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Lopes RI, da Silva Alves Bento A, Nunes RDSS, Vilares RN, Pereira JG, Cezarino BN, Dénes FT. Novel minimally invasive abdominoplasty for selected cases of prune belly syndrome: Step-by-step technique description and clinical indications. J Pediatr Urol 2024:S1477-5131(24)00190-6. [PMID: 38609778 DOI: 10.1016/j.jpurol.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/20/2024] [Accepted: 04/01/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Prune belly syndrome (PBS) is characterized by the triad of abdominal flaccidity, bilateral undescended testicles and genitourinary tract anomalies. A variable spectrum of abdominal wall laxity is observed in PBS. We present the first case of a novel technique using a minimally invasive abdominoplasty to specifically address patients with localized abdominal wall weakness in PBS. CASE PRESENTATION A two-years-old child with PBS presented with recurrent febrile urinary tract infections. Ultrasonography demonstrated a dysplastic right kidney associated with significant ipsilateral ureterohydronephrosis. Voiding urethrocystogram did not show vesicoureteral reflux and DMSA scan depicted a non-functioning right kidney. During laparoscopic right nephroureterectomy and first stage Fowler-Stephens bilateral orchiopexies, a significant right-sided lateral abdominal wall bulging was observed. A minimally invasive laparoscopic abdominoplasty was performed with a one-way running suture using an unabsorbable 2.0 prolene approximating the edges of the musculofascial defect. While undergoing the second-stage Fowler-Stephens orchiopexy, no bulging was observed. CONCLUSION A minimally invasive abdominoplasty to improve abdominal wall lateral bulging in PBS was feasible and presented good cosmetic result. We anticipate that this technique can be applied for children with PBS with primary lateral abdominal wall bulging, employing one or more suture lines depending on the fascial defect size.
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Affiliation(s)
- Roberto Iglesias Lopes
- Pediatric Urology Unit, Division of Urology, University of São Paulo School of Medicine, São Paulo, Brazil.
| | | | | | - Rafael Nascimento Vilares
- Pediatric Urology Unit, Division of Urology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Jéssica Goulart Pereira
- Pediatric Urology Unit, Division of Urology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Bruno Nicolino Cezarino
- Pediatric Urology Unit, Division of Urology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Pediatric Urology Unit, Division of Urology, University of São Paulo School of Medicine, São Paulo, Brazil
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Mello MF, de Bessa J, Reis ST, Kondo EY, Yu L, Dénes FT, Lopes RI. Evaluating TIMP-2 and IGFBP-7 as a predictive tool for kidney injury in ureteropelvic junction obstruction. Int Braz J Urol 2022; 48:284-293. [PMID: 35170890 PMCID: PMC8932023 DOI: 10.1590/s1677-5538.ibju.2021.0340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 09/02/2021] [Indexed: 11/22/2022] Open
Abstract
A major challenge in the management of ureteropelvic junction obstruction (UPJO) is the selection of patients who would benefit from surgical treatment. Tissue inhibitor metalloproteinase-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) indicate renal cell stress and are associated with cell cycle arrest. The [TIMP-2] [IGFBP7] ratio (Nephrocheck®) has been recently applied in patients in intensive care units patients to predict the development of acute kidney injury. In this study, we evaluated the performance of these biomarkers performance to distinguishing obstructive hydronephrosis (HN) from non-obstructive HN.
