Reemplazo ureteral con colgajo de Boari laparoscópico: experiencia multi-institucional en 30 casos / Laparoscopic ureteral replacement by Boari flap: Multi-institutional experience in 30 cases

Introducción: El colgajo vesical tipo Boari es una excelente técnica para el reemplazo de lesiones del uréter distal. Existen pocas comunicaciones con el uso de la vía laparoscópica, sobre todo con resultados a largo plazo. Nuestro objetivo es presentar los resultados de un estudio multi-institucional en 30 casos. Material y método: Se analizan 30 pacientes tratados entre diciembre de 2001 y enero de 2009, en quienes se realizó un colgajo de Boari laparoscópico intracorpóreo en 3 centros latinoamericanos. En todos los casos se empleó la misma técnica quirúrgica. La base de datos fue registrada de forma prospectiva y analizada retrospectivamente. Resultados: La edad media fue de 43,2 años (rango de 9 a 71 años). La mayoría fueron mujeres (22 de 30) con un ligero predominio del lado izquierdo (17 de 30). Las causa más frecuente de lesión ureteral fue la histerectomía en 14 pacientes (46,6%) y la ureterolitotomía endoscópica en 9 pacientes (30%). La longitud ureteral media resecada fue de 7 cm (5 a 20 cm). El tiempo medio operatorio fue de 161,16 min (90 a 280 min). El sangrado intraoperatorio estimado promedio fue de 123 ml (0 a 500 ml) y la estancia hospitalaria de 4,86 días (2 a 10 días). No hubo complicaciones intraoperatorias ni conversión a cirugía abierta. Ocurrieron complicaciones postoperatorias en 5 pacientes (16,6%), Clavien 1 en 2 pacientes (6,6%) y Clavien 3 en 3 pacientes (10%). La tasa de éxito de la cirugía fue del 96,6% (29 pacientes), con un tiempo medio de seguimiento de 32 meses (5 a 60 meses). Conclusiones: Nuestros resultados con la técnica de colgajo de Boari laparoscópico confirman los buenos resultados de esta técnica a corto y largo plazo (AU)

Introduction: The Boari flap is an excellent technique for replacement of distal ureteral injuries. There are few reports with the use of laparoscopic surgery, especially with long term results. Our goal is to present the results of a multi-institutional study of 30 cases. Materials and methods: We analyzed 30 patients treated between December 2001 and January 2009 who underwent a laparoscopic intracorporeal Boari flap, in three Latin American centers. In all cases the same surgical technique was employed. The database was recorded prospectively and analyzed retrospectively. Results: The mean age was 43.2 years (range 9–71 years). Most were women (22 of 30) with a slight predominance of left-side lesions (17 of 30). The most common cause of ureteral injury was hysterectomy in 14 patients (46.6%) and endoscopic ureterolithotomy in 9 patients (30%). The mean length of ureteral resection was 7 cm (5–20 cm). The average operative time was 161.16 min (90–280 min). The average estimated blood loss was 123 mL (0–500 mL), and hospital stay was 4.86 days (2–10 days). There were no intraoperative complications or conversion to open surgery. Postoperative complications occurred in 5 patients (16.6%), Clavien 1 in 2 patients (6.6%) and Clavien 3 in three patients (10%). The success rate was 96.6% (29 patients) with a mean follow up of 32 months (5–60 months). Conclusions: Laparoscopic Boari flap in our hands had good short and long term results (AU)

Laparoscopic ureteral replacement by Boari flap: multi-institutional experience in 30 cases.

