Claudio Bovolenta Murta

Modified Complete Supine Percutaneous Nephrolithotomy: Solving Some Problems

BACKGROUND AND PURPOSE Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for patients with renal stones larger than 2 cm. In this article, we aim to describe our modified technique with the patient in a complete supine position for PCNL (csPCNL). PATIENTS AND METHODS A total of 117 patients (120 renal units) who underwent csPCNL for large stones from November 2008 to November 2011 were prospectively evaluated. One surgeon worked in two different institutions and performed all operations. All patients underwent CT preoperatively, and the stones were classified according to the Guy score. Patients were placed in the supine decubitus position with the posterior axillary line located just outside the border of the surgical table, and the flank was extended to increase the space between the last rib and the iliac crest. The csPCNL was performed without a rolled towel under the flank, and the patients remained in the same position during the entire procedure. Success was evaluated based on CT findings at the end of follow-up. RESULTS There was no failure of access. The median operative time was 100 (20-240) minutes. The immediate and final success rates were 72.5% and 90.4%, respectively. The complication rate was 16.8% (12.7% of Clavien I or II and 4.1% of Clavien III or IV). There were no colon injuries or deaths. The median hospital stay was 48 (24-840) hours. CONCLUSION Modified csPCNL is a safe and effective procedure with excellent outcomes and a low rate of major complications. It provides a good area for renal puncture and surgical instrumentation.

Evaluation of the Incidence of Bladder Perforation After Transurethral Bladder Tumor Resection in a Residency Setting

PURPOSE To evaluate prospectively the actual bladder perforation incidence during transurethral resection of bladder tumor (TURB) performed by residents and to identify possible predisposing factors to such condition. PATIENTS AND METHODS Thirty-four patients with bladder tumor were submitted to TURB in our academic institution in April 2006, and were prospectively studied. Procedures were all done by senior residents under an attending direct supervision. All patients had a cystograms performed after the procedure by the injection of 400 mL of saline-diluted contrast solution with low-pressure infusion through the Foley catheter. The cystograms were evaluated blindly by a single radiologist. All patients were examined by cystoscopy and/or CT every 3 months for the first 2 years postoperatively. RESULTS The cystogram showed contrast leaking compatible with bladder perforation in 17 (50%) cases. None of the perforations were recognized intraoperatively by the surgeon. All perforations were extraperitoneal and managed conservatively. There was no significant correlation between the incidence of bladder perforation and the patient age (p = 0.508), the tumor stage (p = 0.998), the tumor grade (p = 0.833), the number of lesions (p = 0.394), and the tumor size (p = 0.651). The only factor that had impact on the development of bladder perforation was tumor localization at the bottom of the bladder (p = 0.035; OR, 6750; 95% CI, 1.14, 39.8). CONCLUSION Asymptomatic perforations of the bladder wall occur very frequently after a TURB procedure performed by residents in training and, most of the time, are not noticed by the surgeon. Localization of the tumor at bladder dome was the only factor that negatively influenced perforation rates.

Intravenous misplacement of the nephrostomy catheter following percutaneous nephrostolithotomy: two case reports

and it has remained an important approach for removing kidney stones since its inception. A nephrostomy tube is routinely positioned in the renal pelvis in order to tamponade bleeding and drain the collecting system. Although PCNL is an established procedure, major complication rates of up to 7% have been reported.

Analysis of the clinicopathological characteristics of patients with upper urinary tract transitional cell carcinoma.

