Kleiton Yamaçake

Long-term Treatment Outcomes Between Surgical Correction and Conservative Management for Penile Fracture: Retrospective Analysis

Purpose Early surgical management is the standard of care for penile fracture. Conservative treatment is an option with recent reports revealing lower success rates. We reviewed the data and long-term outcomes of patients with penile injury submitted to surgical or conservative treatment. Materials and Methods Between January 2004 and February 2012, 42 patients with penile blunt trauma on an erect penis were admitted to our center. We analyzed the following variables: age, etiology, symptoms and signs, diagnostic tests, treatment used, complications and erectile function during the follow-up. One patient was excluded due to missing information. Thirty-five patients underwent surgical repair and 6 patients were submitted to conservative management. Results Mean follow-up was 19.2 months (range, 7 days to 72 months). The mean elapsed time from trauma to surgery was 21.3±12.5 hours. Trauma during sexual relationship was the main cause (80.9%) of penile fracture. Urethral injury was present in five patients submitted to surgery. Dorsal vein injury occurred in three patients with false penile fracture and concomitant spongious corpus lesion was present in three patients. During follow-up, 31 cases (88.6%) of the surgical group and four cases (66.7%) of the conservative group reported sufficient erections for intercourse, with no voiding dysfunction and no penile curvature. However, the remaining two patients (33.3%) from the conservative group developed erectile dysfunction and three patients (50%) developed penile deviation. Conclusions Surgical approach provides excellent functional outcomes and lower complications. Early surgical management of penile fracture provides superior results and conservative approach should be avoided.

Impact of body mass index, age and varicocele on reproductive hormone profile from elderly men

ABSTRACT Objectives: To study the impact of obesity, age and varicocele on sexual hormones fof adult and elderly men. Materials and Methods: 875 men who were screened for prostate cancer were enrolled in this study. Data recorded comprised age, body mass index (BMI), serum levels of total testosterone (TT), free testosterone (FT), sex hormone-binding globulin (SHBG), luteinizing hormone (LH) and follicular stimulating hormone (FSH). Patients were divided in groups according to their BMI in underweight, normal weight, overweight and obese grades 1, 2 or 3. First, it was studied the association between age, BMI, and hormone profile. Then, clinical varicocele was evaluated in 298 patients to assess its correlation to the others parameters. Results: Obese patients had lower levels of TT, FT and SHBG (p<0.001) compared to underweight or normal weight patients. There were no differences in age (p=0.113), FSH serum levels (p=0.863) and LH serum levels (p=0.218) between obese and non-obese patients. Obese grade 3 had lower levels of TT and FT compared to obese grade 1 and 2 (p<0.05). There was no difference in the SHBG levels (p=0.120) among obese patients. There was no association between varicocele and BMI; and varicocele did not impact on testosterone or SHBG levels. Conclusions: Men with higher BMI have a lower serum level of TT, FT and SHBG. The presence of clinical varicocele as well as its grade has no impact on hormone profile in elderly men.

Revascularization of Living-Donor Kidney Transplant With Multiple Arteries: Long-term Outcomes Using the Inferior Epigastric Artery

OBJECTIVE To study the safety and long-term outcomes of use of the inferior epigastric artery (IEA) for revascularization of small accessory kidney arteries (3 mm or less). MATERIALS AND METHODS Data of 602 living-donor kidney transplants were reviewed. Age was 37.4 ± 15 years (range, 3-78 years). Multiple arteries were present in 98 kidneys (16.3%); of these, 83 (84.7%) had 2 and arteries and 15 (15.3%) had 3 arteries. In 21 kidneys (21.4%) with multiple arteries (group I [GI]), the IEA was used for reconstruction. Four (14.3%) had 3 arteries, and 17 (85.7%) had 2 arteries. In 77 patients (group II [GII]), the inferior accessory renal artery was reconstructed with a side-to-side or an end-to-side anastomosis to the main renal artery. Follow-up was 43.8 ± 38.1 months (range, 1-124 months). The Fisher exact test and the 2-tailed t test were used for statistical analysis. RESULTS Delayed graft function occurred in 1 GI patient (4.8%) and in 5 GII patients (6.5%; P >.05). One partial renal infarction occurred in each group (4.8% vs 1.3%; P >.05). There was 1 urinary fistula in GI and 3 urinary fistulas and 1 ureteral stenosis in GII (P >.05). One graft (4.8%) lost function in GI and 5 (6.5%) in GII (P >.05). Eleven patients (53.4%) were hypertensive in GI and 53 (68.8%) in GII (P >.05). CONCLUSION The use of the IEA for revascularization of a living-donor kidney transplant with multiple arteries is safe and effective, yielding similar long-term outcomes compared with the standard technique. Use of the IEA avoids the risks of manipulation of the main renal artery.

