Irreversible Renal Function Impairment Due to Silent Ureteral Stones.

OBJECTIVE: To evaluate if renal function loss and hydronephrosis due to a silent ureteral stone might be reversed. MATERIALS AND METHODS: We prospectively selected patients with silent ureteral stones between January 2006 and January 2014. A silent case was considered if there were no specific or subjective symptoms related to the ureteral stone. Patient, stone, and kidney characteristics were evaluated preoperatively, 3 and 12 months postoperatively. Renal function was accessed in the same intervals with serum creatinine (SCr), glomerular filtration rate (GFR), and (99m)Tc-dimercaptosuccinic acid. Patients without complete pre- and postoperative evaluation were excluded. Primary end point was midterm progress of global and ipsilateral renal function. Secondary end points included the evaluation of renal and collecting system anatomy from diagnosis to 12 months after treatment. Analysis of variance with repeated measures and marginal homogeneity test were used to evaluate renal function and hydronephrosis progression. RESULTS: Twenty-six patients met our inclusion criteria. Mean preoperative SCr and GFR were 1.24 mg/dL and 72.5 mL/min, respectively. At initial scintigraphy, mean renal function was 33.4%. Laser ureterolithotripsy was performed in 84.6% of cases and all patients were rendered stone free. Two patients (8%) developed ureteral stenosis. There was no difference regarding SCr (P = .89), GFR (P = .48), and renal function at scintigraphy (P = .19) during follow-up. Hydronephrosis significantly improved from preoperatively to 3 months postoperatively (P < .0001), but not from 3 to 12 months (P = .065). CONCLUSION: Patients with silent ureteral stones present with significant impairment of ipsilateral renal function and hydronephrosis at diagnosis. On midterm follow-up evaluation, renal function of the affected unit remains stable whereas hydronephrosis improves after treatment.

Percutaneous nephrolithotomy in obese patients: comparison between the prone and total supine position.

BACKGROUND: Percutaneous nephrolithotomy (PCNL) can be performed in the prone or in the supine position. Comparisons between the two techniques in obese patients are rare in the current literature. METHODS: The records of obese patients (body mass index >30) who underwent PCNL in the prone or complete supine positions were reviewed. All patients had a noncontrast CT before and after the procedure. Stones were graded according to the Guy stone score and complications according to the Clavien grading. The stone-free rates, operative time, surgical complications, and hospital stay were analyzed. RESULTS: A total of 56 PCNL were performed in 42 patients. Twenty-four PCNL were performed in the prone and 32 in the total supine position. Stone-free rate on the first postoperative day was 50% in the prone and 46.9% in the supine position (P=1.0). Final stone-free rates were 83.3% and 78.1%, respectively (P=0.74). Mean operative time was 164.6 minutes in the prone and 120.3 minutes in the supine position (P=0.0017), and hospital stay was 4.38 and 2.68 days (P=0.014), respectively. The transfusion rate was 20.8% in the prone and zero in the supine position patients (P=0.01). Excluding Guy IV stones, transfusion rate was 8.3% in the prone position (P=0.1). Significant surgical complications rate was 12.5% in the prone and 3.1% in the supine position (P=0.302). CONCLUSION: PCNL performed in the prone or in the complete supine position in obese patients presents similar outcomes. The supine decubitus position has the advantages of a significantly shorter operative time and hospital stay.

Metabolic assessment of elderly men with urolithiasis.

OBJECTIVE: To assess the presence of metabolic disorders in elderly men with urolithiasis. METHODS: We performed a case-control study. The inclusion criteria were as follows: (1) men older than 60 years of age and either (2) antecedent renal colic or an incidental diagnosis of urinary lithiasis after age 60 (case arm) or (3) no antecedent renal colic or incidental diagnosis of urolithiasis (control arm). Each individual underwent an interview, and those who were selected underwent all clinical protocol examinations: serum levels of total and ionized calcium, uric acid, phosphorus, glucose, urea, creatinine and parathyroid hormone, urine culture, and analysis of 24-hour urine samples (levels of calcium, citrate, creatinine, uric acid and sodium, pH and urine volume). Each case arm patient underwent two complete metabolic urinary investigations, whereas each control arm individual underwent one examination. ClinicalTrials.gov: NCT01246531. RESULTS: A total of 51 subjects completed the clinical investigation: 25 in the case arm and 26 in the control arm. In total, 56% of the case arm patients had hypocitraturia (vs. 15.4% in the control arm; p = 0.002). Hypernatriuria was detected in 64% of the case arm patients and in 30.8% of the controls (p = 0.017). CONCLUSION: Hypocitraturia and hypernatriuria are the main metabolic disorders in elderly men with urolithiasis.

