Souviens-toi. Processus de deuil,processus de création

ObjectivesThe authors set out to cast light on certain psychic mechanisms that help to give meaning to death, in particular via objects of great symbolic value, as links between the dead and the survivors.MethodsIn this clinical article using a heuristic methodology, we combine the analysis of a clinical situation of antenatal death, a paradigm of loss with a pathological risk, and that of the artistic creation of Michel Nadjar, linked to the genocide of the Jews.ResultsThe psychic processing of the loss of a loved one is accompanied by considerable psychopathological risk. While funeral rites, whether religious or lay, and the support of the family and the community often provide mourners with a framework that favours the achievement of the period of mourning, so as to continue living with the loss (rather than living with the deceased person), there are certain traumatic situations that make access to a non-pathological mourning process impossible.DiscussionThe authors reappraise the exclusiveness of Freud's mourning and melancholia model, and consider Winnicott's theoretical model of transitional phenomena to cast light on the psychic processes at work.ConclusionsThe creativity operating in the two situations maintains a certain distinction: sublimation for the artist, resurgence of transitional phenomena for the bereaved individual.     

后腹腔镜联合经尿道电切镜治疗上尿路移行细胞癌(附83例报告)

目的 探讨后腹腔镜联合经尿道电切镜治疗上尿路移行细胞癌的效果和安全性. 方法 2003年3月～2006年7月,我院采用后腹腔镜联合经尿道电切镜治疗83例上尿路移行细胞癌.经尿道袖状电切患侧输尿管口周围1.5 cm范围膀胱壁达膀胱外脂肪组织,采用后腹腔镜切除肾及全长输尿管.术后留置导尿管7 d.11例术后辅助放疗. 结果 83例手术均成功.手术时间115～205 min,平均156 min.术中出血50～150 ml,平均80 ml.无术中并发症.术后住院7～11 d,平均8.5 d.病理报告：82例上尿路移行细胞癌,1例肾盂上皮中～重度不典型增生.术后随访3～38个月,平均10.8月.术后12个月内行膀胱镜检查发现膀胱肿瘤6例,其中5例行经尿道膀胱肿瘤电切,1例行腹腔镜根治性膀胱全切术、左侧输尿管皮肤造口术.2例肾盂肿瘤（pT3 G3和pT2 G3）于术后3个月肝转移.2例输尿管中段肿瘤（pT3 G3和pT3 G2～3）术后6个月原位复发并肺转移.1例输尿管下段肿瘤（pT3 G3）术后6个月骨转移.失访1例.其余71例均未发现肿瘤复发、切口转移及远处转移. 结论 对于上尿路移行细胞癌,采用后腹腔镜联合经尿道电切镜行肾、输尿管全切及膀胱袖套状切除具有创伤小、安全、恢复快等优点,值得临床推广应用.     

Hand-assisted laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma.

OBJECTIVE: We report our experience with hand-assisted laparoscopic nephroureterectomy (HALN) for upper urinary tract transitional cell carcinoma and compare our results with a contemporary series of open nephroureterectomy (ON) performed at our institution. METHODS: Between August 1996 and May 2003, 90 patients underwent nephroureterectomy for upper-tract transitional cell carcinoma (TCC). Thirty-eight patients underwent HALN, while 52 had an ON. End-points of comparison included operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of hospital stay, pathologic grade and stage of tumor, and tumor recurrence. RESULTS: The mean patient age was 72.3 and 70.6 years in the ON and HALN groups, respectively. Mean operative duration was 243 minutes (ON) and 244 minutes (HALN), with an EBL of 478mL in the open group versus 191 mL in the hand-assisted group (P<0.001). No intraoperative complications occurred, but postoperative complications occurred in 4% and 11% of the ON and HALN groups, respectively (P=0.21). The mean hospital duration was 7.1 days (ON) versus 4.6 days (HALN) (P<0.01). No difference existed in the pathologic grade or stage distribution of urothelial tumors between the 2 groups. The mean follow-up was 51.0 months in the ON group and 31.7 months in the HALN group. Recurrence of urothelial carcinoma occurred in 50% of patients who underwent ON and 40% treated by HALN (P=0.38) at a median interval of 9.1 and 7.7 months, respectively, after surgery. CONCLUSION: Hand-assisted laparoscopic nephroureterectomy is an effective modality for the treatment of upper urinary tract urothelial carcinoma. Patients benefited from less intraoperative blood loss and a shorter hospitalization with an equivalent intermediate-term oncologic outcome compared with that of the open approach.     

