João Batista Gadelha de Cerqueira

Complications in laparoscopic radical cystectomy. The South American experience with 59 cases.

OBJECTIVE In this study, we have gathered the second largest series yet published on laparoscopic radical cystectomy in order to evaluate the incidence and cause of intra and postoperative complication, conversion to open surgery, and patient mortality. MATERIALS AND METHODS From 1997 to 2005, 59 laparoscopic radical cystectomies were performed for the management of bladder cancer at 3 institutions in South America. Twenty nine patients received continent urinary diversion, including 25 orthotopic ileal neobladders and 4 Indiana pouches. Only one case of continent urinary diversion was performed completely intracorporeally. RESULTS Mean operative time was 337 minutes (150-600). Estimated intraoperative blood loss was 488 mL (50-1500) and 12 patients (20%) required blood transfusion. All 7 (12%) intraoperative complications were vascular in nature, that is, 1 epigastric vessel injury, 2 injuries to the iliac vessels (1 artery and 1 vein), and 4 bleedings that occurred during the bladder pedicles control. Eighteen (30%) postoperative complications (not counting mortalities) occurred, including 3 urinary tract infections, 1 pneumonia, 1 wound infection, 5 ileus, 2 persistent chylous drainage, 3 urinary fistulas, and 3 (5%) postoperative complications that required surgical intervention (2 hernias - one in the port site and one in the extraction incision, and 1 bowel obstruction). One case (1.7%) was electively converted to open surgery due to a larger tumor that precluded proper posterior dissection. Two mortalities (3.3%) occurred in this series, one early mortality due to uncontrolled upper gastrointestinal bleeding and one late mortality following massive pulmonary embolism. CONCLUSIONS Laparoscopic radical cystectomy is a safe operation with morbidity and mortality rates comparable to the open surgery.

Single-incision multiport laparoscopic orchidopexy: initial report

PURPOSE We report the first use of single-incision multiport access to perform 1-stage laparoscopic orchidopexy in children without section of the spermatic vessels. MATERIAL AND METHODS Three boys with cryptorchidism were submitted to primary laparoscopic 1-stage orchidopexy by using 3 ports (a 10-mm [or 5-mm] port placed using open technique and 2 additional 5-mm [or 3-mm] ports) inserted through the same periumbilical skin incision with different entrances through the abdominal wall. After dissection of the testicular vessels and vas deferens, a 5-mm port was placed in a tunnel from the scrotum to pull the remnant of the gubernaculum down and fix the testicle in a dartos pouch. RESULTS The mean operative time was 83.3 minutes. The estimated blood loss was almost nil, and there were no intraoperative complications. CONCLUSION This approach was feasible and safe. However, as with any new technique, its use requires a larger number of cases and a longer follow-up to fully evaluate its benefits and limitations.

Stapleless laparoscopic assisted radical cystectomy with ileal neobladder in a male and with ileal loop in a female: initial report from Brazil

ABSTRACTIntroduction: Here, we report our initial experience with laparoscopic assisted radicalcystectomy without the use of surgical staples.Cases Report: A 70 year old male and a 55 year old female were diagnosed to have T2G3transitional cell carcinoma of the bladder with negative metastatic work-out. Both patients werescheduled and agreed to a laparoscopic assisted radical cystectomy. In both cases, urinary diversion(orthotopic ileal Studer neobladder in the male and ileal conduit in the female) was performedextracorporeally following radical cystectomy. In both cases control of the bladder vascular pediclewasaccomplished with a combination of metallic and hem-o-lock clips. The total surgical time was 6.5hours in both cases. Estimated intra-operative blood loss was 500 cc and 350 cc respectively, howeverboth patients required postoperative blood transfusions. No intraoperative complications occurred. Inboth cases, pathology revealed negative surgical margins.Conclusions: Extracorporeal creation of urinary diversion decrease the overall operativetime. Laparoscopic pelvic lymphadenectomy can be performed following the extended template. Theuse of surgical clips instead of vascular Endo-GIA titanium staples to control the bladder vascularpedicles is feasible and safe in selected patients, thus reducing intraoperative surgical costs. Considerableexperience with laparoscopic radical prostatectomy is necessary before one attempts laparoscopicradical cystectomy.Key words : bladder neoplasms; cystectomy; urinary diversion; lymphadenectomy; laparoscopyInt Braz J Urol. 2005; 31: 214-21

Combined liver-kidney transplantation: experience at a brazilian university hospital