Metabolic assessment of elderly men with urolithiasis

OBJECTIVE: To assess the presence of metabolic disorders in elderly men with urolithiasis. METHODS: We performed a case-control study. The inclusion criteria were as follows: (1) men older than 60 years of age and either (2) antecedent renal colic or an incidental diagnosis of urinary lithiasis after age 60 (case arm) or (3) no antecedent renal colic or incidental diagnosis of urolithiasis (control arm). Each individual underwent an interview, and those who were selected underwent all clinical protocol examinations: serum levels of total and ionized calcium, uric acid, phosphorus, glucose, urea, creatinine and parathyroid hormone, urine culture, and analysis of 24-hour urine samples (levels of calcium, citrate, creatinine, uric acid and sodium, pH and urine volume). Each case arm patient underwent two complete metabolic urinary investigations, whereas each control arm individual underwent one examination. ClinicalTrials.gov: NCT01246531. RESULTS: A total of 51 subjects completed the clinical investigation: 25 in the case arm and 26 in the control arm. In total, 56% of the case arm patients had hypocitraturia (vs. 15.4% in the control arm; p = 0.002). Hypernatriuria was detected in 64% of the case arm patients and in 30.8% of the controls (p = 0.017). CONCLUSION: Hypocitraturia and hypernatriuria are the main metabolic disorders in elderly men with urolithiasis.

Management of chronic unilateral hematuria by ureterorenoscopy.

BACKGROUND AND PURPOSE: Chronic unilateral hematuria is characterized by intermittent or continuous gross hematuria that cannot be diagnosed using standard radiology and hematology methods. In the past, it was managed with partial or total nephrectomy. In the age of minimally invasive procedures, however, endoscopy has enabled more accurate diagnosis and management. We analyzed our experience with transurethral ureterorenoscopy using a flexible ureteroscope to determine the feasibility and success of endoscopic management of renal hematuria. PATIENTS AND METHODS: We reviewed the records of 13 patients who presented with chronic unilateral hematuria, in whom radiologic and laboratory tests failed to reveal the source of bleeding. In the cases in which the lesion was identified, after complete inspection of the collecting systems, the bleeding site was treated ureteroscopically with a holmium: yttrium-aluminum-garnet (YAG) laser. RESULTS: Follow-up ranged from 4 to 60 months (mean 26 mos). During the follow-up of the 13 patients, 11 remained symptom-free, with only one session of flexible ureterorenoscopy necessary. Relapse occurred in two patients after 4 months and 6 months, respectively; during a second session of flexible ureteroscopy, the bleeding site was successfully identified and cauterized with a holmium:YAG laser. No surgical complications occurred. CONCLUSIONS: Conservative treatment of patients with chronic unilateral hematuria should always be considered. Laser ureteroscopic treatment is an excellent method and should be considered as the first option for the management of chronic unilateral hematuria.

Laparoscopic dismembered pyeloplasty in 47 cases.

