Fábio César Miranda Torricelli

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.

Development and Initial Validation of a Scoring System to Diagnose Testicular Torsion in Children

PURPOSE Testicular torsion is a surgical emergency requiring prompt intervention. Although clinical diagnosis is recommended, scrotal ultrasound is frequently ordered, delaying treatment. We created a scoring system to diagnose testicular torsion, decreasing the indication for ultrasound. MATERIALS AND METHODS We prospectively evaluated 338 patients with acute scrotum, of whom 51 had testicular torsion. Physical examination was performed by a urologist, and all patients underwent scrotal ultrasound. Univariate analysis and logistic regression were performed, and a scoring system for risk stratification of torsion was created. Retrospective validation was performed with 2 independent data sets. RESULTS The scoring system consisted of testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1), nausea/vomiting (1) and high riding testis (1). Cutoffs for low and high risk were 2 and 5 points, respectively. Ultrasound would be indicated only for the intermediate risk group. In the prospective data set 69% of patients had low, 19% intermediate and 11.5% high risk. Negative and positive predictive values were 100% for cutoffs of 2 and 5, respectively (specificity 81%, sensitivity 76%). Retrospective validation in 1 data set showed 66% of patients at low, 16% intermediate and 17% high risk. Negative and positive predictive values for cutoffs of 2 and 5 were 100% (specificity 97%, sensitivity 54%). The second retrospective data set included only torsion cases, none of which was misdiagnosed by the scoring system. CONCLUSIONS This scoring system can potentially diagnose or rule out testicular torsion in 80% of cases, with high positive and negative predictive values for selected cutoffs. Ultrasound orders would be decreased to 20% of acute scrotum cases. Prospective validation of this scoring system is necessary.

Nocturia is the Lower Urinary Tract Symptom With Greatest Impact on Quality of Life of Men From a Community Setting

Purpose Lower urinary tract symptoms are numerous, but the specific impact of each of these symptoms on the quality of life (QoL) has not been evaluated in community-dwelling men. An assessment of these symptoms and their effects on QoL was the focus of this study. Methods We performed a cross-sectional study with 373 men aged >50 years from a community setting. Patients completed the International Prostate Symptom Score questionnaire, which includes questions on each of the specific urinary symptoms and a question addressing health-related QoL that are graded from 0 to 5. We used the Pearson correlation test to assess the impact of each symptom on QoL. Results Nocturia (58.9%) was the most prevalent urinary symptom. The mean score was 0.9±1.4 for incomplete emptying, 1.0±1.5 for frequency, 0.9±1.3 for intermittency, 0.8±1.3 for urgency, 1.0±1.5 for weak stream, 0.5±1.0 for straining, and 2.0±1.6 for nocturia. Nocturia and frequency were the only symptoms associated with poorer QoL, with nocturia showing a stronger association. Conclusions Nocturia affects 50% of community dwelling men aged >50 years, and is the lower urinary tract symptom with the greatest negative impact on QoL.

Contemporary Trends of Inpatient Surgical Management of Stone Disease: National Analysis in an Economic Growth Scenario

PURPOSE To assess trends in urologic surgical management of upper tract urolithiasis in Brazil over the past 15 years. MATERIALS AND METHODS The Public Health System of Brazil (SUS) provides health coverage to 47% to 74% of the population. SUS has a longitudinal hospital inpatient database (SIH/SUS). Hospital discharges between January 1,1998 and December 31, 2012 were abstracted from the SIH/SUS. All inpatient hospitalizations for patients of any age with a primary/secondary diagnosis code of N20.x (calculus of kidney or ureter) were abstracted (ICD-9/10). All urolithiasis-related procedure codes were analyzed. The absolute number of procedures/year and the proportion among all techniques were analyzed for Brazil and also separately for the five distinguished regions of the country. Prevalence trends over the studied period were quantified by the estimated annual percent change (EAPC) using the least squares linear regression methodology. Significance was set at P<0.05. RESULTS The number of surgical interventions for stone disease increased significantly from 10080 to 24713 (+145%; EAPC=1008.1; P<0.001). The most common surgical modalities in 1998 were nephrectomy (n=2918; 29%), ureterolithotomy (n=2361; 23%), and pyelolithotomy (n=1771; 18%). In 2012, ureteroscopy (URS) was the most commonly performed procedure (n=8725; 35%), followed by ureterolithotomy (n=5822; 24%), and nephrectomy (n=3466; 14%). Between 1998 and 2012, percutaneous nephrolithotomy had the highest significant relative increase (+791.8%; EAPC=0.6%; P<0.001), followed by URS (+607%; EAPC=1.78%; P<0.001). Pyelolithotomy showed the most significant decrease (-47.5%; EAPC = -0.91%; P<0.001). All five regions presented a significant positive increase in the EAPC (P<0.001). CONCLUSION Trends of stone disease surgical management in the public health system of Brazil follow worldwide tendencies toward less invasive treatment modalities.