INTRODUCTION: The Boari flap is an excellent technique for replacement of distal ureteral injuries. There are few reports with the use of laparoscopic surgery, especially with long term results. Our goal is to present the results of a multi-institutional study of 30 cases. MATERIAL AND METHODS: We analyzed 30 patients treated between December 2001 and January 2009 who underwent a laparoscopic intracorporeal Boari flap, in three Latin American centers. In all cases the same surgical technique was employed. The database was recorded prospectively and analyzed retrospectively. RESULTS: The mean age was 43.2 years (range 9 to 71 years). Most were women (22 of 30) with a slight predominance of left-side lesions (17 of 30). The most common cause of ureteral injury was hysterectomy in 14 patients (46.6%) and endoscopic ureterolithotomy in 9 patients (30%). The mean length of ureteral resection was 7 cm. (5 to 20 cm). The average operative time was 161.16 min (90 to 280 min). The average estimated blood loss was 123 mL. (0 to 500 mL), and hospital stay was 4.86 days (2 to 10 days). There were no intraoperative complications or conversion to open surgery. Postoperative complications occurred in 5 patients (16.6%), Clavien 1 in 2 patients (6.6%) and Clavien 3 in three patients (10%). The success rate was 96.6% (29 patients) with a mean follow up of 32 months (5 to 60 months). CONCLUSIONS: Laparoscopic Boari flap in our hands had good short and long term results.

Bilateral nerve-sparing extraperitoneal visual laser ablation radical prostatectomy: potency rates after 1 year follow up.

PURPOSE: Wide variations exist in the methods for reporting potency following radical prostatectomy. In this group we used a validated questionnaires pre and post operatively to access relative return to normal sexual function after bilateral nerve-sparing visual laser ablation radical prostatectomy (VLAP). MATERIALS AND METHODS: One hundred and twenty four patients with ages ranging from 45 to 70 years old were evaluated in the period between January 2004 and March 2007. Sexual function was evaluated using the IIEF questionnaire pre operatively and 3, 6, 9, and 12 months after the surgery. All the procedures were performed by the same surgeon using bilateral nerve-sparing technique. No thermal energy devices were utilized for coagulation and clipping was minimal in order to better preserve the neurovascular bundles. RESULTS: Preoperatively one hundred and four patients had no sexual dysfunction and a 28.2 average according to IIEF score. Thirteen patients were classified in the mild category with 21.8 average score. Five patients were in the mild to moderate group and scored an average of 17 points in the IIEF. Two patients were classified moderate group and scored 10. None were classified in the severe group preoperatively. After 1 year 85 patients were classified in the no dysfunction group and scored an average of 25.3. Eleven patients were in the mild erectile dysfunction group scored 16.9. Sixteen patients in the mild to moderate group scored 12. Eight patients in the moderate group scored seven. Four patients migrated to the severe dysfunction group, scoring two points. 29% of the patients that have had sexual intercourse used medication to improve or obtain erection. CONCLUSION: Careful preservation of the neurovascular bundles provides good potency recovery rates, but no final conclusion should be established before one year of follow-up.

[A diaphragmatic pacemaker in the treatment of ventilatory failure]. / Pace-maker diafragmatico no tratamento da insuficiencia ventilatoria.

Diaphragmatic Pacing was used to treat ventilatory failure in a young boy with bilateral diaphragmatic palsy secondary to cervical cord injury, on chronic mechanical ventilation for 6 months. The indications for diaphragmatic pacing in ventilatory failure were discussed, as well as the assessment of phrenic nerve integrity and the pacing schedules utilized to slowly improve the diaphragm endurance and achieve a full-time weaning from mechanical ventilation.

Renal toxicity mediated by continuous infusion of recombinant interleukin-2.

