Succes des auto-injections intra-caverneuses de Prostaglandine E1 dans des cas d’impuissance par dysfonction veino-occlusive rebelles a la Papaverine

Erectile failure due to veno-occlusive dysfunction (venous incompetence) is generally thought to be resistant to auto-intra-cavernosal injection therapy. Because PGE1 recently emerged as a drug more potent than Papaverine, we tested it in 26 impotent patients presenting this condition. All of them had abnormal Nocturnal Penile Tumescence and Rigidity recording, a non rigid response to intracavernosal injection (ICI) of 80 mg papaverine, and abnormal pharmacocavernosometry (maintenance flow rate exceeding 30 ml/mn after 80 mg of papaverine). When tested with 20 μg of PGE1 and observed for 30 mn in our office, 16 out of 26 developped a rigidity seeming consistent with vaginal intromission, including full rigidity in 2. In several additional patients, partial or full rigidity was achieved after leaving the center. The patients who did not develop rigidity were retested with high dosages. Finally 19/26 developped a rigidity seeming consistent with vaginal intromission within 2 hours of an ICI of 20 to 60 μg of PGE1. Seven of those patients elected to try auto-ICI of 20 to 60 μg of PGE1. The treatment failed in 2. The 5 other ones were able to have intercourse after each ICI, but not without ICI. 2 achieved full rigidity, and 3 only partial rigidity. Papaverine failed in everyone. Until now they have performed about 250 ICI of PGE1, and the maximum follow-up is 18 months. No complications has been observed, including no priapism and no fibrotic nodule. PGE1 widens the possibilities of the auto-ICI therapy. It seems the first medical treatment effective in case of erectile failure due to severe veno-occlusive dysfunction, or at least the most powerful.     

Place de la prostaglandine E1 intra urétrale dans le traitement de l’impuissance érectile

Transurethral alprostadil (Muse) is an effective and safe treatment of erectile dysfunction. Nevertheless, the result after its exit on the US market two years ago were not as good as the investigational studies which claimed aroud 60% of sccess rate. In the litterature success rate were between 35% and 40% all together. The Muse had a better acceptance than the intra-cavernous injection despite a lower success rate (40 % v.s 75 %). Since Sildenafil came on the market, it seems that the place of Muse is reduced because comparative studies give better results for Sildenafil than Muse (70 % v.s 40 %) and of course with a better acceptance. Nevertheless there are absolute and relative counter-indications to the Sildenafil which could benefit to the treatment by Muse. All the comparative studies, IIC, v.s Muse and sildenafil v.s Muse will be studied in this article. In conclusion Muse should be used as an alternative and should remain an effective tool that must be available to all physicians dealing with erectile dysfunction, perhaps using new formula with a combination of alprostadil with an alpha-blocker.     

Facteurs psychologiques et conjugaux de l’impuissance: Toujours d’actualite

Although many cases of impotence are associated with “hidden” organic lesions undetectable by normal clinical assessment, and only detectable by paraclinical examination, it is obvious that interactions between psychological and factors often prevail in such cases. The paper describes the main psychological factors implicated in impotence, as well as recent data wich start to provide an explanation of the mechanisms by which psychological factors perturb sexuality. At the peripheral level, stress-induced sympathetic hyperactivity probably inhibits erection by causing contraction of the cavernosal smooth muscle. At a central level, animal experimentation and results from the pharmacological treatment of human impotence, suggest that psychological factors might inhibit sexual drive, and perhaps erection, through α 2—adrenergic receptors and the hypersecretion of endogenous opioids. These data open some highly stimulating pharmacological pespectives.     

Impact diagnostique de la TEMP–TDM dans l’exploration des tumeurs endocrines

Image fusion using single photon emission computed tomography–computed tomography (SPECT–CT) associates functional and morphological images. This study evaluates the added value of SPECT–CT, obtained with a hybrid SPECT–CT gamma camera, on anatomic localization and diagnostic impact in assessment of endocrine tumours and pheochromocytomas.MethodSix months prospective study was undertaken including 33 consecutive exams encompassing 20 Somatostatin Receptor Scintigraphies (SRS) and 13 ¹²³I-meta-iodo-benzyl-guanidine (MIBG) scans. Two experienced nuclear medicine physicians independently analysed independently planar and SPECT images in a first time, then, SPECT–CT fused images in a second time. They evaluated two parameters: SPECT–CT impact on anatomic localization (LA) and its diagnostic impact (ID). Each parameter was scored according three levels of evaluation.ResultsAn added value of SPECT–CT images was evidenced in 55% of cases on the anatomic localization and in 41% of the patients on the diagnostic impact. Therefore, a more important benefit was noted when SPECT was positive (LA: 90%; ID: 70%) than when it was negative (LA: 15%; ID: 8%). Furthermore, the added value proved higher for the SRS compared to MIBG scans.ConclusionSPECT–CT fusion images obtained by a hybrid system is more relevant to determine anatomic localization and more accurate than SPECT alone, particularly in the assessment of endocrine tumours. The added value of SPECT–CT seems to be lower for MIBG scans in the assessment of pheochromocytomas.     