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Affiliation(s)
- Marcos Figueiredo Mello
- Unidade de Urologia Pediátrica da Divisão de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - José de Bessa
- Divisão de Urologia, Universidade Estadual de Feira de Santana, Feira de Santana, Bahia, BA, Brasil
| | - Sabrina T Reis
- Laboratório de Investigação Médica (LIM55), Divisão de Urologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Enzo Yagi Kondo
- Laboratório de Investigação Médica (LIM55), Divisão de Urologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Luis Yu
- Divisão de Nefrologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Francisco Tibor Dénes
- Unidade de Urologia Pediátrica da Divisão de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Roberto Iglesias Lopes
- Unidade de Urologia Pediátrica da Divisão de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
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Cezarino BN, Lopes RI, Berjeaut RH, Dénes FT. Laparoscopic hidden incision endoscopic surgery (hides) nephrectomy VS. Traditional laparoscopic nephrectomy: Non-inferior surgical outcomes and better cosmetic results. J Pediatr Urol 2021; 17:411.e1-411.e6. [PMID: 33546978 DOI: 10.1016/j.jpurol.2021.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 11/30/2020] [Accepted: 01/14/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The benefits of laparoscopic total nephrectomy in pediatric patients are well established. Traditional Ports placement (TPP) still follows Clayman's classic description: except for the umbilical scar, the other laparoscopic scars are exposed in the abdomen. Advances in robotic surgery permitted the development of HidES (hidden incision endoscopic surgery) technique, to obtain a better final cosmetic aspect with the scars located intraumbilically and in the hypogastric region, in an area easily hidden by underwear. As robotic surgery is related to higher costs and lacks availability, a pure laparoscopic HidES technique was developed. OBJECTIVES 1.Evaluate safety and efficacy of pure laparoscopic HidES.2. Compare HidES with TPP nephrectomy series to assess non-inferiority and cosmetic outcomes. STUDY DESIGN Twenty-one pediatric patients with symptomatic poor functioning kidneys (DMSA<10%) underwent HidES nephrectomy. Their intra and post-operative outcomes were recorded prospectively. HidES group was compared to an equivalent group of thirty-two patients who underwent TPP nephrectomy. RESULTS There were no conversions to open surgery in the TPP or HidES groups. There was a significant difference in operative time between HidES (53.4min) and TPP (109.4 min), with p = 0.004 and the mean bleeding volume was 65.5 ml. There was no significant difference in bleeding between HidES (71 ml) and TPP (120 ml) (p = 0.06), no intraoperative complications and no complications above Clavien-Dindo II during the 6-week follow-up. Satisfaction reached 100% in HidES group, whereas in TPP satisfaction was 63% (p = 0.004). DISCUSSION HidES benefit over TPP is to conceal visible scars above underwear, improving cosmetical outcome. A prospective HidES group was compared to a retrospective TPP database due to decreasing number of nephrectomies being performed, which is a limitation of our study. HidES surgeries were performed by pediatric urologists (associate staff) while TPP group surgeries were performed by PGY-5 urological residents assisted by the associate staff, which is a clear limitation and can explain shorter operative times for HidES. During HidES surgeries an improved visualization of the operative field by the inferior trocar positioning was noted, which helps the posterior dissection of renal pedicle. Previous published study comparing robotic TPP and HidES pyeloplasty showed equal results for both groups with cosmetic advantages. Objective satisfaction was assessed with statistically advantage in favor of HidES procedure, consonant with other evidence that supports the benefit of scar location in patient and parental satisfaction. CONCLUSION HidES nephrectomy proved to be safe, feasible and not inferior to the traditional nephrectomy in experienced hands, with better cosmesis.
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Affiliation(s)
- Bruno Nicolino Cezarino
- Pediatric Urology Unit, Division of Urology, Hospital Das Clínicas, University of São Paulo Medical School, Brazil.
| | - Roberto Iglesias Lopes
- Pediatric Urology Unit, Division of Urology, Hospital Das Clínicas, University of São Paulo Medical School, Brazil
| | - Ricardo Haidar Berjeaut
- Pediatric Urology Unit, Division of Urology, Hospital Das Clínicas, University of São Paulo Medical School, Brazil
| | - Francisco Tibor Dénes
- Pediatric Urology Unit, Division of Urology, Hospital Das Clínicas, University of São Paulo Medical School, Brazil
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Cezarino BN, Lopes RI, Berjeaut RH, Dénes FT. Can extended upper pole ureterectomy prevent ureteral stump syndrome after proximal approach for duplex kidneys? Int Braz J Urol 2021; 47:821-826. [PMID: 33848075 PMCID: PMC8321497 DOI: 10.1590/s1677-5538.ibju.2020.0686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 01/17/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction: Symptomatic duplex kidneys usually present with recurrent urinary tract infection due to ureteral obstruction (megaureter, ureterocele or ectopic ureter) and/or vesicoureteral reflux. Upper-pole nephrectomy is a widely accepted procedure to correct symptomatic duplex systems with poor functioning moieties, also known as upper or proximal approach. The distal ureteral stump syndrome (DUSS) can be a late complication of this approach. There is no consensus upon the length of ureteral dissection and the better approach to symptomatic disease in duplex systems, so we aim to identify if extended ureteral dissection can prevent DUSS in top-down approach. Materials and Methods: Forty-four consecutive patients with symptomatic duplex system were retrospectively classified into two groups: those with limited ureteral excision after heminephrectomy (HN) (group-1) and those with extended ureterectomy after HN (group-2). Patients were followed-up for at least 36 months regarding outcomes of distal ureteral stump. Results: Overall complication was 20%. A total of 8 patients required unplanned further surgery in Group-1 (30%) whereas only 1 patient required unplanned surgery in group 2 (6%) (p=0.07). Subgroup analysis showed that Group-1 presented more DUSS requiring surgery during follow-up than group-2 (p=0.04). Factors possibly affecting complications incidence (such as ureterocele or ectopic ureter) did not differ between groups (p=0.72 and p=0.78). Conclusion: Upper pole nephrectomy should be performed with extended distal ureteral dissection to prevent ureteral stump complications.
