Impact of the COVID-19 pandemic on the urologist's clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period

This letter to the Editor aims to provide suggestions and recommendations for the management of urological conditions in times of COVID-19 crisis in Brazil and other low- and middle-income countries. It is important to highlight that one of the main characteristics of this pandemic is the oversaturation of the health system capacity, mostly due to a high demand for personal protective equipment (PPE), Hospital/ICU beds, as well as ventilators. In places with limited resources and where the health care systems are already saturated, such consideration is even more worrisome. Therefore, most worldwide authorities are recommending to avoid, as much as possible, patient's elective visits to hospitals, as well as a judicious use of the operating room in order to mitigate the strain put on the health system. While efforts should be directed to the care of COVID-19 patients, other conditions (especially urgencies and oncological cases) must continue to be assisted. Thus, through a panel of experts, we have prepared a practical guide for urologists based on the recommendations from the main Urologic Associations, as well as data from the literature to support the suggested management. We will try to follow the standard guideline recommendations from the American Urological Association (AUA) and European Association of Urology (EAU), with the aim of pursuing the best outcomes possible. However, some recommendations were based on the consensus of the panel, taking into consideration the reality of developing countries and the unprecedented situation caused by the COVID-19 crisis. Most importantly, all recommendations on this manuscript are based on the expectancy of a maximum 3-month duration of the crisis. If this period shall extended, these recommendations will be revised and updated. The format of the text will be given through questions and answers.(AU)

Assessing the extent of colon lengthening due to splenic flexure mobilization techniques: a cadaver study / Impacto das técnicas de mobilização do ângulo esplênico sobre o alongamento do cólon esquerdo para a anastomose colorretal: estudo em cadáver

CONTEXT: Failure of a colorectal anastomosis represents a life-threatening complication of colorectal surgery. Splenic flexure mobilization may contribute to reduce the occurrence of anastomotic complications due to technical flaws. There are no published reports measuring the impact of splenic flexure mobilization on the length of mobilized colon viable to construct a safe colorectal anastomosis. OBJECTIVE: The aim of the present study was to determine the effect of two techniques for splenic flexure mobilization on colon lengthening during open left-sided colon surgery using a cadaver model. DESIGN: Anatomical dissections for left colectomy and colorectal anastomosis at the sacral promontory level were conducted in 20 fresh cadavers by the same team of four surgeons. The effect of partial and full splenic flexure mobilization on the extent of mobilized left colon segment was determined. SETTING: University of Sao Paulo Medical School, Sao Paulo, SP, Brazil. Tertiary medical institution and university hospital. PARTICIPANTS: A team of four surgeons operated on 20 fresh cadavers. RESULTS: The length of resected left colon enabling a tension-free colorectal anastomosis at the level of sacral promontory achieved without mobilizing the splenic flexure was 46.3 (35-81) cm. After partial mobilization of the splenic flexure, an additionally mobilized colon segment measuring 10.7 (2-30) cm was obtained. After full mobilization of the distal transverse colon, a mean 28.3 (10-65) cm segment was achieved. CONCLUSION: Splenic flexure mobilization techniques are associated to effective left colon lengthening for colorectal anastomosis. This result may contribute to decision-making during rectal surgery and low colorectal and coloanal anastomosis.

CONTEXTO: A deiscência de uma anastomose colorretal representa uma complicação possivelmente fatal na cirurgia colorretal. A mobilização da flexura esplênica pode contribuir para reduzir a ocorrência de complicações da anastomose secundárias a falhas técnicas. Não há trabalhos publicados medindo o impacto da mobilização da flexura esplênica no comprimento do cólon mobilizado viável para a confecção de uma anastomose segura. OBJETIVO: determinar o efeito de duas técnicas de mobilização da flexura esplênica no aumento do comprimento do cólon durante colectomia esquerda aberta, utilizando modelo em cadáver. DESENHO: Dissecções anatômicas para a colectomia esquerda e anastomose colorretal ao nível do promontório sacral foram conduzidas em 20 cadáveres frescos pelo mesmo grupo de quatro cirurgiões. O efeito da mobilização da flexura esplênica parcial e total na extensão do segmento do cólon esquerdo mobilizado foi determinado. LOCAL: Centro Médico da Faculdade de Medicina, São Paulo (SP), Brasil. Instituição médica terciária e hospital universitário. PARTICIPANTES: Um time de quatro cirurgiões operando em 20 cadáveres frescos. RESULTADOS: O comprimento do cólon esquerdo dissecado permitindo uma anastomose sem tensão ao nível do promontório sacral sem a mobilização da flexura esplênica foi de 46,3 (35-81) cm. Após a mobilização parcial da flexura esplênica, um segmento adicional de cólon medindo 10,7 (2-30) cm foi obtido. Após a mobilização completa do cólon transverso distal, um segmento em média de 28,3 (10-65) cm foi obtido. CONCLUSÃO: Técnicas de mobilização da flexura esplênica estão associadas a um aumento efetivo no comprimento do cólon esquerdo para anastomoses colorretais. Esse resultado pode contribuir na tomada de decisões durante a cirurgia retal e anastomoses colorretais baixas e coloanais.

Transmissão do glioma de um doador de múltiplos órgãos para o enxerto pancreático / Transmission of glioma from multiple organ donor do pancreas recipient

Introdução: A disparidade entre a oferta e a demanda de órgãos para transplante impulsiona a inclusão de doadores com tumores primários do sistema nervoso central (SNC) no programa de transplantes. Objetivo: reportar um caso de um paciente que desenvolveu um glioma no enxerto pancreático proveniente de um doador de múltiplos órgãos cuja causa mortis foi um glioma maligno / Introduction: the disparity between the suplly of and the demand for transplant organs has led to an acceptance of donors with primary central nervous system (CNS) tumors. Purpose: face the rarity, the authors report the case of a patient who developed a glioma on a pancreatic grafft received from a donor with a malignant glioma as cause of brain death...

Transplante de pâncreas e rim simultâneo com órgãos provenientes de doador cadavérico previamente 'transplantado' / Pancreas-kidney simultaneous transplant with graft derived from previously transplanted dead donor

O aumento das listas de espera por órgãos para transplante faz com que cada vez mais se procure meios de aumentar o "pool" de doadores de órgãos. Para tanto, tem-se utilizado doadores vivos, limítrofes ou sem batimentos cardíacos. Uma outra forma de se aumentar o número de doadores utilizados é através do uso de órgãos provenientes de doadores previamente transplantados, população que tende a crescer, dado o aumento do número de transplantes realizados no mundo / The raising increase in the patient's waiting list leaves us search for ways to increase the pool of organ donors. Looking at this, there is the use of living donors, of adjoining donors or non-heart beating donors. Another way to increase the number of donors is through the use of organs that came from previously transplanted donors, a group that is becoming larger, because of the rise of the number of transplants all around the world...