Indications d’une étude méiotique dans l’infertilité masculine

Meiotic investigation is rare in male infertility. Now, some mutations affecting spermatogenesis exhibit characteristic cytogenetic figures, whereas testicular histology does not show specific aspects of this pathology. In male infertility with abnormal somatic caryotype, the aim of meiotic survey is to find the mechanisms inducing spermatogenic failure, and thus to lead to a better understanding of normal spermatogenesis. In addition to cytogenetic techniques, meiosis is also investigated by electron microscopy and molecular biology. Also, we think that a larger place must be grant to meiotic study in male infertility evaluation when the indication of testicular histopathology was settled.     

Intérêt d’une semi-quantification et d’une analyse statistique automatique pour l’interprétation de la tomoscintigraphie cérébrale de perfusion dans la maladie d’Alzheimer

IntroductionAs the visual interpretation of the brain perfusion SPECT for the diagnosis of Alzheimer's disease might be difficult, it is wished to benefit from techniques allowing to improve the diagnostic accuracy especially for the inexperienced readers.Materials and methodsThree readers retrospectively interpreted 77 ^99mTc-ECD SPECT studies within the context of suspected neurodegenerative disease. The probability of Alzheimer's disease was quoted from 1 to 5, and the optimum sensitivity and specificity values were determined from ROC curves. The readers also attributed a hypoperfusion score to 13 brain regions; a diagnosis was obtained from this semi-quantification using a simple logic rule. The SPECT scans were also analyzed using the Planet Neuro software and a diagnosis was reached from a threshold for 2 of the 90 analyzed regions. The gold standard was established by a comprehensive neurological evaluation with at least 5 years of follow-up.ResultsThe sensitivities and specificities of the three readers were 50 %, 56 %, 28 % and 76 %, 83 % and 90 %, respectively. Using the semi-quantification they were 50 %, 67 %, 61 % and 54 %, 85 %, 69 %. The results of two readers were more in agreement. Using the automatic quantification, sensitivity was 78 % and specificity 81 %.ConclusionThe semi-quantification seems to ameliorate the results of and the agreement between certain readers. However, the automatic quantification seems to be the only way of assisting all of the readers to improve their diagnostic performances.     

Hyperparathyroïdie par autonomisation d’une autogreffe de parathyroïde dans l’avant-bras : le rôle de la scintigraphie

We report the case of a 36-year old patient, referred for parathyroid imaging in a context of hyperparathyroidism. He had a history of congenital bilateral renal hypoplasia treated by four successive transplantations, the last one in July 2011. In 1990, a total parathyroidectomy with autologous parathyroid tissue graft in the right forearm has been performed for secondary hyperparathyroidism. However, hypocalcaemia persisted (2.78 mmol/L), associated with high levels of PTH (1329 pg/mL), even after the last renal transplantation. Neck ultrasound and parathyroid scintigraphy images did not show any cervical or thoracic ectopic parathyroid tissue, while right forearm incidences revealed a high uptake focus corresponding to the autonomisation of the parathyroid transplanted tissue. A brief review of the literature evaluating the benefits of this type of intervention is presented.     

Place de l’imagerie dans l’évaluation de l’efficacité des traitements dans le cancer du sein

This paper describes, from the current literature, the role of various imaging methods to assess the response to therapy in breast cancer. Two different clinical situations are considered: neoadjuvant chemotherapy of locally advanced breast cancer and the metastastic breast cancer. Significant clinical data are available for three criteria: the volume of the tumour, the uptake of fluorodeoxyglucose using PET and the perfusion of the tumor evaluated either by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) or by PET using ¹⁵O water. ¹⁸F FDG PET allows prediction of the response after one or two cycles of neoadjuvant chemotherapy. New approaches will offer opportunities to refine the role of imaging in monitoring the response to chemotherapy. PET using thymidine as biomarker is promising in assessing the tissular proliferation. Estrogen analogs could be used to predict hormonally responsive breast cancer. Many other approaches, although less developed, might offer new insights in the response to therapy of breast cancer like magnetic resonance spectroscopy or optical imaging of hemoglobin oxygenation. Imaging also offers potential of monitoring the down-regulation of specialized receptors of the cell membrane in response to treatment: the most studied receptor in preclinical model has been the human epidermal growth factor receptor type 2 (HER2). Integrin, a family of cell adhesion receptor, is also an important target for imaging. Apoptosis, multidrug resistance and hypoxia can also be studied using appropriate biomarkers. To allow reliable multicenter trials of new drugs, these different imaging approaches still require an improved standardization of image acquisition and processing.     