Analysis of the learning curve for transurethral resection of the prostate. Is there any influence of musical instrument and video game skills on surgical performance

OBJECTIVE To evaluate the learning curve for transurethral resection of the prostate (TURP) among urology residents and study the impact of video game and musical instrument playing abilities on its performance. MATERIAL AND METHODS A prospective study was performed from July 2009 to January 2013 with patients submitted to TURP for benign prostatic hyperplasia. Fourteen residents operated on 324 patients. The following parameters were analyzed: age, prostate-specific antigen levels, prostate weight on ultrasound, pre- and postoperative serum sodium and hemoglobin levels, weight of resected tissue, operation time, speed of resection, and incidence of capsular lesions. Gender, handedness, and prior musical instrument and video game playing experience were recorded using survey responses. RESULTS The mean resection speed in the first 10 procedures was 0.36 g/min and reached a mean of 0.51 g/min after the 20(th) procedure. The incidence of capsular lesions decreased progressively. The operation time decreased progressively for each subgroup regardless of the difference in the weight of tissue resected. Those experienced in playing video games presented superior resection speed (0.45 g/min) when compared with the novice (0.35 g/min) and intermediate (0.38 g/min) groups (p=0.112). Musical instrument playing abilities did not affect the surgical performance. CONCLUSION Speed of resection, weight of resected tissue, and percentage of resected tissue improve significantly and the incidence of capsular lesions reduces after the performance of 10 TURP procedures. Experience in playing video games or musical instruments does not have a significant effect on outcomes.

Low-intensity shockwave therapy for erectile dysfunction in kidney transplant recipients. A prospective, randomized, double blinded, sham-controlled study with evaluation by penile Doppler ultrasonography

Objectives:To study the efficacy of Low intensity Extracorporeal Shockwave Therapy (Li- ESWT) for the treatment of erectile dysfunction (ED) in kidney transplanted men.Methods:Twenty men (mean age = 53.7 years) were selected. This was a double-blinded, prospective, randomized, sham-controlled trial. The ESWT protocol was based in a 2 treatment sessions per week for 3 weeks. The sham treatment was performed using the same device replacing the effective probe for one that emits zero energy. Baseline and follow-up assessment was performed with International Index of Erectile Function Questionnaire (IIEF) score and Erection Hardness Score (EHS) after 1, 4 and 12 months. Penile Doppler was performed before and after treatment.Results:A total of 20 patients were recruited, 10 patients in each group. Baseline scores were similar. The mean EHS in after 1 month were 2.5 ± 0.85 (Li-EWST) and 2.4 ± 0.7 (Sham therapy), p = 0.724 . After 4 months it was 2.4 ± 0.7 and 2.6 ± 0.84, p = 0,0004 (between the moments) . The baseline IIEF score was 14.9 ± 3(Sham Theraphy) and 10.9 ± 5.1 (Li-EWST). The mean IIEF score after 1 month was 15.6 ± 6.1 (Li-EWST) and 16.6 ± 5.4 (Sham therapy). The mean IIEF score after 4 months was 17.2 ± 5.7 (Li-EWST) and 16.5 ± 5 (Sham therapy), p < 0.0001 (between the moments). IIEF score improvement was higher than 5 in 70% (ranged from 0-10) and in 10% (ranged from 1-14) in Li-ESWT and Sham groups, respectively. The mean change in IIEF score after 12 months was 4.8 in Li-ESWT group .Penile Doppler parameters were similar between groups and did not present improvements.Conclusions:Li-ESWT is a treatment with clinical efficacy. Despite evidences suggesting neoagiogenesis, our short protocol had no impact in penile Doppler parameters.

