[Disinfection and sterilization of endoscopes in urology. The Committee on Infection of the French Association of Urology].
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Creutzfeldt-Jakob Syndrome↗
Biomedical subjects
M Anidjar
Publications and source records attributed to M Anidjar.
Evaluation of optimal stent size after antegrade endopyelotomy: an experimental study in the porcine model.
OBJECTIVES: To investigate the influence of two sizes of internal ureteral stents, 7 F and 12 F, on ureteropelvic junction (UPJ) healing after antegrade endopyelotomy. METHODS: A right UPJ stricture was created in 10 pigs using an open surgical retroperitoneal approach. This model of obstruction consists of initially bridging the UPJ with a Terumo guide wire through an upper third ureterotomy and securing two 2.0 chronic gut ties around the UPJ over the guide wire and a 6 F ureteral catheter. The ureteral catheter is then withdrawn and the guide wire left in situ coiled up within the lumbar wall and fixed to the urogenital opening. Eight days later, each UPJ stricture was incised percutaneously using the invagination technique. Five pigs received a 7 F double-pigtail ureteral stent, while the remaining 5 pigs received a 12/7 F internal endopyelotomy stent. These stents were removed 1 week later. Retrograde ureteropyelography was performed at three months and the UPJ were examined grossly and harvested for histologic studies. RESULTS: One of the 5 pigs in each study group developed a recurrent stricture. The two groups were not statistically different in terms of histologic findings, although fibrosis of the muscle layer was more pronounced in the 12 F group. CONCLUSION: The use of a large caliber stent after experimental antegrade endopyelotomy does not provide any advantage over the use of a smaller easily positioned 7 F stent.
Animals↗
Laparoscopic fibrin glue ureteral anastomosis: experimental study in the porcine model.
Laparoscopic suturing is still difficult and time-consuming. The aim of this study, using the porcine model, was to evaluate the feasibility, safety, and efficacy of laparoscopic fibrin glue ureteral anastomosis without stay sutures for approximating the ureteral ends. In five pigs, after bilateral cystoscopic insertion of a 7F ureteral catheter, each upper ureter was laparoscopically dissected free and transected with scissors. The ureteral ends were then approximated with two atraumatic grasping forceps, and the fibrin glue was applied over the anastomotic site using a specially designed catheter (Duplocath). After waiting 5 minutes for the sealant to adhere, the forceps were removed, and the anastomotic site was examined for any early disruption. The ureteral stents were then pulled back to the distal ureter, and retrograde ureteropyelography was accomplished bilaterally in order to assess the immediate patency of the anastomoses. The animals were sacrificed and the ureteral anastomoses surgically removed for histologic examination. The operative time after insertion of the trocars averaged 15 minutes for each anastomosis, and no early disruption was observed after withdrawal of the grasping forceps. Immediate ureteral fluoroscopic patency was achieved in all 10 ureteral anastomoses, without leakage in 8 and with minimal leakage in 2. Histologic examination revealed a mild inflammatory reaction in the serosa with no modifications of the mucosa or the muscularis. Subsequently, two pigs were subjected to the same procedure bilaterally and not sacrificed. These two animals died with enormous urinomas on postoperative days 6 and 8. In each case, the anastomotic site was completely disrupted on one side, while the other side remained grossly patent. However, histologic examination of these latter anastomoses revealed no real coaptation of the ureteral ends, while demonstrating complete eversion of the mucosa. In conclusion, fibrin glue ureteroureterostomies, although easy to accomplish, are not safe enough to be used without stay sutures in laparoscopic surgery.
Anastomosis, Surgical↗
Argon laser induced autofluorescence may distinguish between normal and tumor human urothelial cells: a microspectrofluorimetric study.