腹腔镜与开放手术治疗上尿路移行细胞癌的对比研究

目的　评价联合尿道电切镜、腹膜后镜行肾输尿管切除术的临床效果。　方法　肾盂输尿管癌患者 4 4例 ,采用联合尿道电切镜、腹腔后镜行肾输尿管切除术 15例 (A组 ) ,开放性肾输尿管切除术 2 9例 (B组 )。对两组的临床疗效、术后恢复、费用及并发症等进行对比研究。　结果　A组术中出血量 (75 .1± 2 9.5 )ml、术后 (2 4 .1± 12 .6 )h肠功能恢复、(2 4 .3± 10 .5 )h下床活动、应用止痛药(3.0± 0 .8)d、静脉应用抗生素 (7.2± 3.1)d、术后住院 (6 .3± 1.2 )d、(2 8.0± 7.8)d恢复正常工作 ,明显优于B组 ,差异有显著性意义 (P <0 .0 1或P <0 .0 5 )。B组手术时间、手术治疗费用、住院总费用优于A组 ,差异有显著性意义 (P均 <0 .0 1)。A组并发症明显少于B组。两组随访 14～ 36个月 ,均未见肿瘤复发。　结论　联合尿道电切镜、腹膜后镜肾输尿管切除术与开放手术相比 ,疗效相当 ,创伤小、痛苦少、术后恢复快、并发症少 ,费用较高。     

P53、C-erbB-2基因蛋白和EGFR在泌尿系移行细胞癌中的表达及相互关系

应用免疫组化技术研究65例泌尿系移行细胞癌（包括47例膀胱癌和18例肾盂癌）组织中P53、C－erbB－2基因蛋白和表皮生长因子受体（EGFR）的表达及相互关系。结果显示P53在膀胱癌中阳性率为57．5％（27／47），在肾益癌中为50．0％（9／18）；C－erbB－2基因蛋白在膀胱癌和肾盂癌中的表达率分别为40．4％和38．9％；EGFR的表达率分别为42.6％和44．4％。P53、C－erbB－2基因蛋白和EGFR表达均与膀胱癌和肾盂癌的分级和分期有关，P53、C－erbB－2基因蛋白和EGFR有显著相关关系。结果表明P53、C－erbB－2基因蛋白和EGFR对膀胱癌和肾盂癌的恶性程度和预后评估具有重要参考意义。     

联合检测自发凋亡率及p27kip1在膀胱移行细胞癌中的意义

目的探讨自发凋亡率、p27kip1在人膀胱移行细胞癌中表达的临床意义。方法采用TUNEL法检测自发凋亡细胞,用S’P法检测p27kip1基因在50例膀胱移行细胞癌中的表达,分析各检测指标在上述标本中的表达及与膀胱移行细胞癌分级、临床分期间的关系。结果在膀胱移行细胞癌中,自发凋亡率AI均数为(3.0±1.5)%,p27kip1基因的阳性表达率为58.0%(29/50)。其二者的阳性表达均随膀胱癌分级、分期的升高而降低。p27kip1蛋白阳性组中AI均数显著高于p27kip1蛋白阴性组(P<0.05)。结论p27kip1蛋白和自发凋亡率与肿瘤的恶性程度和进展密切相关,联合检测p27kip1和自发凋亡率有助于更准确地解释和描述膀胱癌的生物学行为。     

survivin与nmp22对诊断尿路上皮肿瘤价值的比较

目的 :评价尿脱落细胞中survivin的表达和尿nmp2 2的表达对诊断尿路上皮肿瘤的价值。 方法 :对4 8例尿路上皮肿瘤患者 ,在行膀胱镜检查或手术前留新鲜尿液分别行尿脱落细胞survivin、尿nmp2 2和尿脱落细胞检查 ,并分别比较各方法的敏感性、特异性。结果 :尿路上皮肿瘤患者尿脱落细胞涂片中survivin表达 4 8例中4 6例阳性 ,尿NMP2 2有 38例阳性 ,而尿脱落细胞学仅 15例阳性 ,survivin的敏感性高于nmp2 2及脱落细胞学 (P <0 .0 5及P <0 .0 1)。三者的特异性分别为 10 0 %、90 %和 10 0 % ,差异无统计学意义。结论 :检测尿脱落细胞中survivin的表达方法简单无创敏感性、特异性高对诊断尿路上皮肿瘤的价值优于尿nmp2 2。     

MR泌尿系水成像对原发性输尿管移行细胞癌的诊断价值

目的：提高MR泌尿系水成像（MRU）对原发性输尿管移行细胞癌的诊断正确性。方法：收集46例病理证实的原发性输尿管移行细胞癌患者的病理资料及影像学资料进行回顾分析。结果：MRU对输尿管癌的诊断敏感性及特异性分别为100％（46／46）及82．6％（38／46）。结论：MRU对诊断原发性输尿管移行细胞癌具有较高的临床应用价值。     

直肠癌癌旁移行粘膜细胞动力学变化

应用氚－胸腺嘧啶核苷体外双标记放射自显影法，对１５例直肠癌旁移行粘膜与非移行粘膜作细胞动力学的比较观察。结果表明，移行粘膜的标记指数与非移行粘膜比差异非常显著（Ｐ＜０．０１），在细胞增殖周期和ＤＮＡ合成期时间亦有差别。提示移行粘膜细胞增殖异常，可视为潜在癌前期粘膜。