PURPOSE: To evaluate the results of a sequence of 47 laparoscopic Anderson-Hynes pyeloplasties for the treatment of patients with ureteropelvic junction obstruction, independently of the etiology. MATERIALS AND METHODS: Twenty male and 27 female patients diagnosed with ureteropelvic junction obstruction were treated by Anderson-Hynes transperitoneal laparoscopic dismembered pyeloplasty from April 2002 to January 2006. The age of the patients ranged from four to 75 years, with a mean age of 32.3 years. The follow-up ranged between six and 30 months, with a mean follow-up time of 24 months. The outcomes were evaluated through the assessment of symptoms and imaging studies. RESULTS: In 44 (93.6%) of the 47 patients, resolution of the pain and a reduction in ureteropelvic dilation were observed. The mean operative time was 157 minutes (ranging from 90 to 270 minutes). Neither blood transfusion nor conversion to open surgery was required. The mean hospital stay was 2.2 days. The presence of crossing vessels over the ureteropelvic junction was verified in 26 patients (55%), and vessel transposition in relation to the urinary tract was performed in 25 of these cases. In one patient, the crossing vessel was mobilized out of the ureteropelvic junction with a perivascular suture to the renal capsule associated with the pyeloplasty. CONCLUSIONS: The outcome of transperitoneal Anderson-Hynes laparoscopic pyeloplasty used for different causes of pyeloureteral obstruction presented a success rate similar to a previously-published open procedure, with the advantage of being less invasive. This procedure may be considered the first option for the treatment of ureteropelvic junction obstruction.

Laparoscopic dismembered pyeloplasty in 47 cases

PURPOSE: To evaluate the results of a sequence of 47 laparoscopic Anderson-Hynes pyeloplasties for the treatment of patients with ureteropelvic junction obstruction, independently of the etiology. MATERIALS AND METHODS: Twenty male and 27 female patients diagnosed with ureteropelvic junction obstruction were treated by Anderson-Hynes transperitoneal laparoscopic dismembered pyeloplasty from April 2002 to January 2006. The age of the patients ranged from four to 75 years, with a mean age of 32.3 years. The follow-up ranged between six and 30 months, with a mean follow-up time of 24 months. The outcomes were evaluated through the assessment of symptoms and imaging studies. RESULTS: In 44 (93.6 percent) of the 47 patients, resolution of the pain and a reduction in ureteropelvic dilation were observed. The mean operative time was 157 minutes (ranging from 90 to 270 minutes). Neither blood transfusion nor conversion to open surgery was required. The mean hospital stay was 2.2 days. The presence of crossing vessels over the ureteropelvic junction was verified in 26 patients (55 percent), and vessel transposition in relation to the urinary tract was performed in 25 of these cases. In one patient, the crossing vessel was mobilized out of the ureteropelvic junction with a perivascular suture to the renal capsule associated with the pyeloplasty. CONCLUSIONS: The outcome of transperitoneal Anderson-Hynes laparoscopic pyeloplasty used for different causes of pyeloureteral obstruction presented a success rate similar to a previously-published open procedure, with the advantage of being less invasive. This procedure may be considered the first option for the treatment of ureteropelvic junction obstruction.

Laparoscopic pyeloplasty in secondary obstruction.

PURPOSE: To evaluate the management of secondary ureteropelvic junction (UPJ) obstruction by laparoscopic pyeloplasty. MATERIALS AND METHODS: Thirteen patients with symptomatic secondary UPJ obstruction undergoing laparoscopic pyeloplasty were included. Eight patients had obstruction on the right side and five patients on the left. The causes of obstruction were: failed Acucise retrograde endopyelotomy in seven patients, open pyelolithotomy in three, open pyeloplasty in one, retrograde endopyelotomy with laser in one, and laparoscopic pyeloplasty in one. Laparoscopic transperitoneal pyeloplasty was performed in all patients. A Double J stent was introduced antegrade and intraoperatively and removed 6 weeks later in all patients. RESULTS: Laparoscopic transperitoneal pyeloplasty was successful in 12 patients (92.3%). Operative time ranged from 135 to 270 minutes, with a mean of 195 minutes. The mean hospital stay was 2.2 days (range 2 to 5 days). Follow-up ranged from 16 to 36 months with a mean of 22.4 months. Blood loss was insignificant in all surgeries, and no conversion or intraoperative complications occurred. CONCLUSIONS: Laparoscopic pyeloplasty for secondary UPJ obstruction in our series was performed without conversion to open surgery. The initial results were similar to those of primary laparoscopy in our series or those of open pyeloplasty reported in the literature. These results led us to consider the laparoscopic correction as a good alternative in such cases.