PURPOSE: To assess the ability of argon laser-induced autofluorescence spectroscopy (LIAFS) to discriminate normal from tumor human urothelial cells. MATERIALS AND METHODS: Emission spectra of single living cells excited at 488 nm. have been studied with confocal microspectrofluorimeter. RESULTS: Cellular autofluorescence appeared as a broad band with a maximum in the same "green" spectral range, 550 to 560 nm., probably corresponding to oxidized flavoprotein emission. However, the maximum autofluorescence intensity of normal urothelial cells was much higher, 10 times (p<0.0001) that of any of the tumor cell types tested. CONCLUSIONS: These results, suggesting a significantly reduced oxidized flavoprotein concentration in tumor urothelial cells, should prompt us to evaluate argon LIAFS as a potential tool to detect occult urothelial severe dysplasia and carcinoma in situ.
Argon↗
Laser induced autofluorescence diagnosis of bladder tumors: dependence on the excitation wavelength.
PURPOSE: We assessed the ability of laser induced autofluorescence spectroscopy to distinguish neoplastic urothelial bladder lesions from normal or nonspecific inflammatory mucosa. MATERIALS AND METHODS: Three different pulsed laser excitation wavelengths were used successively: 308 nm. (xenium chloride excimer laser), 337 nm. (nitrogen laser) and 480 nm. (coumarin dye laser). The excitation light was delivered by a specially devised multifiber catheter connected to a 1 mm. core diameter silica monofiber introduced through the working channel of a standard cystoscope with saline irrigation. The captured fluorescence light was focused onto an optical multichannel analyzer detection system. Device performance was evaluated in 25 patients after obtaining consent and immediately before transurethral resection of a bladder tumor. Spectroscopic results were compared with histological findings. RESULTS: At 337 and 480 nm. excitation wavelengths the overall fluorescence intensity of bladder tumors was clearly decreased compared to normal urothelial mucosa regardless of tumor stage and grade. At the 308 nm. excitation wavelength the shape of the tumor spectra, including carcinoma in situ, was markedly different from that of normal or nonspecific inflammatory mucosa. No absolute intensity determinations were required in this situation, since a definite diagnosis could be established based on the fluorescence intensity ratio at 360 and 440 nm. CONCLUSIONS: This spectroscopic study could be particularly useful to design a simplified autofluorescence imaging device for detection of occult urothelial neoplasms.
Carcinoma in Situ↗
[Non-surgical instrumental treatment of benign hypertrophy of the prostate].
Although surgery remains the treatment of reference for symptomatic benign hypertrophy of the prostate, the requirement for locoregional anaesthesia, the risk of complications and the major financial burden for the health care system have led to research into alternative therapies. Basically two categories have been developed, thermal and mechanical. The sensitivity of the hypertrophic prostate tissue to heat depends both on histology and blood flow. It is generally accepted that temperatures < 60 degrees C do not cause definitive tissue damage, that those > or = 60 degrees C lead to necrose of the coagulated tissue and > or = 100 degrees C cells are vaporized producing tissue debris. Currently, thermoablation (temperature > 60 degrees C) is the only thermal alternative which gives results within a range comparable with classical surgery. The more simple techniques (microwaves, focalized ultrasounds, interstitial radiofrequency waves, lateral or interstitial laser) have the disadvantage of aggravating symptomatology in certain patients, limiting indications. More sophisticated techniques (contact radiofrequency, contact laser) still need improvement to reach the level of surgery. Mechanical alternatives include resorbable and non-resorbable stents and dilatation. Stents are a particularly promising route but have the inconvenience of being difficult to implant and sometimes leading to complications (infection, incrustation, calcification). Dilatation procedures have been tried for many years using various methods of control, but results have been disappointing to date. Surgery thus remains the reference treatment for benign hypertrophy of the prostate, but ongoing research emphasizes the need for successful alternatives.
Catheter Ablation↗
[The role of the laser in urology].
