Marcelo Ferreira Cassini

Intermittent urethral catheterization—descriptive study at a Brazilian service

AIMS AND BACKGROUND The rehabilitation process of patients with neurogenic bladder involves psychosocial, cultural, political and economic human factors, representing a challenge for patients/caregivers as well as health professionals. This study was aimed at characterizing patients with neurogenic bladder who use intermittent urethral catheterization and were going through rehabilitation at a teaching hospital. METHOD This descriptive study was undertaken in the interior of São Paulo State-Brazil. All ethical guidelines were complied with. To collect the data, interviews were held during nursing consultations with patients more than 18years of age suffering from neurogenic bladder who used intermittent urethral catheterization. RESULTS Most patients had spinal cord trauma, are single, male and gain a low income. They have been using catheterization for several years, at irregular frequencies, using polyethylene catheters. CONCLUSIONS No standardization exists in the accomplishment of the practices used and strategies are needed to remodel the service.

Why not to use kidney grafts from elderly donors.

BACKGROUND Kidney transplantation is widely recognized as the best treatment in patients who require renal replacement therapy. Although considered a clinical and surgical triumph, it is also a source of frustration because of lack of donor organs and the growth of waiting lists. Strategies need to be developed to increase the supply of organs. One measure is use of expanded criteria for donation. OBJECTIVE To evaluate the effect of donor age on cadaver graft survival. MATERIALS AND METHODS We reviewed the medical records for 454 patients who underwent kidney transplantation with cadaver donors from April 1987 to December 2003. RESULTS Donor age had a significant effect on kidney transplant survival. Survival of grafts from donors aged 16 to 40 years (mean, 143.30 months) was significantly greater compared with that of grafts from donors older than 40 years (66.46 months) (P = .005). The HLA matching and cold ischemia time did not significantly affect transplant survival (P = .98 and P = .16, respectively). CONCLUSIONS Kidneys from cadaver donors older than 40 years significantly compromised graft survival, generating a negative effect via early return of recipients to waiting lists and increasing the rate of repeat transplantation, risk of death, and unnecessary costs.

Postnatal evaluation of intrauterine hydronephrosis due to ureteropelvic junction obstruction

PURPOSE Fetal hydronephrosis is a frequent finding due to advances in prenatal ultrasonography. The definition of fetal and neonatal urinary tract obstruction is a very difficult task requiring confirmation of reduced renal function and hydronephrosis. In this study we followed a series of consecutive patients with intrauterine hydronephrosis that persisted during post-natal life. METHODS 116 newborns with antenatal hydronephrosis diagnosed by ultrasound and submitted to a specific post-natal evaluative protocol with a follow-up period of 6 years. RESULTS In 45 (38.8%) of 116 patients, ureteropelvic junction (UPJ) obstruction was confirmed and surgical correction of the UPJ obstruction was done in 19 patients. From 26 children who were initially submitted to non-surgical treatment, only 6 (23%) needed a surgical approach during follow up. Overall analysis showed that surgery was performed in 25 patients with UPJ obstruction, and the others 20 patients were kept under clinical observation, since normal renal function was confirmed by scintigraphy scans. CONCLUSION Fetal hydronephrosis due to UPJ obstruction deserves careful postnatal evaluation. UPJ obstruction is the most frequent anomaly and its surgical treatment has very precise indications. The evaluative protocol was useful in identify patients that could be followed-up with a non-surgical approach.

Histologic Study of Urethral Extracellular Matrix and Collagen From Aging and Long-Term Alloxan-induced Diabetic Male Rats

OBJECTIVES To evaluate the histological alterations of extracellular matrix in long-term alloxan-induced diabetes and aging urethras of male rats with descriptions of total connective tissue, muscle layer and collagen types I and III relative amounts. METHODS Histologic evaluations were performed in 3 animal groups: group 1, 8 weeks old; group 2, 44 weeks old; and group 3, 44 weeks old with alloxan-induced diabetes. The muscle layer thickness, extracellular matrix fibrosis, and collagen were quantified on digital images of the urethral samples. RESULTS A higher total thickness and muscle layer thickness and higher connective tissue and collagen content were observed in the urethras of group 3. No changes in the collagen type III/I ratio were found in the urethra of groups 2 and 3. CONCLUSIONS Our results suggest that the morphologic alterations of the urethra should also be considered in long-term studies of diabetic lower urinary tract dysfunction. These morphologic alterations due to diabetes differ from the changes induced by aging itself and could represent a final stage in decompensate urethras. Further studies are necessary to establish the real influence of the urethral morphologic changes on lower urinary tract diabetes dysfunction.

Imaging in Kidney Transplantation

At the end-stage of renal failure, the best option for treatment is kidney transplantation, before starting any form of dialysis. The scarcity of organs from cadaveric donors and the comorbidity of the receptors patients, delay this treatment from being routinely performed prior to dialysis. Living-donor kidney transplantation can meet this objective perfectly, since it does not depend on waiting lists imposed by cadaveric donation [1]. In recent years, the expansion of genetically unrelated living donation has facilitated living-donor kidney transplantation as spouses, distant relatives, and even good friends have increased the pool of potential living donors. The living-donor transplants offer better survival than those of cadaveric-donor transplants, despite of HLA compatibility [2, 3].

Therapeutic option for infected urinary tract fistulas in renal transplantation.