Renal pseudoaneurysm after core-needle biopsy of renal allograft successfully managed with superselective embolization

Renal biopsy of the allograft is important to evaluate renal dysfunction (1). Rare complications like pseudoaneurysm (PA) can develop and could lead to life-threatening bleeding (2, 3). It can be safely and effectively managed by endovascular embolization yielding good renal function in the long term follow-up (4, 5). We describe a PA of a kidney transplant (KTX) associated with arteriovenous fistula (AVF) at the site of a core needle percutaneous biopsy (CNPB).

The challenge of cystine and struvite stone formers: clinical, metabolic and surgical assessment.

ABSTRACT Purpose: To compare the clinical, metabolic, and calculi characteristics of cystine and struvite stone patients after percutaneous nephrolithotripsy (PCNL). Material and Methods: Between January/2006-July/2013, 11 cystine stone patients were treated in our clinic. Of those, 3 were excluded due to incomplete follow-up. Eight cystine stone patients (2 with bilateral disease; 10 renal units-RU) were considered for further analysis. A cohort of 8 struvite stone formers (10RU) was matched having the same age, gender, body mass index (BMI) and Guys stone score. Analyzed parameters comprised demographic data, serum/urinary metabolic evaluation and surgical outcomes. Results: Both groups had 6 female patients. Groups were similar in regards to age, gender, BMI, stone burden, and serum creatinine (p=NS). All patients had PCNL as the first surgical treatment modality. Stone free rate (SFR) after the first PCNL tended to be lower (0%) in the cystine compared to the struvite group (40%)(p=0.08). Final SFR after secondary procedures increased to 70% in cystine and 80% in struvite patients (p=1.0); mean number of procedures to achieve stone free status was higher in the first group (3.57 vs. 2.0;p=0.028). Hypocitraturia was found in all patients, but struvite cases presented with lower mean urinary citrate levels (p=0.016). Other common abnormalities were elevated urinary pH (cystine 75% and struvite 62.5%;p=1.0) and low urinary volume (62.5%,37.5%;p=0.63). Conclusion: Multiple interventions and suboptimal stone free rates are trait of the significant stone burden of struvite and cystine patients. Underlying metabolic abnormalities characterized by increased urinary pH, hypocitraturia and low urinary volume are often encountered in both populations.

MP30-07 BLADDER AUGMENTATION IN KIDNEY TRANSPLANT PATIENTS: COMPARISON BETWEEN TYPES OF LOWER URINARY RECONSTRUCTION.

INTRODUCTION AND OBJECTIVES: The aim of this study was to assess the results of kidney transplant(KT) in patients with bladder augmentation (BA) and compare results between enterocistoplasty and ureterocistoplasty. METHODS: Betwenn 1988 and 2015, 64 patients with BA underwent KT ( 3 after KT), due to significant lower urinary tract dysfunction. Ten second and 1 third KT were performed, comprising 75 KT in 64 patients The bowel segments used in the augmentation included ileum in 45(70.3%) patients, ileocecal in 3(4.7%) patients and sigmoid in 4(6.3%) patients. The ureter was used in 12 (18.8%) patients. Redo BA was performed in 4 patients after ureterocistoplasty (1 redo ureterocistoplasty, 3 redo ileocistoplasty); 2 redo BA were performed before the first KT. Mean age at first KT in Group 1(enterocistoplasty, n1⁄448) and Group 2(ureterocistoplasty, n1⁄412) was 24.28 and 15.06 years, respectively. Mean age at BA in Group 1 and 2 was 19.06 and 11.87 years, respectively. Redo KT was performed in 6 (11.3%) and 6 (50%) patients in Group 1 and 2, respectively. KT from deceased donor in Group 1 and 2 was 39.6% and 44.4%, respectively. KT from living donor in Group 1 and 2 was 60.4% and 55.6%, respectively. RESULTS: Mean follow-up after first BA was 188,8 118,9 (17522) months and 140,5 71,5 (16-224) months in Group 1 and 2, respectively. In group 1, overall patient survival after 10 years was 78.78% and actuarial graft survival at 1,3,5,7 and 10 years was 94.3%,92.2%,83.1%,70.1 and 63.1%, respectively. In group 2, overall patient survival after 10 years was 90.9% and actuarial graft survival at 1,3,5,7 and 10 years was 88.5%,76.7%,76.7%,68.2 and 34.1%, respectively. Forty (83.3%) and 8(66.7%) patients in Group 1 and 2 were in clean intermittent catheterism (CIC), respectively. Symptomatic or febrile urinary tract infection occurred at least 1 episode in 81.3% and 83.3% in group 1 and 2, respectively. CONCLUSIONS: Both enterocistoplasty and ureterocistoplasty are safe and effective methods of restoring lower urinary tract function in patients with end stage renal disease and a small, noncompliant bladder. CIC is safe in both groups. Graft survival rates are similar until 9 years, with a tendency of poor results after 10 years in ureterocistoplasty patients.

