Lísias Nogueira Castilho

Laparoscopy for the Nonpalpable Testis: How to Interpret the Endoscopic Findings

We evaluated by laparoscopy 38 patients with 45 nonpalpable testes. Of 24 testes identified in the abdominal cavity 15 were atrophic, 2 had no epididymal connection and 7 were normal in appearance. Of the 38 patients 32 (84.2%) underwent exploration. A correlation of 100% occurred between laparoscopy and surgery concerning the presence or absence of the testis. Of the testes sought 60% were present (all but 1 in the abdomen) and 40% were absent. We conclude that diagnostic laparoscopy is as effective as exploration in adults and children, with a low risk of complication.

Pheochromocytoma: a long-term follow-up of 24 patients undergoing laparoscopic adrenalectomy

PURPOSE Pheochromocytomas are tumors derived from chromaffin cells that often secrete catecholamines and cause hypertension. The clinical diagnosis of pheochromocytoma depends on the presence of excessive production of catecholamines. Conventional imaging modalities that have been used in the preoperative evaluation include CT, MRI, and 131I-MIBG scintigraphy. Surgical resection is the definitive treatment for patients with pheochromocytoma. The goal of this study was to evaluate the long-term follow-up of 24 patients undergoing laparoscopic adrenalectomy for pheochromocytoma. MATERIALS AND METHODS From January 1995 to September 2006, 24 patients underwent laparoscopic adrenalectomy for adrenal pheochromocytoma. Twenty (83.3%) patients had arterial hypertension. The inclusion criteria of patients in this retrospective study were laparoscopic approach, unilateral or bilateral adrenal tumor, pathological diagnosis of pheochromocytoma and a minimum follow-up of 18 months. RESULTS Intra-operative complications occurred in 4 (16.7%) patients. Two (8.3%) patients had postoperative complications. Two patients (8.3%) had blood transfusion. The mean postoperative hospital stay was 3.8 days (range 1 to 11). Eighteen (90%) of the twenty patients who had symptomatic hypertension, returned to normal blood pressure immediately after surgery, during the hospital stay. In one patient, the high blood pressure levels remained unchanged. Another patient persisted with mild hypertension, well controlled by a single antihypertensive drug. CONCLUSIONS Our results confirmed that laparoscopic adrenalectomy for pheochromocytoma is a safe and effective procedure, providing the benefits of a minimally invasive approach. In our study, the initial positive results obtained in the treatment of 24 patients were confirmed after a mean follow-up of 74 months.

Prognostic factors for late urinary toxicity grade 2-3 after conformal radiation therapy on patients with prostate cancer

OBJECTIVE Identify prognostic factors associated to late urinary toxicity in patients with prostate cancer submitted to radical conformal radiotherapy (3DCRT). MATERIALS AND METHODS From July 1997 to January 2002, 285 patients with localized prostate cancer were consecutively treated with 3DCRT and retrospectively analyzed. Thirty seven (13%) patients were submitted to transurethral prostate resection previously to 3DCRT. The median dose delivered to the prostate was 7920 cGy (7020-8460). Patient and treatment characteristics were analyzed and correlated to late urinary toxicity grade 2-3, especially whether certain radiation doses applied to certain bladder volumes, when visualized through computerized tomography (CT) planning, correlated with the observed actuarial incidences of late urinary complications, using bladder volume as a continuous variable. RESULTS On a median follow-up of 53.6 months (3.6-95.3), the 5-year actuarial free from late urinary toxicity grade 2-3 survival was 91.1%. Seven and fifteen patients presented late urinary toxicity grades 2 and 3, respectively. Prior transurethral resection of prostate and radiation dose over 70 Gy on 30% of initial bladder volume were independent prognostic factors for late urinary toxicity grade 2-3. CONCLUSIONS This study suggests that restricting radiation doses to 70 Gy or less on 30% of bladder volume, visualized through CT planning, may reduce late urinary complications. It furthermore suggests that patients with prior transurethral resection of prostate may indicate a group of patients with a greater risk for late urinary toxicity grade 2-3 after 3DCRT.