Rôle du sens de l’effort dans le syndrome d’influence

Centrally generated signals from premotor areas play a key role in voluntary muscle force perception. Indeed, sensations of effort, rather than sensations of intramuscular tension, make it possible to evaluate the intensity of willed muscle forces. We suggest that the sense of effort is involved in agency, the cognitive process by which one is aware of one’s actions. We argue that effort awareness accompanies each action and is the key component of the feeling of will. In delusions of alien control, patients with schizophrenia do not recognize some of their acts as their own and are convinced that they are under the control of someone else. Some experimental data suggest that delusions of control are related to an altered awareness of effort and an exaggerated awareness of afferent neural information, caused by neurological disorders in the frontal and parietal lobes. This impairment could lead to the inability to identify the author of an action. In this pathological condition, the cerebral state coding for “I intend to act” might move toward the state coding for “someone else intends to act”, even in the absence of another agent.     

Pour une approche psychosomatique de l’Andrologie

Through the opening offered by the psychosomatic approach, we encounter patients with all kinds of andrologic complaints, even quite unspecific ones. But we do know this mode of contact is particulary useful and fruitful when the troubles lean towards chronicity, or are linked to anxiety and/or depression, be that condition cause or consequence. As far as functional symptoms are involved, there is a specific value to this approach. The key-time of that consultant, i.e; psychosomatic andrology, will be described, with the particularity of a ?conversation” instead of the mandatory anamnesis, meanwhile in his life, the possibly perturbing psychological events, as well as an attempt to evaluate the patient’s behaviour. The richness of the clinical examination within this doctor’s induced environment of ?words” coupled to some therapeutic means will be summarized: drugs, somatic and psychological methods (meaning all kind of psychotherapic techniques: support, behaviourist, couple, psychoanalytic or psychoanalysis…) When symptom(s) tend towards chronicity, an emotional subjective life grafts itself on the anatomical substratum, thus creating the opening for psychoemotional affects. This is the core we try to attain and assess through the psychosomatic approach.     

Prevention de l’infertilite d’origine infectieuse chez l’adolescent

Some causes of infertility can be prevented, as is the case for infertility of infectious origin. Genital infections represent a major source of infertility. Prostato-epididymitis consecutive to an urinary infection can be prevented by identifying and treating prostatic localizations at an early stage of urinary infection. The prevention of sexually transmitted diseases (STD), which cause male and female infertility, is, at the moment, accomplished by the prevention of the sexual transmission of the HIV. Teenagers represent a target of choice for the educational campaigns promoting condom use. The role of physicians, especially when teenagers are asking for a contraception, must be complementary to the public health campaign to decrease the spread of HIV and other STDs.     

Performance de la 18FDG-TEP dans le dépistage de paragangliome chez des patients porteurs d’une mutation SDHx

ObjectiveTo evaluate the performance of ¹⁸FDG-PET/CT for detecting infra-clinic paraganglioma (PGL) in SDHx mutation carriers (relatives).Patients and methodsSixty-six patients, from 13 distinct families underwent a genetic testing on the SHD genes between 2003 and 2012. Among the 45 patients with a mutation, 30 with a ¹⁸FDG-PET performed at initial work-up were included in this retrospective study. A gadolinium-enhanced magnetic resonance angiography of the neck (angio-MR) was performed in all cases, a thoracoabdominal-pelvic contrast-enhanced computed tomography (TAP-CT) in 25 cases, a TAP-MR in 20 cases, a ¹²³I-metaiodo-benzylguanidine scintigraphy (¹²³I-MIBG) in 20 cases and a somatostatin receptor scintigraphy (SRS) in 20 cases. Gold standard was histologic or composite (confirmation by another imaging method and follow-up).ResultsA tumor was found in five subjects: 2 abdominal PGL, 1 pheochromocytoma and 2 PGL of the neck. The sensitivity of ¹⁸FDG-PET was 100 %, of SRS was 80 %, of ¹²³I-MIBG was 60 % and of anatomical imaging (association between angio-MR of the neck and TAP-CT and/or TAP-MR) was 100 %. Three false positive lesions were described: 2 with the ¹⁸FDG-PET imaging and 1 with the TAP-MR technique.Conclusion¹⁸FDG-PET/CT is an excellent tool for screening SDHx relatives and should be completed by an angio-MR of the neck if suspicion of abnormality. Association of angio-MR of the neck and TAP-MR has the advantage of being a non-irradiating imaging method but with limited access in some countries.     