Endopielotomia com cateter acucise / Endopyelotomy with acucise catheter

Objetivo: Avaliar a eficácia, complicaçöes e resultados do tratamento endoscópico das obstruçöes da junçäo uretero-piélica (JUP) com cateter acucise. Material e métodos: quinze pacientes portadores de obstruçäo da foram tratados por meio de endopielotomia com cateter acucise. Todos os pacientes realizaram previamente ao procedimento uma urografia excretora. Destes, 13 pacientes também realizaram um renograma diurético. Em 12 pacientes a cirurgia foi realizada por via retrógrada. Três pacientes eram portadores de cálculo ranal no grupo calicinal inferior de aproximadamente 2 cm de diâmetro, sendo indicado a cirurgia por via anterógrada para extraçäo simultânea do cálculo. Em todos os pacientes, ao término do procedimento, foi passado um cateter duplo-J que permaneceu por 6 semanas. Resultado: Considerou-se como sucesso os pacientes que apresentaram melhora ou desaparecimento dos sintomas de dor, melhora da dilataçäo pielocalicinal avaliado por meio da urografia excretora e melhora no renograma diurético. O índice de sucesso foi de 86 porcento. Um paciente apresentou pielonefrite aguda sendo tratado com antibioticoterapia, havendo resoluçäo do quadro. Conclusäo: A endopielotomia com cateter acucise pode ser considerada a primeira opçäo de tratamento das obstruçöes da JUP em adultos e crianças a partir de 8 anos

Transplantes renal com arterias multiplas: experiencia com tecnicas de reconstruçao vascular / Renal transplantation with multiple arteries: experience with several techniques of vascular reconstruction

Os autores apresentam sua experiencia em transplante renal com a utilizaçao de rins com arterias multiplas. Foram utilizados 23 rins nestas condiçoes empregando-se 6 tecnicas diferentes de reconstruçao vascular, com excelente resultado evidenciado por perfusao imediata e boa funçao renal tardia

Transplante renal: experiência com 97 casos / Kidney transplantation: experience with 97 cases

É mostrada a experiência de 97 casos de transplante renal, sendo discutido o diagnóstico, tratamento e evoluçäo das complicaçöes cirúrgicas. Fístula urinária ocorreu em 8 casos, linfoceles em 3, complicaçöes vasculares em 4, calculose em 2 e retençäo vesical em 2. Esta experiência cirúrgica foi adquirida por um grupo de transplante ligado a um hospital convencionado com a Previdência Social

Amputaçäo traumática de pênis / Traumatic amputation of the penis

Este é um caso de amputaçäo traumática de pênis, que foi reimplantado por reanastosome primária, com sucesso em sua evoluçäo

Consideraçöes diagnósticas e terapêuticas em fibrose retroperitoneal idiopática: análise de 6 casos / Diagnostic and therapeutic considerations in idiopathic retroperitoneal fibrosis: analysis of 6 cases

Fibrose retroperitoneal idiopática é um processo inflamatório inespecífico localizado no retroperitônio entre L4 e L5, cuja etiopatogenia é desconhecida. Sua sintomatologia é incaracterística, com mal-estar, dor abdominal ou lombar e desconforto gastrintestinal. A morbidade está relacionada à obstruçäo ureteral, que pode levar à destruiçäo do rim, e, caso seja bilateral, à insuficiência renal. Säo apresentados 6 casos desta doença, sendo que em 4 pacientes havia obstruçäo ureteral unilateral e, em 2, bilateral. Todos apresentavam antecedentes de dor abdominal ou lombar. Dois apresentavam-se com edema de membros inferiores e 2 com insuficiência renal. Os dois pacientes em insuficiência renal foram tratados inicialmente com cateterizaçäo ureteral, sendo que em um deles optou-se pela permanência dos mesmos (cateteres duplo J) a longo prazo, com ótimos resultados. Cinco pacientes foram tratados cirurgicamente pela ureterolise. Dois destes apresentaram recorrência contralateral de obstruçäo ureteral, que regrediu com uso de corticóides

Cistite enfisematosa / Emphysematous cystitis

Em 1961, pneumatúria primária e cistite enfisematosa, até entäo entidades distintas, foram integradas por Bailey em cistite enfisematosa. Säo apresentados dois casos, um dos quais exibindo em trato urinário superior, bilateralmente. A etiologia do processo, que é de bom prognóstico, associa glicosúria, estase e infecçäo urinária, em geral por E. coli ou Aerobacter aerogenes