Interleukin-2 (IL-2), a potent lymphokine with antitumoral activity, was used in continuous intravenous infusion for 5 days (18,000,000 IU/m2/day) in 9 treatment cycles in 5 patients with metastatic colorectal carcinoma. During the infusion, patients received aggressive fluid replacement titrated by invasive hemodynamic monitoring, aiming at a stable central volemia. Body weight went up an average of 4.5 kg in 5 days, mean arterial blood pressure dropped slightly from day 1 to day 5 (105.4 +/- 11.6 to 86.1 +/- 12.5 mm Hg, p < 0.05), systemic vascular resistance decreased from 1304.7 +/- 242.1 to 871.7 +/- 237.2 dyn/s/cm-5 (p < 0.05), with stable pulmonary capillary wedge pressure, cardiac output and central venous pressure. The urinary output significantly dropped from 1.9 +/- 1.2 to 0.2 +/- 0.1 ml/min (p < 0.05) with very significant rises in serum creatinine from 76.0 +/- 28.3 to 242.2 +/- 144.9 mumol/l (0.86 +/- 0.32 to 2.47 +/- 1.64 mg/dl) and N-acetyl-beta-D-glucosaminidase urinary activity from 4.97 +/- 5.0 to 23.0 +/- 12.1 U/l, and significant decrement of creatinine clearance (1.86 +/- 0.65 to 0.29 +/- 0.27 ml/s or 111.5 +/- 38.9 to 17.1 +/- 16.6 ml/min) and urinary sodium (113.8 +/- 78.3 to 9.0 +/- 6.7 mmol/l). Urine sediment evolved from normal at day 1 to 9.0 +/- 3.7 epithelial cells/mm3 and 6.9 +/- 3.6 brown casts/mm3 (p = 0.001). We concluded that cancer treatment with IL-2 in continuous infusion, even with stable hemodynamics, induces an acute renal failure in most patients treated.

Renal tubular sodium and water metabolism in brain tumour patients submitted to craniotomy.

PURPOSE: To evaluate the effect of Brain Tomour (BT) and Neurosurgery (NS) on the renal handling of H2O and Na, and the clinical importance of SIADH in this setting. METHODS: Fourteen patients with BT pre-op for NS and 6 controls (C) pre-op for general surgery, were assessed in a controlled prospective trial. All patients were normovolaemic, with normal renal function. They received 400 mg of lithium carbonate (Li) 8 hours before each of two test periods (I and II) and a standard water load only before period II. Clearances studies were performed pre-op (period I) and 24 hours post-op (period II). RESULTS: Serum Na was normal at all times. Despite normovolaemia, a 1% decrement in serum osmolality and the water load, ADH dramaticaly increased from time I to II mainly in the BT group (36.2 +/- 9.4 vs 7.1 +/- 0.6 pmol/L, p = 0.02). FENa, FELi and FEUricA were significantly more elevated in the BT group pre and post-op (at time II respectively 4.6 +/- 1.6 vs 1.1 +/- 0.3%; 29.3 +/- 4.9 vs 22.6 +/- 5.5; 26.0 +/- 8.1 vs 11.3 +/- 2.2, p = 0.03). Proximal and distal H2O re-absorption and distal fractional Na re-absorption were identical in both groups pre and post-operatively. CONCLUSIONS: 1-BT and NS always induce a SIADH. 2-There was a primary Na loss at the proximal tubule level not explained by ADH increment, that did not significantly changed H2O handling. 3-To prevent hyponatraemia, hypotonic I.V. fluids should be avoided, but more importantly saline must be provided to this potentially salt-wasting condition.

Aplicação da reação de Bengtson ao diagnóstico das riquetsioses benignas em São Paulo / Application of the Bengtson reaction to the diagnosis of benign rickettsiosis in São Paulo