PD38-11 KIDNEY TRANSPLANTATION IN PATIENTS WITH BLADDER AUGMENTATION: LONG TERM OUTCOMES

INTRODUCTION AND OBJECTIVES: The aim of this study was to assess the results of kidney transplant (KT) in patients with bladder augmentation (BA). METHODS: Between 1988 and 2015, 64 patients with BA (3 after KT) underwent kidney transplantation, due to significant lower urinary tract dysfunction. There were 40 males and 24 females. Ten second and 1 third KT were performed, comprising 75 KT in 64 patients. 44 were from living donor and 31 from deceased donor. Mean age at first KT was 22.54 15.09 (3-64) years and mean age at first bladder augmentation was 18.31 13.83 (2-64) years. The etiology of bladder dysfunction was neurogenic bladder due to spina bifida (23 patients), posterior urethral valve (12 patients), vesico-urethral reflux (6 patients), tuberculosis (8 patients) and other causes (14 patients). The bowel segments used in the augmentation included ileum in 45(70.3%) patients, ileocecal in 3(4.7%) patients and sigmoid in 4(6.3%) patients. The ureter was used in 12 (18.8%) patients. Redo BA was performed in 4 patients (1 ureterocistoplasty and 3 ileocistoplasty), all after ureterocistoplasty. In 2 patients, it was performed before the first kidney transplant. RESULTS: Mean follow-up after first BA was 172.47 112,07 (11-522) months. Overall patient survival was 77.6% and actuarial graft survival at 1,2,5,7,9 and 10 years was 92%, 87.6%, 81.2%, 67.8%, 65.7% and 53.9%, respectively. Surgical complications included 1 vesicocutaneous fistula and 1 stenosis of ureteral reimplant. 51(79.7%) patients were in clean intermittent catheterization. Symptomatic or febrile urinary tract infections (UTI) occurred at least 1 episode in 79.3% of patients. Ten (62.5%) patients died of unrelated cause and 6 (37.5%) patients died due to related causes. The main cause of graft loss was chronic allograft nephropaty in 21 (77.7%) patients. CONCLUSIONS: Augmentation cystoplasty is a safe and effective treatment for lower urinary dysfunction. Patients must be followed up closely with special attention to UTIs. Survival graft after 10 years seems to similar to regular KT recipients.

Donor Transmission Intestinal Carcinoma After Kidney Transplantation: Case Report

Tumor transmission is a rare complication of organ transplantation. Despite several improvements in excluding donor malignant disease, there continue to be reports of unknown tumors in the donors. The risk of having a donor with an undetected malignancy ranges between 1.3% and 2%. The cases of two kidney transplant recipients who had intestinal carcinoma transmitted from the same deceased donor are described. The clinical presentation, previous data, and management options are discussed. As a result of the increase in the overall donor pool, using extended criteria donors, donors of extreme ages, donors with prolonged intensive care admission, and donors who may potentially transmit disease to their recipients, the risk of tumor transmission and also infections should be considered.