Indocyanine Green as a Beacon Light in Laparoscopy: A New Application in Transplant Surgery: A Case Report.

INTRODUCTION: Indocyanine green (ICG) fluorescence imaging system is a now a consolidated complementary technique for several surgical fields. The development of post-transplant lymphocele following lymph spread could affect kidney function; between therapeutic options, the literature reports a 12% overall conversion rate from laparoscopic to open surgery with a major risk of damaging the urinary tract. OBJECTIVE: The goal of the present study was to demonstrate that intraoperative ICG fluorescent imaging is a safe technique that can be used in laparoscopy establishing the exact location of the lymphocele and reducing intraoperative risks. METHOD: Fifty milligrams of ICG dissolved in 20 mL of saline solution was injected via percutaneous drainage placed into the lymphocele to decompress transplanted kidneys 2 weeks before a laparoscopic lymphocele marsupialization procedure. RESULTS: During the first exploratory laparoscopy, in the flank and right iliac fossa, near the 2 renal grafts, fluorescence was identified in 3 raised areas that were the internal side of the lymphocele lobes. The lymphocele wall was dissected and 300 mL of serous fluid was aspirated after puncturing. A 5 cm breach was then made in the cyst wall using the Ultracision harmonic scalpel (Ethicon US). Afterwards, a pedicle of the omentum in the lymphocele core was interfered with and fixed by 2 stitches. CONCLUSIONS: Laparoscopic surgery seems to be the preferred surgical option for the treatment of primary symptomatic lymphocele after kidney transplantation. Intraoperative ICG fluorescent imaging is a safe technique to establish the exact location of the lymphocele and reduces the risk of damaging urinary structures during surgery.

Aortobisiliac Bypass Using a Venous Homograft Concomitant With Kidney Transplantation in a Patient With Severe Bilateral Iliac Occlusive Disease: A Case Report.

Aortoiliac occlusive disease (AOD) is a great threat for kidney transplantation (KT). Here we report the case of an aortoiliac bypass, performed simultaneously with renal transplantation using venous grafts obtained from the deceased donor. The recipient was a 68-year-old woman with significant stenosis of the aortoiliac axis. We performed an aortobisiliac bypass using donor's femoral veins because presence of methicillin-resistant Staphylococcus aureus was detected on donor hemoculture and contraindicated a prosthetic implant on the recipient. KT was then carried out using standard technique. Operative time amounted to 330 minutes and cold ischemia time of the renal graft was 900 minutes. Delayed graft function was observed until postoperative day 12, but the patient showed a good urine output and a serum creatinine of 2.1 mg/dL at discharge. AOD is not an absolute contraindication to renal transplantation, and simultaneous surgical repair of aortoiliac lesions with KT seems feasible. The patient's return to function after initial delayed graft function suggests that such interventions may allow transplantation to be offered to those patients who otherwise may be excluded for severe vascular comorbidities. Homologous vascular grafts are an excellent choice because prosthetic vascular replacement during immunosuppression must be avoided as long as possible, especially in patients with coexisting infective risk.

Psychotherapy: a missing piece in the puzzle of post radical prostatectomy erectile dysfunction rehabilitation.

OBJECTIVES: To measure the impact of psychotherapy associated to the use of Tadalafil in the improvement of erectile function after radical prostatectomy. METHODS: From 132 patients surgically treated for prostate cancer, thirty sequential patients with bilateral nerve sparing, low risk controlled disease and post-surgery erectile dysfunction (ED) took Tadalafil 20mg and underwent psychotherapy sessions, both weekly for three months. Patients were interviewed to establish the quality of erection using the instrument IIEF-5 and to measure psychological features impacting erectile function, aspects related to function, dysfunction, physical and emotional discomfort were evaluated with the help of an intensity scale. RESULTS: The average age was 62.5 (46 to 77 years), 96.7% had a stable relationship, 56.6% of the patients accepted the diagnosis and 43.2% exhibited defense mechanisms (3.3% negation, 6.6% revulsion, 33.3% concern). A positive correlation was observed between erectile function and time exposed to treatment (IIEF-5 - 9.7 to 13.3, p=0.0006), with increased satisfaction with life in general (2.1 to 2.7, P=.028) and sexual life (3.1 to 3.7, P=.028), added to facilitation of expressing feelings/emotions (1.8 to 3.0, P=.0008). Satisfaction with relationship and intimacy with partner did not present significant improve (P=.12 and P=.61, respectively). CONCLUSIONS: A holistic patient care with more complete ED rehabilitation includes psychotherapy with a positive correlation between erectile function and treatment exposition. Psychotherapy allowed the identification of important spouse related factors in this scenario.

[Does the criterion for prostate biopsy indication impact its accuracy? A prospective population-based outpatient clinical setting study]. / ¿Impacta el criterio para indicar la biopsia prostática sobre su exactitud? Estudio prospectivo llevado a cabo sobre una población de pacientes ambulantes.