Em comunicação anterior, os autores trataram de um caso humano de tifo exantemático murino observado na capital de S. Paulo. O diagnóstico do caso foi feito pelo isolamento e pela identificação de uma amostra de Rickettsia mooseri. Já, anteriormente, haviam sido observados, no Estado de S. Paulo, casos benignos de doença tifo-exantemática semelhantes ao estudado pelos autores. Durante anos, porém, não se conseguiu estabelecer o diagnóstico específico desses casos, os quais, com os casos graves de riquetsiose, eram englobados sob a designação de "tifo exantemático de S. Paulo". Mais tarde, receberam muitos desses casos benignos o diagnóstico de tifo murino, feito apenas com base em dados clínicos e epidemiológicos. No presente trabalho, os autores prosseguem no relato das pesquisas feitas para esclarecer a etiologia de tais casos. A reação de fixação do complemento foi praticada com um certo número de soros com Weil-Felix positivo. Uma grande parte das amostras de sangue foi obtida de indivíduos que sofriam, ou haviam sofrido, uma infecção benigna e que residiam em zonas quer rurais quer urbanas do Estado de S. Paulo. Na parte preliminar do trabalho, realizada em janeiro de 1944, foi utilizado um antígeno, preparado no Instituto Bacteriológico do Chile, por Palácios e Avendaño, com a Rickettsia mooseri. A partir de novembro de 1945, foram empregados antígenos Bengtson, preparados com a riquétsia da febre maculosa das Montanhas Rochosas e com as do tifo murino e tifo epidêmico. Em 1944, foi praticada a prova, em presença do cocto-antígeno, com o soro de 7 casos verificados em zona rural do Estado de S.Paulo. Naquela ocasião, a falta de antígeno para o diagnóstico da febre maculosa tornou impossível o controle perfeito da reação. Não se pôde, assim, concluir, com certeza, pela existência em S. Paulo de uma doença exantemática do grupo "tifo" (tifo murino e tifo epidêmico). Contudo, os resultados falavam fortemente a favor da hipótese de ocorrer, em S. Paulo, mais de um tipo de infecção tifo-exantemática. Cerca de 2 anos mais tarde, as reações realizadas com antígenos Bengtson vieram trazer a prova definitiva de que uma parte dos assim chamados casos de "tifo exantemático de S. Paulo" ou de "febre maculosa" eram realmente casos de uma infecção exantemática do grupo "tifo". De todos os casos clínicos, nos quais foi praticada a reação com os antígenos Bengtson, 58 foram selecionados para serem discutidos nesta comunicação. Em dois deles, conseguiu-se firmar, pela fixação de complemento, o diagnóstico de febre maculosa das Montanhas Rochosas. Em 51 casos, a reação foi positiva, quer com o antígeno murino, quer com o epidêmico. Em muitos desses 51 casos, não houve uma diferença significativa entre os títulos observados com o antígeno murino e com o epidêmico; o título foi, ora mais alto com o murino, ora com o epidêmico. Devido à intensa reação de fixação cruzada, verificada entre o tifo murinho e o epidêmico, só foi possível chegar-se, pela primeira vez, a um diagnóstico seguro de tifo murino pela identificação de uma amostra de Rickettsia mooseri, isolada do caso humano ("Vollet") acima referido. Em uma nota a ser publicada, relataremos o isolamento da Rickettsia mooseri de mais 10 casos humanos de tifo murino, alguns deles provenientes de zona rural. Foi praticada ainda a reação de fixação do complemento com o soro de 75 empregados de um armazém de cereais, onde trabalhava o paciente "Vollet", tendo sido utilizados os antígenos Bengtson. Em 3 desses casos, a reação foi positiva com o antígeno murino ou o epidêmico. Nenhuma dessas 3 pessoas havia apresentado sintomas de infecção nos 30 dias anteriores à sangria. A reação foi também aplicada ao diagnóstico de 4 casos de infecção acidental de laboratório. Verificaram-se todos os 4 entre o pessoal técnico do Laboratório de Riquétsias do Instituto Butantan, onde o trabalho relatado nesta comunicação foi realizado. A reação foi positiva nos 4 casos com os antigenos Bengtson, murino e epidêmico. Posteriormente, foi isolada, de cada caso, uma amostra de Rickettsia mooseri. Em um desses casos, nem pelo emprego dos antígenos de Plotz foi possível chegar-se ao diagnóstico diferencial entre tifo murino e epidêmico. O título da reação realizada na Army Medical School, em Washington, com uma amostra de sangue colhida 4 meses após a infecção, foi mais alto com o antígeno murino do que com o epidêmico. Mas o título de aglutinação de riquétsias foi significativamente mais alto com a Rickettsia mooseri do que com a Rickettsia prowazeki (AU).