There is currently a renewed interest in laser in the field of urology, essentially for the treatment of benign prostatic hypertrophy, as a result of recent developments in the field of fibres. Laser is light coherent in time and space emitted continuously or in pulses. Only its thermal and photochemical properties are used in urology. Endoscopic coagulation of superficial bladder tumours by Nd YAG laser does not seem to be better than classical endoscopic resection, at the present time, as although it is less haemorrhagic, it does not decrease the recurrence rate. Photochemotherapy of bladder carcinoma in situ still constitutes a complex treatment protocol reserved for specialized centres. Lastly, upper urinary tract tumours can be treated by Nd YAG laser coagulation, in rare indications which are the same as those of ureteroscopic or percutaneous resection. The recent development of lateral firing laser fibres and contact tip fibres has led to a renewed interest in laser in benign prostatic hypertrophy. Two different techniques have been proposed: Nd YAG laser coagulation under direct visual or ultrasound control (TULIP), which gives delayed objective results (two or three months) and contact tissue vaporization (Nd YAG, diode), whose effects are more immediate. In both cases, intraoperative bleeding is minimal and the length of hospital stay is decreased, but the duration of urine drainage remains to be defined. Endoscopic pulsed laser urinary lithotripsy (dye, Ho YAG), although effective and atraumatic, is not justified at the present time because of its high cost compared to mechanical percussion lithotripters. Lastly, laser treatment for urethral stricture has not been found to be superior to classical scalpel urethrotomy and laser tissue welding is still in the experimental stages. In conclusion, laser technology, especially fibers, has currently reached an important phase of development with applications for urological disease, essentially in the treatment of benign prostatic hypertrophy in order to reduce the morbidity of classical endoscopic resection. However, other urological applications of laser could be validated in the near future due to the development of less expensive lasers (diode) and/or with multiple functions (Ho YAG).
Humans↗
[Initial clinical experiences with the Storz Modulith SL 20 lithotripter: the results 3 months after a single session].
The objective of this study was to evaluate the performances of the Storz Modulith SL20 lithotriptor. Fifty patients with a total of 52 renal (31) or ureteric (21) stones were treated, in a single session, between June and October 1993. The mean stone diameter was 7.9 mm. All patients were reviewed after 3 months. The complete success rate, with radiological cure, was 65% at 3 months. The partial success rate, defined as fragmentation of the stone with persistence of residual fragments less than 3 mm in diameter, not requiring further treatment, was 12% at 3 months. The failure rate at 3 months was 23%. The commonest complication was renal colic in 12 patients (24%). Two patients developed an extrarenal haematoma. The Modulith SL20 possesses a good detection system: firing is well tolerated under minimal analgesia. Our success rates are slightly lower than those obtained by other teams using the same apparatus.
Adolescent↗
[Endoscopic retropubic colpopexy for stress urinary incontinence in women (Stamey's operation). 55 cases].
Fifty five women with a mean age of 59 years, suffering from urinary stress incontinence (U.S.I.), were treated by endoscopic percutaneous cervicocystopexy (Stamey's operation), 39 patients (71%) suffered from pure U.S.I. and 16 (29%) presented a combination of stress and urge incontinence. Bonney's manoeuvre was positive in every case. With a mean follow-up of 21.5 months, 30 patients (58.8%) were completely continent, 9 (17.6%) presented occasional incontinence with intense effort, 12 (23.5%) were failures and 4 patients were lost to follow-up. The complications were minimal. The results were less favourable in patients with a history of pelvic surgery, particularly for correction of U.S.I., associated urge incontinence, detrusor hyperactivity or low urethral closure pressure, although one half of the patients in this group were nevertheless cured. Stamey's operation is a simple, reliable, easily reproducible technique which gives good results at the cost of low morbidity, short hospital stay and a low cost.
Adult↗
Extraperitoneal endosurgical lymphadenectomy with insufflation in the staging of bladder and prostate cancer.
A new technique of endosurgical pelvic lymph node dissection was performed for the staging of 10 prostate and 8 bladder cancers. The technique, involving an exclusive extraperitoneal space development with CO2 insufflation, is described in detail. Using the standard endosurgical (laparoscopic) equipment, we performed a complete bilateral ilio-obturator lymph node dissection in 15 patients (83%). In the remaining three patients, because of technical difficulties, only unilateral dissection was performed. The average operating time was 84 minutes. Morbidity was low (one instance of sepsis). Prospective assessment of CO2 homeostasis showed that arterial CO2 pressure (PaCO2) increased significantly but could be controlled by increasing minute ventilation output. Our results show that perioperative assessment of end-tidal CO2 partial pressure is necessary and sufficient for the adaptation of minute ventilation output. Two patients with prostate cancer had positive nodes. No intraoperative or postoperative morbidity related to the procedure was observed in patients submitted to radical surgery. Extraperitoneal endosurgical pelvic lymphadenectomy with CO2 insufflation is a rapid, safe, and effective method in the staging of urologic pelvic malignancies and represents an alternative to traditional open surgery as well as to conventional transperitoneal laparoscopic lymphadenectomy.
