Taking up again inquiries already known in the past, documents of pathological anatomy of his own person experience, and facts of embryology, the authors explain the etiology of the obstructive malformation of pyelo-ureteral function the etiology brings out two phenomena: --The insufficient hollowing of the cephalic end of the ureteral bud, which is initially grooved, when it detaches itself from the Wolffian canal, can transform itself into a full cellular cord which secondarily forms a groove after 23 mm stage.--The insufficient vascularization of the ureter just below the pelvis because of an abnormal anatomical disposition which causes displacement of the longitudinal uretero-pelvic arteries to a point clearly below the ureteropelvic junction. There an ischemia impedes the muscular development of the ureter just below the pelvic of which the wall becomes more sclerotic and fibrous than muscular. Thus a defect in the grooving of the ureteral bud and an arterial blood deficit results in a congenital ureteral stenosis. Pathological anatomical documents illustrate this theory from which flow two imperative technics; the necessity to eliminate the initial obstructive ureteral segment; care to protect the pelvic vessels which will have to vascularize the ureter which will be anastomosed to the cut edge of the pelvis.
After recalling the difficulty of comparing the various series published in the literature. in the absence of common histological criteria. the authors review the records of patients with a class III or IV carcinoma of the bladder. strictly confined to the musoca, whether or not the basal membrane was damaged (stage O or A), with the exclusion of all cases with histological invasion of the muscularis and any other clinical or radiological signs of deep infiltration: 135 records with a follow-up of at least 6 months. This study led to the following findings: - One third of the tumours progressed to deep infiltration and/or metastases. - This unfavourable course occurred. in almost 3/4 of cases. during the 2 years following the clinical presentation of the tumour. - Such a grave course may develop for tumours not affecting the basal membrane without it having always been possible to define the stage of infiltration of the chorion. - A metastasis may develop while the tumour remains superificial. - 5 out of these 135 patients developed 2 or more extra-urological carcinomas. - Two thirds of these superifical tumours did not invade the muscularis during the period of observation which in 41 cases exceeded 6 years. - The difficulty lies in detecting which superificial malignant tumours of the bladder will not recur. which will recur superficially (where preservation of the bladder is automatic) and which will recur with infiltration and/or metastases. where an aggressive therapeutic attitude should be adopted before any infiltration or diffusion of the tumour manifests itself. - Tumours which did not recur were unifocal. - All multifocal tumours treated conservatively recurred.
The authors emphasise the value of bilateral posterior iliac oestotomy in facilitating aponeurotic and cutaneous closure of ectopia vesicae. The osteotomy cuts the wing of the iliac bone above the greater sciatic notch 2 cms lateral to the sacroiliac joint. The new point made by the author is the use of an external fixation device the pins of which are implanted only in the iliac crest in the still young child, whilst in the adolescent a more solid method of fixation involves in insertion of additional pins in the pubis (taking care to avoid the femoral vessels). The recommended operative schedule is as follows: 1) Simple posterior iliac osteotomy. 2) Bed rest for 8 to 15 days until cutaneous healing of the iliac incisions. 3) Urological phase (which for the author consists of excision of the plaque with ureterocolic implantation) with aponeurotic closure (using eliptical strips fashioned from the rectus sheath) and simple cutaneous closure without any traction because of the osteotomies. 4) Insertion of external fixation device at the end of the urological phase. This is supported by 2 cases reports with and uncomplicated postoperative course from both a urological and orthopaedic standpoint.
The authors underline the frequency with which trichomoniasis is located in the prostate. In these cases the parasite is rarely in its trophozoite form but has a circular shape which resembles the resistant pseudocystic type. They are found by phase contrast microscopy after staining with 1% cresyl blue which makes the difference with white blood cells. Out of a total of 178 men presenting with urethroprostatic signs (urethral discharge and burning), sterility with oligospermia, or a history of dyspareunia, the circular type of trichomoniasis was found in 40 (22%) of the cases, with urethritis in 26 cases, and prostatitis in the other 14 patients. Two courses of treatment, at one month's interval, with Tinidazole (2 tablets daily for 6 days) or Nimorazole (2 tablets daily for 8 days) produced healing in 4 cases with urethroprostatic effections, disappearance of dyspareunia in 2 out of the 3 cases treated, and return of fertility in 3 out of 7 patients. An up-to-date list of references is given.
The sixth report of the "Diaphane Dialyse Informatique" Program concerns 2,518 adult patients (age 15 and over) treated by chronic hemodialysis or hemofiltration in 33 French dialysis centres between June 1972 and December 1978. 1) The number of centers participating to the program is progressively increasing. Overall duration of follow-up represents 4,192 patient-years, allowing precise evolutive studies of terminal renal failure treated by hemodialysis. 2) Mean age at start of treatment continues to increase. Among 709 patients who started treatment in 1977-1978, 8,8 p. 100 of men and 11 p. 100 of women were over 69 years old. 3) Patients with diabetic nephropathy represent 4,4 p. 100 of all patients dialyzed between 1972 and 1978 and 5,9 p. 100 of the patients starting treatment in 1977-1978. 4) The percentage of patients temporarily treated by peritoneal dialysis before hemodialysis decreases from 32,9 p. 100 in 1973-1974 to 15,9 p. 100 in 1977-1978. 5) In 1978, 65,3 p. 100 of patients are dialyzed 3 times a week with a mean weekly duration of 14,0 h for male and 12,9 for female. 73 p. 100 of the patients are dialyzed during the night. 6) Disposable parallel plate hemodialyzers (71,8 per cent of dialysis sessions in 1978) and hollow fiber hemodialyzers (11,6 per cent) progressively replace disposable coil dialyzers and non disposable Kiil dialyzers. 7) Transient hypotensive episodes during dialysis sessions remain the most frequent complications (21,7 per cent of sessions in 1978). Transient hypotensive episodes are more frequently observed with coils than with parallel plate hemodialyzers or with hollow fiber dialyzers. 8) Mean diastolic blood pressure (DBP) +/- SD is 101,9 +/- 21,7 mmHg at start of dialysis and 81,4 +/- 11,8 mmHg when dialysed. During the course of treatment 28,7 per cent of the patients receive long term antihypertensive treatment. In spite of dialysis and antihypertensive treatments 11 per cent of all patients followed up maintain DBP greater than or equal to 95 mmHg. 9) Viral hepatitis remain the most prominent infectious problem with 30 per cent of patients being chronic Hbs antigen carriers. 10) Annual death rate calculated in the 2,518 patients dialyzed between 1972 and 1978 (78/1000) is 12 times superior to the death rate of the French population, adjusted for sex and age to the dialysis population. 43,1 per cent of deaths are of cardiovascular origin. Risk factors for overall mortality are age, sex (male), existence of a vascular or diabetic nephropathy, twice weekly dialysis strategy, elevation of systolic or diastolic blood pressure during the course of dialysis treatment, hypocholesterolemia and to a lesser extent hypotriglyceridemia. On the contrary, hypercholesterolemia, hypertriglyceridemia and hyperuricemia do not appear as risk factors for overall mortality or cardiovascular mortality. These results plead for a perfect control of hypertension and to the extension of thrice weekly dialysis for the whole population of patients treated by maintenance hemodialysis.
