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Urol Oncol ; 37(3): 179.e9-179.e18, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30448030


PURPOSE: We aimed at this study to test the value of immediate postoperative intravesical epirubicin instillation in intermediate and high-risk non-muscle-invasive bladder cancer patients. MATERIALS AND METHODS: After approval of Institutional Review Board, 260 patients were randomly allocated into 2 groups, including transurethral resection of bladder tumor (TURBT) alone in control group and TURBT plus immediate postoperative epirubicin (50 mg) in test group. Patients were monitored for postoperative complications. Adjuvant instillation therapy was administered according to risk categorization. Patients were followed every 3 months by cystourethroscopy and urine cytology. The primary end points were recurrence, progression, and/or death from cancer. RESULTS: Of the 260 patients, 236 were eligible and followed for a mean of 29 months. The 2 study groups were comparable regarding perioperative baseline demographic criteria. There was no statistically significant difference between the 2 groups regarding recurrence rate (27.1% vs. 26.2%), interval to first recurrence (16.3 ± 6.6 vs. 16.4 ± 6.4 months) or progression rate to muscle invasion (8.5% vs. 5.9%). Site, size, and number of recurrences were also comparable between the 2 groups. Recurrences and progression-free survival were comparable between the 2 groups (Log-rank P = 0.88 and 0.47, respectively). Postoperative complications were all low-grade according to modified Dindo-Clavian system, with no significant difference in their rate between the 2 groups. CONCLUSIONS: Immediate post-TURBT epirubicin instillation is ineffective in intermediate and high-risk non-muscle-invasive bladder cancer. It neither prolongs time to recurrence and/or progression nor reduces number of recurrences. We advocate strict specification of patient and tumor criteria in which immediate instillation is indicated.

J Urol ; 201(2): 350-357, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30218763


PURPOSE: We prospectively assessed the efficacy and the predictors of the success of oral dissolution therapy by alkalization for lucent renal calculi. MATERIALS AND METHODS: Patients with radiolucent renal stones were counseled to undergo oral dissolution therapy, which entails oral potassium citrate 20 mEq 3 times daily, 3 L daily fluid intake and a dietary regimen. The study primary end point was the achievement of a 6-month stone-free rate with oral dissolution therapy. The other end point was a change in stone surface area as measured by noncontrast computerized tomography at 3 and 6 months. RESULTS: Between February 2015 and January 2016 only 182 of the 212 eligible patients who agreed to participate were compliant with oral dissolution therapy and included in the final analysis. Mean stone surface area at enrollment was 1.3 cm (range 0.16 to 11.84). At 3 months 97 (53.2%), 65 (35.7%) and 20 (11.1%) patients were oral dissolution therapy responders (stone-free), partial responders and nonresponders, respectively. Oral dissolution therapy achieved a 6-month stone-free rate of 83%, including 97 and 54 patients after 3 and 6 months of oral dissolution therapy, respectively. On regression analysis the initial 3-month response to oral dissolution therapy (p = 0.001), lower stone density (p = 0.03) and higher urine pH 12 weeks after treatment (p = 0.01) independently predicted the oral dissolution therapy response at 6 months. CONCLUSIONS: Regardless of stone size, oral dissolution therapy was an effective treatment approach for lucent renal stones. The initial response to oral dissolution therapy after 3 months was the key factor in determining the potential oral dissolution therapy response after 6 months. In addition, treatment compliance in achieving the targeted urine pH and low stone density has an independent role in the oral dissolution therapy response.

Diuréticos/uso terapêutico , Cálculos Renais/tratamento farmacológico , Citrato de Potássio/uso terapêutico , Adulto , Feminino , Humanos , Concentração de Íons de Hidrogênio , Cálculos Renais/diagnóstico por imagem , Cálculos Renais/dietoterapia , Cálculos Renais/urina , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente/estatística & dados numéricos , Prognóstico , Estudos Prospectivos , Tomografia Computadorizada por Raios X , Resultado do Tratamento
Urolithiasis ; 47(4): 365-370, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29700572


To evaluate the long-term changes of selective renal function after anatrophic nephrolithotomy (ANL). A retrospective study was conducted for patients who underwent ANL between January 1995 and December 2016. Inclusion criteria were availability of preoperative and follow-up (1 year or more) radio-isotopic renal scans. Stone-free status was evaluated after 1 month with KUB and ultrasonography or NCCT. Renal isotope scans using 99mTc MAG3 were performed to measure the changes in selective function of the affected kidney (GFR%). Eligible patients were classified into two groups, group 1 patients with stable or improved function and group 2 patients with deteriorated function (> 5% decrease in GFR%). Univariate and multivariate analyses were performed to determine risk factors for deterioration of renal function. The cutoff value for any significant variable was determined using ROC curve. The study included 50 patients with mean age 43.8 + 13.9 years. Complications developed in 26 patients (52%), and stone-free status was documented in 42 patients (84%). After a median follow-up of 2.7 years (range 1-11), mean GFR% of all cases significantly decreased from preoperative value of 52.7% + SD 20 to 45.4% + SD 25% during follow-up (P < 0.001). Deterioration of GFR% was documented in 21 kidneys (42%). Cold ischemia time with a cutoff value 50 min was the independent risk factor (RR 3.986, 95% CI 1.069-14.869, P 0.039). The results of this study support limiting ANL to a selected group of patients and taking all the possible efforts to minimize cold ischemia time below 50 min.