Carbon Dioxide↗
[Urodynamic ultrasonography in the management of urinary disorders in women].
The authors report the preliminary results of a study on the use of perineal sonography with a vaginal probe as a complement to urodynamic investigation, in patients with stress urinary incontinence or other urinary symptoms. This technique seems useful especially in stress urinary incontinence to precise the existence and the importance of bladder neck hypermobility, and in the evaluation of post-opérative outcome after surgical suspension of the bladder neck.
Female↗
[Sub-urethral diverticulum in women. Apropos of 6 cases].
Six female patients with a mean age of 40 years presenting with a suburethral diverticulum were treated between August 1990 and October 1992. The commonest functional symptoms were recurrent urinary tract infections (2/3 of cases) and post-voiding urethral discharge (1/2 of cases). Clinical examination revealed a tender anterior vaginal mass in only one half of cases. Only retrograde and voiding cystourethrography and transvaginal ultrasonography always demonstrated a direct or indirect image of the diverticulum. The suburethral diverticulum was resected via a transvaginal approach in the ventral supine position after sterilisation of the urine by prolonged antibiotic therapy. Urine drainage was generally ensured by a suprapubic catheter allowing antegrade cystography on the 15th day, prior to clamping then removal of the catheter. All but one of the patients immediately regained satisfactory micturition without dysuria or stress incontinence. Restoration of micturition was delayed in one patient with feelings of incomplete bladder emptying, but she urinated normally at three months. Postoperative imaging (retrograde and voiding cystourethrography, transvaginal ultrasonography) demonstrated resolution of the diverticulum in 5 cases. One patient had persistent signs of a small, residual diverticulum on antegrade cystography on the 15th day. Suburethral diverticulum is a rare disease of middle-aged women for which transvaginal surgical excision in the ventral supine position gives very good results.
Adult↗
[Urinary lithiasis and pregnancy].
The incidence of renal stones in pregnant women is 1 in 1500. The diagnosis may be made more difficult by the particular anatomo-physiological conditions of pregnancy. Ultrasonography is not always sufficient to localise the stone and can be completed by intravenous urography, which is not contraindicated in pregnant women. In more than one half of cases, the stones are eliminated spontaneously during conservative treatment. The urologist may need to intervene in the case of complicated stones: internal or external urinary diversion is generally sufficient to palliate the problem until term. As extracorporeal lithotripsy is contraindicated in pregnant women, some authors recommend ureteroscopy or percutaneous nephrolithotomy when radical treatment is required. Surgical treatment is very rarely indicated.
Cystoscopy↗
[Extraperitoneal endoscopic lymph node dissection with insufflation in the staging of bladder and prostate cancer].
Endoscopic pelvic lymph node dissection was performed in 30 patients as part of the staging of prostate (19) or bladder (11) cancers. The technique, using a procedure of detachment of the retroperitoneal space with CO2 insufflation, is described. Complete bilateral dissection of the ilio-obturator lymph nodes was performed in 24 patients (80%) using conventional laparoscopic surgical equipment. Only a unilateral dissection could be performed in 6 other patients because of technical difficulties. The mean operating time was 72 minutes. The intraoperative and postoperative complications consisted of 2 venous injuries and one infection. A prospective study of systemic diffusion of CO2 demonstrated that the blood Co2 level increased significantly during the procedure, but could be controlled by adaptation of the ventilation. Postoperative monitoring of blood CO2 levels using a capnograph is recommended. 4 out of 30 patients (13%), 2 with prostate cancer and 2 with bladder cancer, had lymph node metastases. Amongst the other 26 patients, 12 were treated by radiotherapy (bladder cancer), 12 patients underwent perineal prostatectomy and 12 others underwent retropubic prostatectomy (5) or prostatocystectomy (7]). No intraoperative and postoperative morbidity related to endoscopic lymph node dissection was observed in the patients subsequently undergoing a radical operation. Endoscopic retroperitoneal lymph node dissection with CO2 insufflation is a rapid, safe and effective technique for staging of malignant pelvic tumours and constitutes an alternative to open surgery and to endoscopic transperitoneal surgery.