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Affiliation(s)
- Bruno Nicolino Cezarino
- Unidade de Urologia Pediátrica, Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, SP, Brasil
| | - Roberto Iglesias Lopes
- Unidade de Urologia Pediátrica, Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, SP, Brasil
| | - Ricardo Haidar Berjeaut
- Unidade de Urologia Pediátrica, Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, SP, Brasil
| | - Francisco Tibor Dénes
- Unidade de Urologia Pediátrica, Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, SP, Brasil
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Lopes RI, Sucupira DG, Mello MF, Berjeaut RH, Cezarino BN, Dénes FT. Hidden incision ureterocystoplasty: step-by-step description of a novel technique. Cent European J Urol 2021; 73:575. [PMID: 33552589 PMCID: PMC7848838 DOI: 10.5173/ceju.2020.0241.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/01/2020] [Accepted: 10/08/2020] [Indexed: 11/22/2022] Open
Affiliation(s)
- Roberto Iglesias Lopes
- Hospital das Clínicas, University of São Paulo Medical School, Pediatric Urology Unit, Division of Urology, São Paulo, Brazil
| | - Daniel Gabriele Sucupira
- Hospital das Clínicas, University of São Paulo Medical School, Pediatric Urology Unit, Division of Urology, São Paulo, Brazil
| | - Marcos Figueiredo Mello
- Hospital das Clínicas, University of São Paulo Medical School, Pediatric Urology Unit, Division of Urology, São Paulo, Brazil
| | - Ricardo Haidar Berjeaut
- Hospital das Clínicas, University of São Paulo Medical School, Pediatric Urology Unit, Division of Urology, São Paulo, Brazil
| | - Bruno Nicolino Cezarino
- Hospital das Clínicas, University of São Paulo Medical School, Pediatric Urology Unit, Division of Urology, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Hospital das Clínicas, University of São Paulo Medical School, Pediatric Urology Unit, Division of Urology, São Paulo, Brazil
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Lopes RI, Tavares A, Dénes FT, Cocuzza M. Gonadal Function and Reproductive System Anatomy in Postpubertal Prune-Belly Syndrome Patients. Urology 2020; 145:292-296. [PMID: 32544553 DOI: 10.1016/j.urology.2020.04.124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To gain insight into the causes of infertility in Prune Belly Syndrome (PBS) by evaluating reproductive system anatomy and gonadal function in a cohort of postpubertal PBS patients. METHODS We contacted all PBS patients 14 years old or older treated and followed at our institution. Age at orchiopexy, type of orchiopexy (with or without ligation of gonadal vessels), testicular volumes and positions were evaluated. Pelvic magnetic resonance imaging (to assess prostate size, seminal vesicles, and vas) and hormonal profile were ordered. Sperm analysis and analysis of urine after masturbation were performed after informed consent. RESULTS Fifteen patients were included in this study. Mean age was 19.2 years. Mean age at orchiopexy was 18 months. Fourteen patients (93.3%) had normal and orthotopic testes. Mean testicular volume was 6.9 cc. Eight patients collected semen, 5 of them (62.5%) had spermatozoa in the specimen and motile sperm was found in 4 (50%). Mean hormone levels were LH: 5.3 mg/dL, FSH: 6.9 mg/dL, testosterone 531 mg/dL. Magnetic resonance imaging revealed hypoplastic prostates in 66.6% and unilateral seminal vesicle absence in 66.6%. No vasal abnormality was noted. CONCLUSION Patients with PBS may have normal sexual hormonal levels. Motile spermatozoa were found in half of the patients. Our study highlights a high prevalence of prostate and seminal vesicle abnormalities that may represent an important cause for their infertility.