Hepatorenal syndrome: an update

Hepatorenal syndrome (HRS) is the development of renal failure in patients with chronic previous liver disease, without clinical or laboratory evidence of previous kidney disease. It affects up to 18% of cirrhotic patients with ascites during the first year of follow-up, reaching 39% in five years and presenting a survival of about two weeks after its establishment. HRS diagnosis is based on clinical and laboratory data. The occurrence of this syndrome is related to the mechanism for ascites development, involving vasoconstriction, low renal perfusion, water and sodium retention, increased plasma volume, and consequent overflow at the splanchnic level. Renal vasoactive mediators like endothelin 1, thromboxane A2, and leukotrienes are also involved in the genesis of this syndrome, which culminates in functional renal insufficiency. The treatment of choice can be pharmacological or surgical, although liver transplantation is the only permanent and effective treatment, with a four-year survival rate of up to 60%. Liver function recovery is usually followed by renal failure reversion. Early diagnosis and timely therapeutics can increase life expectancy for these patients while they are waiting for liver transplantation as a definitive treatment.

Laparoscopy-assisted ileal pouch-anal anastomosis: surgical outcomes after 10 cases.

We analyzed outcomes of laparoscopy-assisted ileal pouch-anal anastomosis (LAIPA) from 10 patients (7 with ulcerative colitis and 3 with familial adenomatous polyposis) operated on between January 1998 and March 2004. Median operating time was 246 minutes. There were no intraoperative complications. There were no conversions. Postoperative complications occurred in 3 (30%) patients: 2 cases of wound infection and 1 case of a foreign body retrieved during pouch endoscopy. There was a 30% reoperation rate due to unsuspected duodenal perforation, a persistent postoperative pain, and 1 case of intestinal obstruction after ileostomy closure. There were no deaths. Median time to resumption of diet was 24 hours. Median hospital stay was 7 days. All ileostomies were closed 6 to 8 weeks after LAIPA. LAIPA is feasible and safe and should be selectively offered to nonobese patients.

Metanephric Adenoma: clinical, imaging, and Histological findings

Metanephric adenoma (MA), also designated nephronogenic nephroma or renal epithelial tumor resembling immature nephron, has just been recently recognized as a special type of benign renal epithelial tumor. Only few reports are found in the literature regarding this rare renal tumor. The purpose of this paper is to describe our clinical, imaging and histological / immunohistochemical observations of MA diagnosed in two patients and compare these data to previous information reported in medical databases.

Impact of laparoscopic surgery training laboratory on surgeon's performance

Minimally invasive surgery has been replacing the open standard technique in several procedures. Similar or even better postoperative outcomes have been described in laparoscopic or robot-assisted procedures when compared to open surgery. Moreover, minimally invasive surgery has been providing less postoperative pain, shorter hospitalization, and thus a faster return to daily activities. However, the learning curve required to obtain laparoscopic expertise has been a barrier in laparoscopic spreading. Laparoscopic surgery training laboratory has been developed to aid surgeons to overcome the challenging learning curve. It may include tutorials, inanimate model skills training (box models and virtual reality simulators), animal laboratory, and operating room observation. Several different laparoscopic courses are available with specific characteristics and goals. Herein, we aim to describe the activities performed in a dry and animal-model training laboratory and to evaluate the impact of different kinds of laparoscopic surgery training courses on surgeon’s performance. Several tasks are performed in dry and animal laboratory to reproduce a real surgery. A short period of training can improve laparoscopic surgical skills, although most of times it is not enough to confer laparoscopic expertise for participants. Nevertheless, this short period of training is able to increase the laparoscopic practice of surgeons in their communities. Full laparoscopic training in medical residence or fellowship programs is the best way of stimulating laparoscopic dissemination.