Endoscopy↗
[Value of voiding ultrasonography combined with urodynamic studies in the assessment of vesical sphincter dyssynergy].
Fifteen paraplegic patients all presenting with vesico-sphincteric dyssynergia underwent, between January and September 1990, a urodynamic and electromyographic examination combined with pre-voiding or voiding transrectal ultrasonography. The ultrasound apparatus used was a Siemens Sonoline SL1 with a MHz linear intracavitary probe giving a strictly longitudinal plane of section. The urodynamic apparatus used was a Wiest 6000 with a Böhler 7 F urethral catheter and an electromyography needle-electrode implanted in the striated sphincter. This type of ultrasonography provided a precise and dynamic image of the bladder neck, prostatic urethra and external striated sphincter during the phases of filling and voiding. Spastic contractions of the striated sphincter during detrusor contraction were observed in 8 patients with an intermittent and jerky urinary stream. In 7 patients, the striated sphincter remained closed during detrusor contraction and only opened briefly as soon as detrusor contraction decreased, allowing only a weak and transient flow. By allowing the direct visualisation of the sphincteric obstruction during voiding, dynamic transrectal ultrasonography clearly confirmed the diagnosis of vesico-sphincteric dyssynergia. In contrast with classical voiding cystourethrography, this is a non-invasive, inexpensive and, most importantly, repeatable technique, as it does not require any irradiation. It is therefore suitable for drug evaluation trials, particularly of alpha-blockers and to assess one of the many treatments proposed in vesico-sphincteric dyssynergia.
Adult↗
[Endo-surgical dissection of the upper urinary tract through the retroperitoneal and transperitoneal route: an experimental study with pigs and cadavers].
In order to define the best method for endosurgical dissection of the upper urinary tract, an experimental study comparing the retroperitoneal and transperitoneal approaches was performed. Between September 1991 and February 1992, 15 female pigs and 8 human cadavres underwent endosurgical dissection of the upper urinary tract. The retroperitoneal approach was used in 8 pigs and 5 cadavres. In the lateral supine position, the retroperitoneum was insufflated at the lower pole of the kidney, via a 2 cm cutaneo-muscular incision, followed by a blind dissection with the finger to create a space in the retroperitoneal fat. Four trocars were inserted into the retroperitoneal space allowing dissection of the ureter, kidney and its vascular pedicle. The renal vessels and the ureter were then clipped or stapled with the endo-GIA then sectioned. The operation was successfully performed in all of the pigs with a mean operating time of 2 hours. Complications were limited to two peritoneal effractions. Retroperitoneal endosurgical dissection was much longer and more difficult to perform on the cadavre (mean operating time: 3 hours). Satisfactory retropneumoperitoneum was never able to be obtained due to the large amount of retroperitoneal fat and the proximity of the twelfth rib and posterior iliac crest interfered with the insertion of the trocars and made dissection more difficult. The transperitoneal approach was performed in 7 pigs and three cadavres. In the lateral supine position, after creating pneumoperitoneum using a Veress needle, 4 trocars were inserted into the peritoneal cavity. Toldt's fascia was gripped and incised allowing retraction of the colon towards the midline, thereby exposing the renal region. The ureter and the renal vessels were dissected. The renal artery and vein were then clipped or stapled with the endo-GIA then sectioned, while the ureter was clipped and sectioned. The complications of the transperitoneal route were: an injury to the small intestine during insertion of a trocar and haemorrhage due to accidental section of a lower pole renal artery, which was able to be controlled by application of clips. In the pig, the transperitoneal approach was as simple to perform as the retroperitoneal approach and the mean operating time was the same (two hours).(ABSTRACT TRUNCATED AT 400 WORDS)
Animals↗