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Affiliation(s)
- Roberto Iglesias Lopes
- Uropediatric Unit and Division of Urology, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil.
| | - Alessandro Tavares
- Uropediatric Unit and Division of Urology, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Uropediatric Unit and Division of Urology, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Marcello Cocuzza
- Human Reproduction Unit, Division of Urology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Wisniewski AB, Batista RL, Costa EMF, Finlayson C, Sircili MHP, Dénes FT, Domenice S, Mendonca BB. Management of 46,XY Differences/Disorders of Sex Development (DSD) Throughout Life. Endocr Rev 2019; 40:1547-1572. [PMID: 31365064 DOI: 10.1210/er.2019-00049] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions that result in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. Advances in the clinical care of patients and families affected by 46,XY DSD have been achieved since publication of the original Consensus meeting in 2006. The aims of this paper are to review what is known about morbidity and mortality, diagnostic tools and timing, sex of rearing, endocrine and surgical treatment, fertility and sexual function, and quality of life in people with 46,XY DSD. The role for interdisciplinary health care teams, importance of establishing a molecular diagnosis, and need for research collaborations using patient registries to better understand long-term outcomes of specific medical and surgical interventions are acknowledged and accepted. Topics that require further study include prevalence and incidence, understanding morbidity and mortality as these relate to specific etiologies underlying 46,XY DSD, appropriate and optimal options for genitoplasty, long-term quality of life, sexual function, involvement with intimate partners, and optimizing fertility potential.
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Affiliation(s)
- Amy B Wisniewski
- Psychology Department, Oklahoma State University, Stillwater, Oklahoma
| | - Rafael L Batista
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Elaine M F Costa
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Courtney Finlayson
- Division of Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Maria Helena Palma Sircili
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Division of Urology, Department of Surgery, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Sorahia Domenice
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Berenice B Mendonca
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
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Sircili MHP, Dénes FT, Mendonca BB. Letter to the Editor re 'Variations of sex development: The first German interdisciplinary consensus paper'. J Pediatr Urol 2019; 15:585. [PMID: 31427250 DOI: 10.1016/j.jpurol.2019.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Affiliation(s)
- M H P Sircili
- Uropediatric Unit, Division of Urology, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, Brazil.
| | - F T Dénes
- Uropediatric Unit, Division of Urology, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, Brazil
| | - B B Mendonca
- Developmental Endocrinology, Division of Endocrinology, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, Brazil
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Giron AM, Mello MF, Berjeaut RH, Machado MG, Silva GCDA, Cezarino BN, Oliveira LM, Lopes RI, Dénes FT. Single-stage Abdominoplasty Using Groin Flaps Without Osteotomies: Management of Exstrophy-epispadias Complex. Urology 2018; 120:266. [PMID: 30031829 DOI: 10.1016/j.urology.2018.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/27/2018] [Accepted: 07/02/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVE The optimal treatment for children born with exstrophy-epispadia complex is still a matter of debate.1,2,3 We demonstrate the Single-Stage Abdominoplasty using Groin Flap technique to close the abdominal wall of children with classic bladder exstrophy (CBE) without osteotomy neither radical soft tissue mobilization. Advantages over current techniques are less risk of penile tissue loss and avoidance of osteotomies. MATERIAL AND METHODS Abdominal wall repair consists in using the hypogastric skin, rectus, and obliquus externus abdominalis muscle fascial flaps. These groin flaps are rotated medially resulting in a very strong abdominal wall support. Groin flaps are made of rectus anterior fascia rotated medially, flipped over, and sutured with Prolene sutures to close the defect. By rotating the fascial flaps medially, complete reinforcement of the abdominal wall to the level of the pubic bone is achieved. This permits abdominal closure maintenance without tension. RESULTS Groin flap was applied to 128 patients with CBE referenced from all over the country. Most of these patients returned to their home areas making difficult their follow up. However, we have 44 cases that have regular clinical visits. Mean follow-up was 10.3 ± 4.5 years (2 years 8 months-16 years). Successful closure was achieved in 43 patients (97.7%) as a single procedure; one patient had a complete wound dehiscence and needed another reconstruction (2.2%). Four patients (9.1%) presented abdominal hernias that needed surgical management. When continence is evaluated, we present similar literature rates (60%).4 CONCLUSION: Abdominal reconstruction using Groin flaps has advantages over the traditional approaches to CBE. It reduces the surgical steps and facilitates the closure of the abdominal wall without the need of osteotomies and consequent immobilization during the postoperative period. It is feasible at any age and can be also very useful as a salvage technique even after previous failed procedures. Finally, it minimizes the number of surgeries.