OBJECTIVE To describe the clinicopathological characteristics of patients with upper urinary tract transitional cell carcinomas who are treated surgically and to analyze the occurrence of bladder tumors as well as the development of metastases outside the urinary tract. MATERIALS AND METHODS The study comprised a retrospective analysis of 25 patients treated between February 1994 and August 2006. The variables analyzed were: patient age, gender, and clinical presentation; diagnostic methods; pathologic characteristics at the primary site of the tumor (pelvis or ureter); tumor stage and grade; and presence of carcinoma in situ, microvascular invasion and squamous differentiation. The Kaplan-Meier method and the Log-Rank test were used for statistical analysis of bladder recurrence-free survival. RESULTS Eighty-four percent of patients were male, and macroscopic hematuria was the most common clinical presentation. The majority of cases (56%) were infiltrative (T2–T3) and high-grade (76%) tumors. Synchronous or metachronous bladder tumors were found in 72% of cases. Five (20%) patients had a history of bladder tumor before the diagnosis of upper urinary tract transitional cell carcinomas. The mean follow-up period was 36 months (range: 1.5 to 156). During the follow-up period, eleven (44%) patients developed bladder tumors. After five years, the probability of being free of bladder tumor recurrence was 40%. No pathological variable was predictive for bladder tumor recurrence. Four patients presented disease recurrence outside the urinary tract. CONCLUSIONS The presence of metachronous bladder tumors is more often observed after the diagnosis of upper urinary tract transitional cell carcinomas. All of these patients should undergo rigorous follow-up during the postoperative period. Only patients with infiltrative and high-grade tumors developed metastases outside the urinary tract.

Fatores prognósticos da revascularização na fase aguda do infarto agudo do miocárdio

OBJECTIVES: To determine the predictors of bad evolution in patients submitted to myocardial revascularization (MR) in the acute myocardial infarction (AMI). MATERIAL E METHODS: Between March 1998 and November 1999, 49 patients were submitted to MR in AMI. Patients with mechanical complications of the AMI and those submitted to associated procedures to MR were excluded. The patients were divided into two groups: Group I - 29 cases without AMI related complications and Group II - 20 cases with one or more complications. The later ones included persistent ischemia (18 patients), congestive heart failure (11), cardiogenic shock (9), hypotension (7), recurrent AMI (4), sustained ventricular tachycardia (4) and ventricular fibrillation (3). Both groups were considered comparable in terms of preoperative demografics, except for older patients in Group II. In order to determine the prognostic factors for early mortality, the patients profiles and AMI complications were analysed by multivariate and variance tests. RESULTS: The overall mortality was 6.12% (3 patients), all of them in Group II. The multivariate analysis identified as predictors of hospital mortality arterial hypotension (p=0.045), cardiogenic shock (p=0.001) and ventricular fibrillation (p=0.012). CONCLUSIONS: MR in AMI is a safe procedure in patients without preoperative complications, with no deaths. The presence of preoperative complications such as cardiogenic shock, ventricular fibrillation and hypotension were considered predictors of bad evolution in this condition.

Giant Perineal Solitary Fibrous Tumor: A Rare Case Report

Background. Solitary fibrous tumor (SFT) is a fibroblastic mesenchymal tumor that was initially described from the pleura but currently arises at almost every anatomic site. It is usually benign, and surgical resection is curative. SFT involving the perineum is extremely rare. This is the third case report of a perineal SFT in the literature. Case Presentation. We reported an uncommon case of a 64-year-old man presenting with a huge perineal mass that started growing 3 years before his arrival in our service. He was asymptomatic. A contrast-enhanced CT scan revealed a heterogeneous well-circumscribed perineal mass with soft-tissue density. Invasion of the surrounding organs, distal metastasis, and lymph node swelling were absent. The complete resection of mass was done successfully. The specimen was a 23.0 × 14.0 × 8.0 cm encapsulated tumor. Mass weight was 1,170 g. After pathological analysis, we confirmed that the mass was a solitary fibrous tumor. The diagnosis was based on clinical findings and histological morphology and immunohistochemistry study. Conclusion. SFTs are usually indolent tumors with a favorable prognosis. The perineal location is extremely rare. Complete resection of the mass is the treatment of choice.

Perioperative and 90-day complication rates in patients with localized prostate cancer treated with high intensity focused ultrasound (HIFU): A prospective case series study.

e17083Background: Localized prostate cancer (PC) has been treated with radical prostatectomy, radiotherapy, or active surveillance. Recently, focal treatment was introduced as an alternative option...