BACKGROUND Approximately 20% of urinary tract fistulas after renal allografting are complicated by urinary tract infection, which presents a therapeutic challenge. OBJECTIVE To evaluate an option for treatment of urinary tract fistulas associated with urinary tract infection and unsuitable for minimally invasive or primary surgical urinary tract repair. PATIENTS AND METHODS The study included 650 recipients who underwent transplantation over 17 years. Urinary leakage was initially treated with indwelling bladder catheterization. Patients with fistulas refractory to treatment underwent surgical intervention to repair the urinary tract. In patients who were not candidates for primary repair of the urinary tract, temporary urinary diversion was performed, rather than classic percutaneous or open nephrostomy, using a ureteral stent (ie, a 6F or 8F Foley catheter with the balloon placed inside the renal pelvis). RESULTS Overall, urinary leakage occurred in 36 patients (5.5%). Conservative management was successful in 14 vesical fistulas (42.4%) and no ureteral fistulas (0%). Three patients died of sepsis during conservative treatment, before the new surgical approach. Five of 36 urinary leaks (13.9%) were managed using ureteral intubation with an 8F Foley catheter, with a success rate of 80%. CONCLUSION Ureteral catheterization with an 8F Foley catheter is a feasible therapeutic option to treat complicated urinary tract fistulas unsuitable for primary surgical repair of the urinary tract.

Complications after bladder augmentation in children

PURPOSE Bladder augmentation is an effective surgical procedure for increasing bladder capacity and reducing pressure on the urinary system. It is indicated for patients with anomalies such as spina bifida, myelomeningocele, urethral valve and bladder exstrophy, who progress with low tolerance of medication. CASES This was a retrospective study conducted on pediatric patients submitted to bladder augmentation from 2000 to 2011. RESULTS 34 patients aged 4 to 17 years were submitted to bladder augmentation, 30 of them with an ileal loop and 4 with a ureter.A continent urinary shunt was performed in 16 patients, the Mitrofanoff conduit was associated in 15, and the Macedo technique was used in one. Mean follow-up was 34.35 months (1 to 122 months). Mean creatinine was 1.5 ng/ml (0.4 to 7.5 ng/ml) preoperatively and 1.78 ng/ml postoperatively. Three patients required a renal transplant during follow-up. There was improvement or resolution of vesicoureteral reflux in 83.5% of the kidneys on the right and in 75% on the left. Bladder capacity increased, on average, from 152.5 ml to 410 ml. The main complications were vesical lithiasis in 3 patients and conduit perforation in one. CONCLUSION Bladder augmentation showed good results in this series, preserving renal function in most of the patients.

Expression of VEGF and collagen using a latex biomembrane as bladder replacement in rabbits

OBJECTIVE To investigate the VEGF expression and collagen deposition using a latex biomembrane as bladder replacement in rabbits. MATERIALS AND METHODS After partial cystectomy, a patch of a non-vulcanized latex biomembrane (2 x 2 cm) was sewn to the bladder of rabbits with 5/0 monofilament polydioxanone sulfate sutures in a watertight manner. Groups of 5 animals were killed at 15, 45 and 90 days after surgery and the bladder was removed. Sections of 5µm were cut and stained with picrosirius-red in order to estimate the amount of extracellular matrix in the graft. To confirm the presence of VEGF in tissues, protein expression was determined by immunohistochemistry. RESULTS No death, urinary leakage or graft extrusion occurred in any group. All bladders showed a spherical shape. A progressive reduction in the amount of collagen occurred in the graft area and was negatively and linearly correlated with time (p < 0.001). VEGF expression was higher in grafted areas when compared to controls at 15 and 45 days after surgery and decreased with time (p < 0.001). CONCLUSION The latex biomembrane as a matrix for partial bladder replacement in rabbits promotes temporary collagen deposition and stimulates the angiogenic process.

Lovastatin protects mithochondrial and renal function in kidney ischemia-reperfusion in rats

PURPOSE To investigate the effect of lovastatin on renal ischemia followed by reperfusion. METHODS Thirty one Wistar rats submitted to left renal ischemia for 60 minutes followed by contralateral nephrectomy were divided into two groups: A (n =17, control, no treatment), and B (n=14, lovastatin 15 mg/kg/day p.o. ten days before ischemia). The animals were sacrificed at the end of ischemia, after 24 hours and at seven days after reperfusion. Survival, serum urea and creatinine levels and renal mitochondrial function were evaluated. RESULTS Mortality was 29.4% in group A and 0.7% in group B. Urea and creatinine levels were increased in both groups, but the values were significantly lower in group B. Mitochondrial function showed decoupling in 83.4% of group A, as opposed to 38.4/% of group B. CONCLUSIONS The result shows a protective action of renal function by lovastatin administered before ischemia/reperfusion. Since most of the mitochondrial fraction presented membranes with the ability to maintain ATP production in group B, stabilization of the mitochondrial membrane should be considered as part of the protective action of lovastatin on renal function in ischemia/reperfusion.

Chronic partial urethral obstruction in female rats: description of an experimental model and initial results

PURPOSE To develop an experimental model of infravesical urinary obstruction in female rats. METHODS After median caudal laparotomy, the urethra of 14 female rats was delicately separated from the vagina and loosely wrapped with cellophane tape measuring 0.4 x 1.0 cm. The animals were evaluated 4 (n=7) and 8 (n=7) weeks later. Five additional control animals were only subjected to separation of the urethra and vagina and monitored for 12 weeks. RESULTS After four weeks, three rats presented vesical dilation associated with discrete ureteral ectasis in 2 animals, with the third presenting discrete hydronephrosis in one kidney. After eight weeks, five rats (71.4%) presented vesical distension with bilateral ureterohydronephrosis. No significant changes (p>0.05) in serum urea or creatinine occurred in any group compared to preoperative values. CONCLUSION We present here an inexpensive and simple method for the slow induction of urethral obstruction in adult female rats, with the development of progressive vesical hypertrophy and ureterohydronephrosis, which may be used as an experimental model for the study of different aspects of obstructive nephropathy.