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Affiliation(s)
- Amilcar Martins Giron
- Divisao de Urologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Marcos Figueiredo Mello
- Divisao de Urologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Ricardo Haidar Berjeaut
- Divisao de Urologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil.
| | - Marcos Giannetti Machado
- Divisao de Urologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | | | - Bruno Nicolino Cezarino
- Divisao de Urologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Lorena Marçalo Oliveira
- Divisao de Urologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Roberto Iglesias Lopes
- Divisao de Urologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil; Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Francisco Tibor Dénes
- Divisao de Urologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
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Brunhara JA, Moscardi PRM, Mello MF, Andrade HS, Carvalho PA, Cezarino BN, Dénes FT, Lopes RI. Transperitoneal laparoscopic pyeloplasty in children: does upper urinary tract anomalies affect surgical outcomes? Int Braz J Urol 2018; 44:370-377. [PMID: 29368877 PMCID: PMC6050553 DOI: 10.1590/s1677-5538.ibju.2017.0224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 11/15/2017] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess the feasibility and outcomes of laparoscopic pyeloplasty in children with complex ureteropelvic junction obstruction (UPJO) and compare to children with iso-lated UPJO without associated urinary tract abnormalities. MATERIAL AND METHODS Medical records of 82 consecutive children submitted to transperitoneal laparoscopic pyeloplasty in a 12-year period were reviewed. Eleven cases were con-sidered complex, consisting of atypical anatomy including horseshoe kidneys in 6 patients, pelvic kidneys in 3 patients, and a duplex collecting system in 2 patients. Patients were di-vided into 2 groups: normal anatomy (group 1) and complex cases (group 2). Demographics, perioperative data, outcomes and complications were recorded and analyzed. RESULTS Mean age was 8.9 years (0.5-17.9) for group 1 and 5.9 years (0.5-17.2) for group 2, p=0.08. The median operative time was 200 minutes (180-230) for group 1 and 203 minutes (120-300) for group 2, p=0.15. Major complications (Clavien ≥3) were 4 (5.6%) in group 1 and 1 (6.3%) in group 2, p=0.52. No deaths or early postoperative complications such as: urinoma or urinary leakage or bleeding, occurred. The success rate for radiologic improvement and flank pain improvement was comparable between the two groups. Re-garding hydronephrosis, significant improvement was present in 62 patients (93.4%) of group 1 and 10 cases (90.9%) of group 2, p=0.99. The median hospital stay was 4 days (IQR 3-4) for group 1 and 4.8 days (IQR 3-6) for group 2, p=0.27. CONCLUSIONS Transperitoneal laparoscopic pyeloplasty is feasible and effective for the management of UPJO associated with renal or urinary tract anomalies.