INTRODUCTION: Prostate specific antigen (PSA) and digital rectal examination (DRE) are the main tests for initial prostate investigation; there is no consensus about the best criterion for prostate biopsies. We aim to check the accuracy of different criteria in this context including PSA derivatives to detect prostate cancer. MATERIAL AND METHODS: Four different criteria for indication of prostate biopsy were compared: (A) PSA-density (>15 ng/ ml/ cc); (B) PSA > 2,5 ng/ml; (C) PSA-velocity (> 0.7 ng/ ml/ year); (D) free/total PSA ratio (<15%). All biopsies and histopathological examinations were performed by the same urologist and pathologist, respectively. RESULTS: The study was performed on 180 consecutive biopsies with 37.7% overall cancer detection rate: 29 (16.1%) performed following criterion A, 42 (23.3%) criterion B, 65 (36.1%) criterion C and 44 (24.4%) criterion D. Based on PSA criteria alone, the predictive positive value (PPV) was 37.9% for criterion A, 33.3% for B, 32.3% for C and 50.0% for criterion D, respectively, (p > 0.05). Associating positive DRE with changed PSA, the PPV increased to 50%, 50%, 43.9% and 68.2% for criteria A, B, C and D, respectively (p>0.05). In univariate analysis, DRE (positive versus negative), PSA level (>10 ng/ ml versus <4.0 ng/ ml), free/total PSA ratio (<10% versus >15%) and age were associated with PC. In multivariate analysis only positive DRE was associated with prostate cancer. CONCLUSIONS: All the criteria of PSA derivatives are complementary and useful predictors of cancer risk. However, a positive DRE increased the PPV of PSA derivatives. New tools are needed to improve the accuracy of prostate cancer detection.

[Strategies for transfusion-free radical retropubic prostatectomy in Jehovah's witnesses]. / Estrategias para la prostatectomía retropúbica radical sin transfusión en testigos de Jehová

OBJECTIVES: While radical retropubic prostatectomy carries significant potential for blood loss requiring transfusion, Jehovah's Witnesses do not permit the use of allogeneic blood products. This study presents strategies for transfusion-free radical retropubic prostatectomy for prostate cancer treatment in Jehovah's Witnesses patients. METHODS: From March 1998 to May 2009, 25 Jehovah's Witnesses patients diagnosed with prostate cancer underwent radical prostatectomy and bilateral iliac and obturatory lymphadenectomy. Preoperative hemoglobin boost utilizing erythropoietin aiming hemoglobin over 14 g/dL, normovolemic hemodilution and availability of cell salvage machine were provided for blood loss management. RESULTS: The mean age was 62 (43 to 70) years and the mean hospitalization time was 3.5 (3 to 7) days. Mean intra-operative bleeding was 430 (+/-120) ml and the mean pre- and post-operative hemoglobin (measured before discharge) was 15.1 (+/-0.8) and 11.7 (+/-2.3) g/dL, respectively. There was no need for cell salvage machine or transfusion. The lowest hemoglobin was 5.7 g/dL due to post-operative bladder neck bleeding, which responded to twenty days of office based erythropoietin subcutaneously on alternate days reaching 12 g/dL hemoglobin. There was no complication related to non-transfusion. CONCLUSIONS: The proposed techniques were essential for maximum reduction of the need for transfusions without increasing complications. Further studies are needed to introduce these methods in all cases of radical retropubic prostatectomy regarding the benefits in lowering costs and risks related to transfusion.

[Extracorporeal lithotripsy in children - the efficacy and long-term evaluation of renal parenchyma damage by DMSA-99mTc scintigraphy]. / Litotricia extracorpórea en niños. Eficacia y evaluación a largo plazo de la lesión del parénquima renal mediante gammagrafía con DMSA-99mTc.

PURPOSE: To determine the effectiveness of extracorporeal shock-wave lithotripsy (ESWL) and possible deleterious effects on renal parenchyma of children subjected to treatment of renal lithiasis, using renal scintigraphy with 99mTc dimercapto-succunic acid (DMSA). PATIENTS AND METHODS: From January 2004 to November 2007, 18 children (age 3-10 years) underwent ESWL (Philips-Dornier) for kidney urolithiasis. All patients underwent preoperative evaluation, including physical examination, urine culture, image exams and renal scintigraphy with Tc99-DMSA. Evaluation after treatment consisted of a clinical examination, blood pressure measurement, urine culture, renal ultrasound and Tc99-DMSA, repeated at 3, 6 and 12 months, which were compared to the scans obtained before ESWL to determine possible morphological or functional changes. RESULTS: Success in the stones fragmentation was achieved in all cases - in 9 patients (50%) with one session of ESWL, in 6 (33%) with two sessions and in 3 patients (17%) with 3 sessions of ESWL. Only one patient (5%), after three sessions of ESWL and 6 months of follow-up showed change in size of right kidney with a decrease in tubular function, without hypertension or other major changes. In the other cases, there was absence of hypertension up to 12 months of follow-up, absence of renal hematomas detected by ultrasound or significant renal scars in scintigraphic examinations. CONCLUSION: ESWL is effective and safe for treating renal lithiasis in children. Renal parenchyma lesions may occur early after treatment, but these lesions are transients and resolve spontaneously in virtually all cases; generally, there are no irreversible renal lesions associated with ESWL, even after the follow-up period with clinical examination, ultrasound examination and 99mTc-DMSA scintigraphy.