Laparoscopic adrenal surgery in a Brazilian center

BACKGROUND AND PURPOSE The laparoscopic approach to the adrenal gland was first reported in 1992. Since then, many publications about this issue have come from Europe, Japan, and North America. We reviewed our 7-year experience with laparoscopic adrenal surgery. This is the first large series presented from Latin America. PATIENTS AND METHODS Laparoscopic adrenalectomy was carried out in 61 female and 33 male patients between January 1994 and February 2001. Their ages ranged from 1 to 72 (42.8 +/- 16.4 years) years. Ten patients (10.6%) were 20 years or younger, 10 (10.6%) had unilateral tumors >4 cm, 22 (23.4%) had a Body Mass Index >/= 30, and 10 (10.6%) had had previous open upper abdominal surgery. The size of the lesion ranged from 1 to 9 cm (2.9 +/- 4 cm). Ninety-seven operations were performed, of which 91 were unilateral and 6 were bilateral, adding up to 103 adrenalectomies. Among the 97 procedures, the lateral transperitoneal approach was employed in 94 cases, whereas a lateral retroperitoneal approach enabled 3 adrenalectomies. RESULTS Unilateral procedures lasted 117 +/- 43.7 minutes (range 45-250 minutes); bilateral procedures lasted 186 +/- 91.6 minutes (range 100-345 minutes). Five operations (5.1%) were converted to open surgery. Twenty patients (21.3%) suffered complications, 8 (8.5%) being intraoperative and 12 (12.8%) postoperative. Six cases (6.4%) were considered major complications. No deaths occurred. The blood transfusion rate was 4.2%. The hospital stay averaged 6.1 +/- 15.3 days (range 1-140 days). The follow-up period was 17 +/- 12.6 months (range 1-60 months). CONCLUSIONS Laparoscopic adrenalectomy is feasible and has excellent results in properly selected patients.

Comparison of clamping modalities in a rabbit model of normothermic renal ischemia.

PURPOSE The objective of this study was to investigate the patterns of renal function recovery with different renal vessel clamping modalities during a prolonged warm ischemia (WI) condition in an experimental two-kidney rabbit model. MATERIALS AND METHODS Twenty-eight rabbits were randomly clustered into four groups and underwent laparotomy with different types of renal pedicle clamping. Group 1 (n=4) was sham-operated. Group 2 (n=8) underwent 80 minutes of WI with artery only clamping. Group 3 (n=8) underwent arteriovenous clamping for 80 minutes, and group 4 (n=8) received an arteriovenous clamping for 80 minutes with 10-second declamping periods every 20 minutes. Serum levels of creatinine (SCr) were recorded preoperatively and on postoperative days (PODs) 1, 3, and 7. Renal function was evaluated by (99m)technetium-mercaptoacetyltriglycine scintigraphy. Afterward, the animals were euthanized, and the kidneys were harvested and evaluated microscopically. RESULTS Renal function completely recuperated on POD 7 in the groups that underwent artery only and ateriovenous intermittent clamping, and both of these methods were superior to ateriovenous clamping (P<0.001). SCr showed a similar variation in all the clamping groups and did not demonstrate statistical differences among the groups. Histopathologic changes were similar among the ischemic groups. CONCLUSION The less deleterious clamping modalities in this experimental model were the artery only and intermittent en bloc clamping methods.

Analysis of the effect of renal excretory system cooling during thermal radiofrequency ablation in an animal model

OBJECTIVE Analysis of renal excretory system integrity and efficacy of radiofrequency ablation with and without irrigation with saline at 2°C (SF2). MATERIALS AND METHODS The median third of sixteen kidneys were submitted to radiofrequency (exposition of 1 cm) controlled by intra-surgical ultrasound, with eight minutes cycles and median temperature of 90°C in eight female pigs. One excretory renal system was cooled with SF2, at a 30mL/min rate, and the other kidney was not. After 14 days of post-operatory, the biggest diameters of the lesions and the radiological aspects of the excretory system were compared by bilateral ascending pyelogram and the animals were sacrificed in order to perform histological analysis. RESULTS There were no significant differences between the diameters of the kidney lesions whether or not exposed to cooling of the excretory system. Median diameter of the cooled kidneys and not cooled kidneys were respectively (in mm): anteroposterior: 11.46 vs. 12.5 (p = 0.23); longitudinal: 17.94 vs. 18.84 (p = 0.62); depth: 11.38 vs. 12.25 (p = 0.47). There was no lesion of the excretory system or signs of leakage of contrast media or hydronephrosis at ascending pyelogram. CONCLUSION Cooling of excretory system during radiofrequency ablation does not sig¬nificantly alter generated coagulation necrosis or affect the integrity of the excretory system in the studied model.