Outcomes of more than 1 000 percutaneous nephrolithotomies and validation of Guy's stone score

To present the experience with percutaneous nephrolithotomy (PCNL) at a high‐volume Brazilian centre and to evaluate Guys stone score (GSS) as a predictor of success and complications in PCNL.

MP04-17 BLOOD-BASED BIOMARKERS AS PREDICTORS OF ONCOLOGIC OUTCOMES FOR NON-MUSCLE-INVASIVE UROTHELIAL BLADDER CARCINOMA

INTRODUCTION AND OBJECTIVES: Our group has previously demonstrated that blood-based tumor markers can be useful clinical outcome predictors for non-muscle invasive urothelial carcinoma of the bladder (UCB) Our aim in this study is to further evaluate the predictive value of CEA, CA 19-9 and CA 125 on disease recurrence and progression. METHODS: We prospectively included 328 consecutive patients between February 2008 and August 2014 to measure preoperative serum levels of CEA, CA 19-9 and CA 125 before first transurethral resection of the bladder (TUR). Institutional Ethical Committee approval was obtained prior to this study. Patients diagnosed with pT2 UBC were excluded (42), leaving 286 patients for analysis of recurrence or progression. After first TUR, patients were followed with routine cystoscopy, cytology and ultrasound every 6 months. All patients with non-muscle invasive (NMI) bladder cancer with high-grade disease, previous recurrence, carcinoma in situ (CIS) or T1 received induction and maintenance intravesical BCG. RESULTS: We found that CEA and CA 19-9 levels were significantly higher in patients who had either tumor recurrence and/or progression compared to those who had no UBC recurrence during follow-up (p1⁄40.02; p1⁄40.03). As we had found previously, however, CA 125 levels did not differ between the two groups (p1⁄40.42). Overall, mean CEA level was 2.1 (0.2-12.8), CA 19-9 was 17.1 (0.4-189.9) and CA 125 was 12.5 (1.2-103.9). In patients who presented tumor recurrence and/or progression, mean CEA was 5.5, mean CA 19-9 was 21.0 and CA 125 was 13.8, while in the non-recurring group, mean CEA was 3.1, mean CA 19-9 was 11.1 and CA 125 was 11.3. Mean follow-up was 4.9 years. Patients were 70.3% males (201); 63.3% (181) of patients had pTa at first TUR. Concomitant carcinoma in situ was present in 25 cases (8.7%). CONCLUSIONS: Biomarkers utilized in routine follow-up of other malignancies, such as CEA and CA 19-9, can also be included in UCB management, since it proved able to distinguish a higher risk group of patients that could be managed accordingly. Future studies may add these blood-based tumor markers to a predictive model and validated in a larger cohort. Although CA 125 was not significantly associated with oncologic outcome, further studies are required before excluding this potential biomarker in UBC.

MP30-19 IMPACT OF THE GUY'S STONE SCORE ON SUCESS RATES FOR PERCUTANEOUS NEPHROLITHOTOMY

to review the post-operative infectious complications in a series of patients for whom our practice was compliant with AUA guidelines. METHODS: A retrospective review was performed of consecutive percutaneous nephrolithotomy procedures performed. Patients in Group 1 underwent PCNL with antibiotics given in accordance with AUA Guidelines 2.0 cm in 79% versus 80% respectively, mean OR time was 107 versus 125 minutes respectively, p1⁄4 NS). In Group 1, 5 patients (9.6%) developed fever on POD 1 during inpatient inadmission, but all urine, serum, and stone cultures were negative. No patients in group 1 demonstrated bacteruria during hospital course or prior to follow up visit. In Group 2, 4 patients (13.3%) developed fever during inpatient admission and one of those patients had a urine culture which demonstrated bacteruria. No patients had positive blood cultures or infectious complications occurring after discharge. CONCLUSIONS: In this pilot series, compliance with AUA guidelines and use of < 24 hours of perioperative antibiotics for PCNL in patienst without a history of infection did not appear to be associated with increased infection rates. Prospective studies would be useful to confirm these findings.