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Affiliation(s)
- João Arthur Brunhara
- Unidade de Urologia Pediátrica, Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brasil
| | | | - Marcos Figueiredo Mello
- Unidade de Urologia Pediátrica, Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brasil
| | - Hiury Silva Andrade
- Unidade de Urologia Pediátrica, Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brasil
| | - Paulo Afonso Carvalho
- Unidade de Urologia Pediátrica, Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brasil
| | - Bruno Nicolino Cezarino
- Unidade de Urologia Pediátrica, Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brasil
| | - Francisco Tibor Dénes
- Unidade de Urologia Pediátrica, Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brasil
| | - Roberto Iglesias Lopes
- Unidade de Urologia Pediátrica, Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brasil
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Duarte RJ, Cristofani LM, Odone Filho V, Srougi M, Dénes FT. Videolaparoscopic radical nephrectomy after chemotherapy in the treatment of Wilms' tumor: Long-term results of a pioneer group. J Pediatr Urol 2017; 13:50.e1-50.e5. [PMID: 28288778 DOI: 10.1016/j.jpurol.2016.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 09/05/2016] [Indexed: 12/22/2022]
Abstract
INTRODUCTION A high cure rate for Wilms' tumor has been achieved using a multidisciplinary approach. The natural step forward is to offer the benefits of a minimally invasive technique for surgery, which is an obligatory part of treatment. Nevertheless, some authors resist using videolaparoscopic radical nephrectomy (VRN) because of concerns about reducing the cure index. METHODS The present study included children with unilateral Wilms' tumor treated from December 2003 to December 2015 with neoadjuvant chemotherapy followed by VRN. Patients were selected based on the size of their tumors compared with the contralateral kidney, and on their stature. RESULTS VRN was performed in 24 patients of age range 10-93 months, with an average of 38.04 ± 23.37 months. The tumoral kidney's largest diameter after chemotherapy averaged 10% of a patient's height. There was no tumor rupture or spillage and no patient presented intra or immediate postoperative complications, except for prolonged ileum in two patients. One patient required intraoperative transfusion because of preoperative anemia. Another developed a late herniation in the umbilical port that required surgical correction. After an average of 6.65 years of follow-up, two patients presented relapse: one with a stage IV disease had relapse in the lung and another with a stage III, involving the liver, had local relapse because of an unwanted delay in the adjuvant treatment. CONCLUSION VRN can be considered a feasible alternative to open surgery in selected cases of children with Wilms' tumor. The present experience shows that besides the benefits of minimally invasive procedures and better cosmetic results, there is no evidence of increased tumor rupture or spillage, peritoneal or port site metastasis, and the long-term oncological results are the same as open procedures.
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Affiliation(s)
- Ricardo Jordão Duarte
- Uropediatric Unit, Division of Urology, Hospital da Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Lilian Maria Cristofani
- Department of Pediatrics, Instituto da Criança, Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Vicente Odone Filho
- Department of Pediatrics, Instituto da Criança, Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Miguel Srougi
- Uropediatric Unit, Division of Urology, Hospital da Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Uropediatric Unit, Division of Urology, Hospital da Clínicas, University of São Paulo Medical School, São Paulo, Brazil.
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Moscardi PRM, Lopes RI, Mello MF, Barbosa CM, Cezarino BN, Oliveira LM, Dénes FT, Srougi M. Laparoscopic Pyeloplasty in children with Horseshoe Kidney. Int Braz J Urol 2016; 43:375. [PMID: 27778495 PMCID: PMC5433381 DOI: 10.1590/s1677-5538.ibju.2016.0042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 04/05/2016] [Indexed: 11/26/2022] Open
Abstract
Introduction Horseshoe kidney occurs in 1 per 400-800 live births and are more frequently observed in males (M:F 2:1). Ureteropelvic junction obstruction (UPJO) is commonly associated with horseshoe kidneys. The variable blood supply, presence of the isthmus and high insertion of the ureter contribute to this problem. Case report An asymptomatic 6 year-old boy presented with antenatal hydronephrosis. Ultrasonography and CT scan demonstrated left UPJO associated with a horseshoe kidney. DMSA showed 33% of function on the left side. DTPA showed a flat curve and lack of washout. A left dismembered laparoscopic pyeloplasty was performed after identification of crossing vessels and abnormal implantation of the ureter. After one year, the child is asymptomatic. DTPA demonstrated a good washout curve. Results Our cohort consisted of six patients, five males and one female, with a mean age of 6 years (range 6m-17 years) and a mean follow-up of 3 years. Ureteropelvic junction obstruction was more common on the left side. Symptoms appeared only in 34% of the cases. Mean operative time was 198 minutes (range 120-270 minutes). Crossing vessels were common (observed in 50% patients). High implantation of ureter was seen in 67% patients and intrinsic obstruction in 83%. Surgical difficulties were found in two cases. Hospital stay was 4.3 days (3 to 6 days), with only one patient having a mild complication (pyelonephritis). All cases had clinical and radiologic improvement. Conclusion Laparoscopic pyeloplasty is safe and feasible in children with UPJO in horseshoe kidneys, with good results and minimal morbidity.