Rim/fisiopatologia , Nefrolitotomia Percutânea/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Cálculos Coraliformes/cirurgia , Adulto , Isquemia Fria/efeitos adversos , Feminino , Seguimentos , Humanos , Rim/diagnóstico por imagem , Rim/cirurgia , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Nefrolitotomia Percutânea/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Renografia por Radioisótopo , Estudos Retrospectivos , Fatores de Risco , Cálculos Coraliformes/diagnóstico por imagem , Resultado do Tratamento , Adulto Jovem
World J Urol ; 35(8): 1241-1246, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28013344


OBJECTIVES: To compare the intraoperative surgeon perspective for detection of residual fragments (RFs) after percutaneous nephrolithotomy (PNL) with postoperative NCCT. METHODS: A prospective study of adult patients who underwent PNL between March and September 2014 was conducted. Stone complexity was evaluated using the Guy's stone score (GSS). All patients were evaluated by pre- and postoperative NCCT. After the procedure, the surgeon had been asked whether there were residual stones or not. The sensitivity, specificity and predictive values were tested against postoperative NCCT. Predictors of accurate intraoperative assessment were determined using univariate and multivariate statistical analyses. RESULTS: The study included 306 consecutive patients. The surgeons reported no residual stones in 236 procedures; of whom 170 (72%) were reported stone-free by NCCT. On the other hand, 65 out of 70 procedures (93%) reported with residual stones by the surgeons were true by NCCT. The sensitivity was 50% and the NPV was 72%, while the specificity was 97% and the PPV was 93%. On multivariate analysis, only lower GSS (p < 0.001) was independently associated with true negative surgeon opinion. CONCLUSIONS: Although there was a high surgeon ability to detect post-PNL residual stones, postoperative imaging is mandatory because of the high false negative rates and low NPV. The surgeon opinions can be judged only in stones with lower GSS. The NPV could be enhanced if a consistent definition of clinically significant RFs is introduced.

Cálculos Renais/cirurgia , Nefrolitotomia Percutânea/métodos , Adulto , Feminino , Humanos , Cuidados Intraoperatórios , Cálculos Renais/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios , Prognóstico , Estudos Prospectivos , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios X , Resultado do Tratamento
J Urol ; 194(5): 1414-9, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25986509


PURPOSE: We sought to evaluate long-term outcomes of the Bricker conduit urinary diversion in children. MATERIALS AND METHODS: We retrospectively reviewed the database of a single tertiary center for children who had undergone ileal conduit between 1981 and 2011. Patients followed for less than 1 year were excluded. Patient files were reviewed for demographics, diversion indication, preoperative imaging, surgical details, hospital readmissions and followup data. Renal function at baseline and last followup was assessed by estimated glomerular filtration rate, calculated using the modified Schwartz or MDRD (Modified Diet in Renal Disease) formula. Growth charts elucidated patient growth patterns, while an internally designed quality of life questionnaire demonstrated patient and family satisfaction with the procedure. RESULTS: We evaluated 29 children who underwent Bricker conduit at a median age of 10 years (range 2 to 18) and were followed for a median of 91 months (16 to 389). Neuropathic bladder was the underlying diagnosis in 72.4% of cases. Hydronephrosis improved or remained stable in 39 of 55 studied renal units (70.9%). Although no statistically significant difference was observed between mean ± SD baseline (64.5 ± 46 ml/minute/1.73 m(2)) and last followup estimated glomerular filtration rate (54.1 ± 44.9 ml/minute/1.73 m(2)), chronic kidney disease stage had worsened in 13 patients (44.8%), end-stage kidney disease had developed in 11 patients and 9 patients had died. Six patients underwent undiversion after stabilization of renal function. Linear growth was negatively affected in 12 patients (41.4%), and 85% reported poor quality of life. A total of 19 hospital readmissions were required in 14 patients to treat diversion related complications. CONCLUSIONS: The Bricker conduit does not seem to halt renal deterioration in children. Negative impact on growth and quality of life, and the anticipated rate of complications are significant limitations of the procedure in the pediatric population.

Íleo/cirurgia , Nefropatias/cirurgia , Complicações Pós-Operatórias/epidemiologia , Qualidade de Vida , Derivação Urinária/métodos , Adolescente , Criança , Pré-Escolar , Egito/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Derivação Urinária/psicologia