Background Combined liver-kidney transplant is a routine procedure in many transplant centers. The increase in its number coincided with the introduction in 2002 of the MELD (Model for End-stage Liver Disease) score for allocation of livers, prioritizing patients with renal dysfunction. Aim To analyze the experience with combined liver-kidney transplantation in a liver transplant center in Brazil. Method A retrospective review was conducted. All transplants were performed using grafts from deceased donors. Results Sixteen combined liver-kidney transplantations were performed in the same period, which corresponds to 2.7% and 2.5% of the kidney and liver transplants, respectively. Fourteen patients were male (87.5 %) and two were female (12.5%). The average patients and donors age was 57.3±9.1 and 32.7±13.1, respectively. The MELD score mean was 23.6±3.67. The main cause of liver dysfunction were chronic hepatitis C virus (n=9). As for renal dysfunction, diabetic nephropathy (n=4) was the most frequent. There were six deaths, two of them by severe dysfunction of the liver graft and four by infectious causes. The 1, 3 and 5 years survival rate in patients undergoing liver-kidney transplantations was 68.8%, 57.3% and 57.3%, respectively. Conclusion The survival rates achieved in this series are considered satisfactory and show that this procedure has an acceptable morbidity and survival.

Identification of mechanisms involved in the relaxation of rabbit cavernous smooth muscle by a new nitric oxide donor ruthenium compound

PURPOSE The aim of this study was to evaluate the relaxation in vitro of cavernous smooth muscle induced by a new NO donor of the complex nitrosil-ruthenium, named trans-[Ru(NH3)4(caffeine)(NO)]C13 (Rut-Caf) and sodium nitroprusside (SNP). MATERIALS AND METHODS The tissues, immersed in isolated bath systems, were pre-contracted with phenilephrine (PE) (1 µM) and then concentration-response curves (10 (-12) - 10(-4) M) were obtained. To clarify the mechanism of action involved, it was added to the baths ODQ (10 µM, 30 µM), oxyhemoglobin (10 µM), L-cysteine (100 µM), hydroxicobalamine (100 µM), glibenclamide, iberotoxin and apamine. Tissue samples were frozen in liquid nitrogen to measure the amount of cGMP and cAMP produced. RESULTS The substances provoked significant relaxation of the cavernous smooth muscle. Both Rut-Caf and SNP determined dose-dependent relaxation with similar potency (pEC50) and maximum effect (E(max)). The substances showed activity through activation of the soluble guanylyl cyclase (sGC), because the relaxations were inhibited by ODQ. Oxyhemoglobin significantly diminished the relaxation effect of the substances. L-cysteine failed to modify the relaxations caused by the agents. Hydroxicobalamine significantly diminished the relaxation effect of Rut-Caf. Glibenclamide significantly increased the efficacy of Rut-Caf (pEC50 4.09 x 7.09). There were no alterations of potency or maximum effect of the substances with the addition of the other ion channel blockers. Rut-Caf induced production of significant amounts of cGMP and cAMP during the relaxation process. CONCLUSIONS In conclusion, Rut-Caf causes relaxation of smooth muscle of corpus cavernosum by means of activation of sGC with intracellular production of cGMP and cAMP; and also by release of NO in the intracellular environment. Rut-Caf releases the NO free radical and it does not act directly on the potassium ion channels.

Experimental model of human corpus cavernosum smooth muscle relaxation

PURPOSE To describe a technique for en bloc harvesting of the corpus cavernosum, cavernous artery and urethra from transplant organ donors and contraction-relaxation experiments with corpus cavernosum smooth muscle. MATERIALS AND METHODS The corpus cavernosum was dissected to the point of attachment with the crus penis. A 3 cm segment (corpus cavernosum and urethra) was isolated and placed in ice-cold sterile transportation buffer. Under magnification, the cavernous artery was dissected. Thus, 2 cm fragments of cavernous artery and corpus cavernosum were obtained. Strips measuring 3 x 3 x 8 mm(3) were then mounted vertically in an isolated organ bath device. Contractions were measured isometrically with a Narco-Biosystems force displacement transducer (model F-60, Narco-Biosystems, Houston, TX, USA) and recorded on a 4-channel Narco-Biosystems desk model polygraph. RESULTS Phenylephrine (1 microM) was used to induce tonic contractions in the corpus cavernosum (3-5 g tension) and cavernous artery (0.5-1 g tension) until reaching a plateau. After precontraction, smooth muscle relaxants were used to produce relaxation-response curves (10(-12) M to 10(-4) M). Sodium nitroprusside was used as a relaxation control. CONCLUSION The harvesting technique and the smooth muscle contraction-relaxation model described in this study were shown to be useful instruments in the search for new drugs for the treatment of human erectile dysfunction.