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Affiliation(s)
| | | | | | | | | | | | - Francisco Tibor Dénes
- Divisão de Urologia do Departamento de Cirurgia, Universidade de São Paulo, SP, Brasil
| | - Miguel Srougi
- Divisão de Urologia do Departamento de Cirurgia, Universidade de São Paulo, SP, Brasil
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Moscardi PRM, Barbosa JABA, Andrade HS, Mello MF, Cezarino BN, Oliveira LM, Srougi M, Dénes FT, Lopes RI. Reoperative Laparoscopic Ureteropelvic Junction Obstruction Repair in Children: Safety and Efficacy of the Technique. J Urol 2016; 197:798-804. [PMID: 27789217 DOI: 10.1016/j.juro.2016.10.062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE Failure after pyeloplasty for ureteropelvic junction obstruction in children may occur in up to 10% of cases. Therapeutic options include Double-J® stent placement, endoscopic treatment and reoperation. Laparoscopic and robotic reoperative modalities seem safe and efficacious, although pediatric series are limited in the literature. We report the largest known series of reoperative laparoscopic ureteropelvic junction obstruction repair in children and compare this approach to primary laparoscopic pyeloplasty. MATERIALS AND METHODS We reviewed all children undergoing laparoscopic pyeloplasty at a single institution from 2004 to 2015. Reoperative laparoscopic ureteropelvic junction obstruction repair was compared to primary pyeloplasty. Groups were analyzed regarding demographics, operative time, complications, length of hospital stay and success, defined by improvement of symptoms, ultrasound and renogram. RESULTS We identified 11 cases of reoperation (8 redo pyeloplasties and 3 ureterocalycostomies) and 71 primary pyeloplasties. Groups were not different in age, gender or weight. Median followup was 37 months. Median time between primary pyeloplasty and reoperation was 34 months. Median operative time was 205 minutes for the reoperative group and 200 for primary pyeloplasty (p = 0.98). Length of stay was longer in the reoperative group (p = 0.049), although no major complications were recorded in this group. All reoperative cases and 96% of primary pyeloplasty cases remained asymptomatic following surgery (p = 0.99). Postoperative improvement was similar for both groups on ultrasound (90% for reoperation vs 92% for primary pyeloplasty, p = 0.99) and renogram (80% vs 88%, p = 0.6). CONCLUSIONS Laparoscopy seems to be safe and effective for management of failed pyeloplasty in children. Based on our data, reoperation is as safe and effective as primary pyeloplasty.
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Affiliation(s)
| | | | - Hiury Silva Andrade
- Division of Urology, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | | | | | - Miguel Srougi
- Division of Urology, University of São Paulo School of Medicine, São Paulo, Brazil
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Sircili MHP, Bachega TSS, Madureira G, Gomes L, Mendonca BB, Dénes FT. Surgical Treatment after Failed Primary Correction of Urogenital Sinus in Female Patients with Virilizing Congenital Adrenal Hyperplasia: Are Good Results Possible? Front Pediatr 2016; 4:118. [PMID: 27833904 PMCID: PMC5081340 DOI: 10.3389/fped.2016.00118] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 10/12/2016] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Genital reconstruction in female patients with virilizing congenital adrenal hyperplasia (CAH) is very challenging. Our aim was to evaluate the techniques employed to treat complications after failure of primary urogenital sinus (UGS) surgery, as well as the result of these reoperations. PATIENTS AND METHODS Twenty girls with virilizing CAH who were previously submitted to genitoplasty in our service and elsewhere had recurrent UGS stenosis and vaginal introitus stenosis that required surgical treatment. The main symptoms were recurrent urinary tract infection (UTI) in nine, dyspareunia in six, and hematocolpos in three (two associated with sepsis). The anatomical findings were the persistence of UGS with stenosis in 17 patients and vaginal introitus stenosis in 3. The mean age at procedure was 15.2 years, averaging 13.1 years after the first surgery. The surgical techniques employed were isolated perineal flap in 17 patients and perineal flap with partial mobilization of UGS in 3. The mean follow-up after the procedure was 4.8 years (varying from 1 to 17 years). RESULTS Vaginal dilations were performed after surgery in 15 patients. Good functional and anatomical results were obtained in 15 patients, with vaginal introitus amenable to dilators of 3.0 cm in diameter. Five patients with high vaginal insertion had recurrent vaginal stenosis and required a surgical revision. No patients presented menstrual obstruction or UTI after surgery. Eight of the 15 adult patients are sexually active. CONCLUSION The reoperation to treat failed primary UGS treatment using Y-V flap and partial mobilization techniques associated with vaginal dilations, promoted good anatomical, and functional results with low morbidity in 75% of the patients.