Laparoendoscopic single site surgery versus conventional laparoscopy for transperitoneal pyeloplasty: A systematic review and meta‑analysis

We aimed to review studies comparing the outcomes of the laparoendoscopic single site (LESS) pyeloplasty with those of conventional laparoscopic pyeloplasty (CLP). A systematic review of the literature was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analysis) criteria. The methodological quality of the studies was rated according validated scales. The level of evidence (LE) was reported as described by the Oxford criteria. Preoperative demographic parameters and perioperative outcomes between the two surgical techniques were assessed. A meta-analysis of the included studies was performed. A total of 5 studies were elected for the analysis, including 164 cases, 70 (42.6%) of them being LESS and 94 (57.4%) being CLP. Four studies were observational retrospective comparative studies (LE: 3a-4); one was a prospective randomized controlled trial (LE: 2b). There was no significant difference in age, body mass index, gender, side and presence of the crossing vessel, between the groups. There was no significant difference regarding the operative time (weight mean difference [WMD]: −7.02; 95% confidence interval [CI]: −71.82-57.79; P = 0.83) and length of hospital stay (WMD: 0.04; 95% CI: −0.11-0.20; P = 0.58), whereas the estimated blood loss was statistically lower for LESS (WMD: −16.83; 95% CI: −31.79-−1.87; P = 0.03). The postoperative use of analgesic favored the LESS group but without reaching statistical significance (WMD: −7.52; 95% CI: −17.56-2.53; P = 0.14). In conclusion, LESS pyeloplasty offers comparable surgical and functional outcomes to CLP while providing the potential advantages of less blood loss and lower analgesic requirement. Thus, despite being more technically challenging, LESS pyeloplasty can be regarded as a minimally invasive approach for patients seeking fewer incisional scars.

Impact of Renal Anatomy on Shock Wave Lithotripsy Outcomes for Lower Pole Kidney Stones: Results of a Prospective Multifactorial Analysis Controlled by Computerized Tomography

PURPOSE We evaluated which variables impact fragmentation and clearance of lower pole calculi after shock wave lithotripsy. MATERIALS AND METHODS We prospectively evaluated patients undergoing shock wave lithotripsy for a solitary 5 to 20 mm lower pole kidney stone between June 2012 and August 2014. Patient body mass index and abdominal waist circumference were recorded. One radiologist blinded to shock wave lithotripsy outcomes measured stone size, area and density, stone-to-skin distance, infundibular length, width and height, and infundibulopelvic angle based on baseline noncontrast computerized tomography. Fragmentation, success (defined as residual fragments less than 4 mm in asymptomatic patients) and the stone-free rate were evaluated by noncontrast computerized tomography 12 weeks postoperatively. Univariate and multivariate analysis was performed. RESULTS A total of 100 patients were enrolled in the study. Mean stone size was 9.1 mm. Overall fragmentation, success and stone-free rates were 76%, 54% and 37%, respectively. On logistic regression body mass index (OR 1.27, 95% CI 1.11-1.49, p = 0.004) and stone density (OR 1.0026, 95% CI 1.0008-1.0046, p = 0.005) significantly impacted fragmentation. Stone size (OR 1.24, 95% CI 1.07-1.48, p = 0.039) and stone density (OR 1.0021, 95% CI 1.0007-1.0037, p = 0.012) impacted the success rate while stone size (OR 1.24, 95% CI 1.04-1.50, p = 0.029), stone density (OR 1.0015, 95% CI 1.0001-1.0032, p = 0.046) and infundibular length (OR 1.1035, 95% CI 1.015-1.217, p = 0.015) impacted the stone-free rate. The best outcomes were found in patients with a body mass index of 30 kg/m(2) or less, stones 10 mm or less and 900 HU or less, and an infundibular length of 25 mm or less. The coexistence of significant unfavorable variables led to a stone-free rate of less than 20%. CONCLUSIONS Obese patients with higher than 10 mm density stones (greater than 900 HU) in the lower pole of the kidney with an infundibular length of greater than 25 mm should be discouraged from undergoing shock wave lithotripsy.