Effects of chronic administration of tamsulosin and tadalafil, alone or in combination, in rats with bladder outlet obstruction induced by chronic nitric oxide deficiency

PURPOSE The aim of this study was to define if tadalafil causes detrusor muscle impairment and to observe the effect of combination of tadalafil with tamsulosin on the lower urinary tract of rats with bladder outlet obstruction (BOO) induced by chronic nitric oxide deficiency. MATERIALS AND METHODS Thirty-one male rats were randomized to following groups: 1 - control; 2 - L-Nitroarginine methyl ester (L-NAME); 3 - Tamsulosin + L-NAME, 4 Tadalafil+L-NAME; and 5 - Tamsulosin + Tadalafil + L-NAME. At the end of the treatment period (30 days), all animals were submitted to urodynamic study. RESULTS The administration of L-NAME increased the number of non-voiding contractions (NVC) (1.04 ± 0.22), volume threshold (VT) (1.86 ± 0.35), and micturition cycle (MC) (1.34 ± 0.11) compared with control (0.52 ± 0.06, 0.62 ± 0.06, and 0.67 ± 0.30), respectively. The administration of tamsulosin reduced the number of NVC (0.57 ± 0.42) and VT (0.76 ± 0.24 ) compared with L-NAME group. Co-treatment with tadalafil decreased the number of VT (0.85 ± 0.53) and MC (0.76 ± 0.22) compared with L-NAME group. The combination of tamsulosin with tadalafil improved the number of NVC (0.56 ± 0.18), VT (0.97 ± 0.52) and MC (0.68 ± 0.30) compared with L-NAME group. CONCLUSION In rats with BOO induced by chronic nitric oxide deficiency, tadalafil did not cause impairment in detrusor muscle and seems to have an addictive effect to tamsulosin because the combination decreased non voiding contractions as well the number of micturition cycles.

PanCD44 Immunohistochemical Evaluation in Prostatectomies from Patients with Adenocarcinoma

Introduction CD44 has been proposed as a prognostic marker and a stem cell marker but studies in patients with prostate cancer have yielded inconsistent results. Patients and Methods Patients submitted to radical prostatectomy between 2008 and 2013 at a university hospital were followed with biannual serum PSA tests to determine the biochemical recurrence (BR). Archived paraffin blocks with neoplastic and nonneoplastic tissue were evaluated immunohistochemically for a panCD44 and MYC. Results Sixty-nine patients completed follow-up and were included. CD44 positivity was observed in inflammatory cells (42%), nonneoplastic epithelium (39.7%), and neoplastic tissue (12.3%). In nonneoplastic tissues staining was observed in basal and luminal cells with the morphology of terminally differentiated cells. In neoplastic tissues, CD44 negativity was correlated with higher Gleason scores (Rho = −0.204; p = 0.042) and higher preoperative serum PSA levels when evaluated continuously (p = 0.029). CD44 expression was not associated with tumor stage (p = 0.668), surgical margin status (p = 0.471), or BR (p = 0.346), nor was there any association between CD44 and MYC expression in neoplastic tissue (p = 1.0). Conclusion In the bulk of cells, the minority of cancer stem cells would not be detected by immunohistochemistry using panCD44. As a prognostic marker, its expression was weakly correlated with Gleason score and preoperative PSA level, but not with surgical margin status, tumor stage, or BR.

MP26-05 RELAXING EFFECT OF PHOSPHODIESTERASE INHIBITORS AND β3-ADRENOCEPTOR AGONIST IN AN EXPERIMENTAL MODEL OF DETRUSOR OVERACTIVITY

nanoparticles. Based on characterization of the ECA matrix by biomimetic analyses, this novel collagen-based biotextile may serve as a promising pelvic fascial substitute material for slings and reconstructive surgery. These findings support further experimentation of adding other nano-particles and cross-linking manufacturing steps to further enhance the balance between additional biomechanical and biocompatibility features.

Splenogonadal fusion associated with delayed skeletal maturation: A case report and review of the literature

In this report of a 13-year old boy, we describe the first case of splenogonadal fusion (SGF) associated with growth hormone deficiency, delayed skeletal maturation and stunting, and provide a review of the literature on SGF based on a search in major medical indexes using the descriptors splenogonadal, splenogonadal fusion and congenital anomalies of the spleen. Predominant in males (15:1), SGF is a rare congenital anomaly with only around 200 cases described involving the presence of splenic tissue in the gonads and, in some cases, a fibrous cord connecting the two structures. SGF may be associated with severe limb anomalies, micrognathism and testicle cancer. Despite frequently increased testicle volume, the condition is usually asymptomatic. Knowledge of SGF is important in the differential diagnosis of malignancies, avoiding unnecessary orchiectomy. Nevertheless, SGF has been observed in association with malignant tumors, especially in patients with cryptorchidism.