Prevention de l’infertilite d’origine infectieuse chez l’adolescent

Some causes of infertility can be prevented, as is the case for infertility of infectious origin. Genital infections represent a major source of infertility. Prostato-epididymitis consecutive to an urinary infection can be prevented by identifying and treating prostatic localizations at an early stage of urinary infection. The prevention of sexually transmitted diseases (STD), which cause male and female infertility, is, at the moment, accomplished by the prevention of the sexual transmission of the HIV. Teenagers represent a target of choice for the educational campaigns promoting condom use. The role of physicians, especially when teenagers are asking for a contraception, must be complementary to the public health campaign to decrease the spread of HIV and other STDs.     

Étude de l’impact d’une correction d’atténuation par tomodensitométrie en scintigraphie myocardique

Myocardial perfusion SPECT is a routine for the assessment of patients with coronary artery disease (CAD). However, attenuation artifacts may decrease the specificity of the test. These artifacts can be corrected with an attenuation correction. We prospectively included 70 patients who underwent myocardial perfusion SPECT with (IRAC) and without (IRNC) attenuation correction using transmission CT imaging integrated in the acquisition system in patients with low prevalence of CAD. Automatic quantitative analysis with summed stress score (SSS) and rest (SRS) and summed difference score (SDS) was used as interpretation criteria. The results showed a specificity of 80% for IRAC and 56% for IRNC, a positive predictive value of 40% for IRAC and 23% for IRNC, without any significant change in sensitivity. An unpaired t-test showed no significant difference between the overall population and one where an artifact was corrected for heart rate and breath rate during the acquisition effort, the body mass index, chest and abdomen circumferences, and the ratio of these two parameters. Attenuation correction significantly improves the specificity of myocardial scintigraphy with no significant difference in sensitivity. The majority of corrections were for artifacts from the inferior wall in men. There is no correlation between the anthropomorphic and physiological parameters and the occurrence of an artifact of attenuation corrected with CT data.     

Place du scanner dans l’imagerie de l’hyperparathyroïdie primaire

Primary hyperparathyroidism is a biological diagnosis. The reference treatment is surgery. When minimally invasive surgery is considered, it is recommended to perform a cervical ultrasound and a scintigraphic examination to localize the hypertrophied parathyroid glands. The multiphasic scanner (4D CT) is a very effective examination to detect and locate precisely the parathyroid adenomas. The study of densities makes it possible to differentiate the adenoma from the thyroid and the lymph nodes that are the differential diagnoses. Without injection, the adenoma is more hypodense than the thyroid with a threshold set at 75 UH. On the early phase after injection, the adenoma appears very hypervascularized with a density > 114 UH. The ganglion appears hypovascularized with a density < 114 UH. In the late phase, there is a decrease in the density within the adenoma, while density within the ganglion increases. The parathyroid scan is indicated in case of negativity or discordance of the couple ultrasound scintigraphy. It is also strongly recommended, in case of persistence or recurrence of hyperparathyroidism after surgery, as well as to better study a parathyroid ectopy.     

Etude d’un modèle expérimental d’infection de l’appareil génital mâle

Injection of uropathogenic E. coli into the rat cauda epididymidis results in chronic epididymitis in 74.2% of cases, accompanied by necrotic orchitis (16.1% of cases) or non-infectious testicular lesions (45.2% of cases). Injection of killed bacteria caused the same noninfectious testicular lesions, most probably due to toxic damage. Injection of bacteria into the seminal vesicles caused a vesiculitis which regressed after seven days and disappeared progressively. Simultaneously, the prostate was invaded by polymorphonuclear leucocytes, an infection which persisted for more than three months. E. coli injection in association with bilateral castration gave rise to the formation of chronic vesicular abscesses. Examination of the male genital tract lymphatic system allowed explanation of the spread of infection from the epididymis to the testis, and from the seminal vesicle to the prostate. The epididymis is an organ with poor defense against against infection whereas the seminal vesicle is able, owing to the activity of its epithelium, to fight infection. On the other hand, prostatitis secondary to vesiculitis is immediately chronic.     

La consultation psychologique dans l’indication d’une prothèse pénienne : une expérience originale de complémentarité médicopsychologique

In the Center for the Study and Treatment of Male Sexual Dysfunction (CETISM) of our University Department of Urology, a psychological consultation is systematically provided when penile prosthesis implantation is considered by the patient ?? and the urologist ?? as a possible solution to his erectile dysfunction. This consultation has three key objectives: to identify ?? rare ?? cases of psychological contraindication, to complete the information already given to the patient during urologic consultations, and to explore the relational, emotional, cognitive and erotic aspects that could influence the decision-making and the integration of the prosthetic solution. It is also and especially to give to the man a central position, an active position, not only for the decision-making, but also for developing a life project which takes into account the decision (positive or negative), a position he often lost from the time he had become ??powerless??.