cancer but also preservation of their sexual and urinary functions. Ideally, surgery should preserve the striated sphincter and levator muscles, the neurovascular pedicles when oncologically acceptable, and the bladder neck and a leak-proof anastomosis must be ensured. The surgeon must satisfy two imperatives to achieve these objectives: a good knowledge of anatomy and meticulous preservation of this anatomy from the beginning to the end of the operation by highly selective dissection in selected patients. Finally, the Comité des Troubles Mictionnels de l’Homme (Male Voiding Disorders Committee) proposes guidelines for the diagnosis and treatment of urinary incontinence after radical prostatectomy.

Mots clés:
Incontinence / prostatectomie radicale / Incidence / sphincter / Bandelettes neurovasculaires
Mots-clés:
Incontinence / radical prostatectomy / Incidence / sphincter / neurovascular pedicles
Traitement de l'incontinence urinaire masculine par sphincter urinaire artificiel avec manchette intracaverneuse
2008
- Réf : Prog Urol, 2008, 2, 18, 114-119


Introduction



Objective

The aims of this study are to describe the implantation technique of an artificial urinary sphincter (AUS) with intracavernous cuff, define the indications and report the preliminary results of this technique.


Material and method

A single-centre retrospective study was carried out in 10patients with a median age of 66years. The aetiology of urinary incontinence was radical prostatectomy alone in four cases, combined with radiotherapy in four cases and transurethral resection of the prostate in two cases.

The initial treatment consisted of AUS in seven cases and suburethral tape in two cases and the last patient had not been previously treated. Failure of AUS was due to atrophy in three cases and urethral erosion in four cases. Six patients needed to use more than three pads per day. Erections were absent in all patients. All patients were treated by insertion of an intracavernous cuff according to the same technique: perineoscrotal incision on the median raphe, dissection of the bulbar urethra and inferior aspect of the corpora cavernosa, vertical incision of the tunica albuginea on either side of the urethra, passage of the cuff from one incision to the other behind the tunica albuginea and leaving the tunica albuginea against the urethra, and closure of the tunica albuginea by interrupted sutures leaving a passage for the cuff. The median follow-up was 15.5months.


Results

The median operating time was 90min. No intraoperative complication was observed. Two patients had to be explanted because of infection of the material. Seven of the remaining eight patients were satisfied and six of them needed less than one pad per day. A history pelvic irradiation did not appear to have any impact on the results.


Conclusion

The treatment of male urinary incontinence by artificial urinary sphincter with intracavernous cuff is a simple technique that improves the trophicity and calibre of the urethra underneath the cuff. This technique achieved good results in patients with a history of pelvic irradiation.

Mots clés:
Incontinence urinaire  / Prothèses et implants  / Sphincter artificiel
Mots-clés:
Urinary incontinence / Prostheses and implants / artificial sphincter