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Affiliation(s)
- Maria Helena Palma Sircili
- Division of Urology, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil; Division of Endocrinology, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Guiomar Madureira
- Division of Endocrinology, Hospital das Clínicas, School of Medicine, University of São Paulo , São Paulo , Brazil
| | - Larissa Gomes
- Division of Endocrinology, Hospital das Clínicas, School of Medicine, University of São Paulo , São Paulo , Brazil
| | - Berenice Bilharinho Mendonca
- Division of Endocrinology, Hospital das Clínicas, School of Medicine, University of São Paulo , São Paulo , Brazil
| | - Francisco Tibor Dénes
- Division of Urology, Hospital das Clínicas, School of Medicine, University of São Paulo , São Paulo , Brazil
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Lopes RI, Dénes FT, Bartolamei MG, Reis S, Sanches TR, Leite KR, Srougi M, Seguro AC. Serum and Urinary Values of CA 19-9 and TGFß1 in a Rat Model of Partial or Complete Ureteral Obstruction. Eur J Pediatr Surg 2015; 25:513-9. [PMID: 25560248 DOI: 10.1055/s-0034-1395263] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Abnormal levels of serum and urinary markers occur in the presence of renal damage associated to obstructive uropathy. Urinary and serum transforming growth factor beta 1 (TGFß1) and carbohydrate antigen (CA 19-9) have not yet been evaluated in an experimental model of obstructive uropathy. MATERIAL AND METHODS Rats were divided into seven groups: reference, sham operation, unilateral nephrectomy, complete unilateral ureteral obstruction, partial unilateral ureteral obstruction, partial bilateral ureteral obstruction, and unilateral nephrectomy with contralateral partial ureteral obstruction. Kidney and ureter morphometry, TGFß1 and CA 19-9 serum and urinary concentrations and CA 19-9 renal tissue expression were analyzed. Correlation of these markers to complete, partial obstruction, or unobstructed groups was performed. RESULTS Pathological findings correlated positively with the degree of ureteral obstruction, but negatively with urinary CA 19-9 levels. Marked underexpression of CA 19-9 was observed in kidneys with complete ureteral obstruction. No statistically significant differences were found for urinary and serum TGFß1 and also for serum CA 19-9. CONCLUSION Urinary CA 19-9 correlated negatively with ureteral obstruction grade. Immunohistochemistry depicted CA 19-9 expression on epithelial tubular cells cytoplasm, suggesting renal origin. Serum and urinary TGFß1 did not show alterations in response to severity and length of urinary obstruction, which might be associated with less intense renal remodeling.
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Affiliation(s)
| | | | | | - Sabrina Reis
- Division of Urology, University of São Paulo, São Paulo, Brazil
| | | | | | - Miguel Srougi
- Division of Urology, University of São Paulo, São Paulo, Brazil
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Dénes FT, Park R, Lopes RI, Moscardi PRM, Srougi M. Abdominoplasty in Prune Belly Syndrome. J Pediatr Urol 2015; 11:291-2. [PMID: 26227565 DOI: 10.1016/j.jpurol.2015.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 06/21/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Many patients with Prune Belly Syndrome (PBS) require abdominoplasty alone or in combination with correction of any urogenital abnormalities. This video presents a simplified technique with which to treat the abdominal flaccidity in PBS. METHODS A longitudinal xypho-pubic fusiform figure is drawn on the abdomen, based on the area of skin and subcutaneous tissue to be removed. This is performed with preservation of the musculo-fascial layer and the umbilicus. A lateral elliptical single xypho-pubic line is drawn in the most lax side of the fascia, which is incised along this line. After urinary tract reconstruction and orchidopexy, closure is initiated by suturing the medial edge of the wider fascial flap laterally to the peritoneal side of the contralateral flap. Next, the now outer fascial flap is laid over the inner flap, and a buttonhole is made to expose the umbilicus. The subcutaneous tissue of the inner flap is laterally undermined to gain extra distance for the suture of the outer flap over the inner flap. The subcutaneous tissue and skin are sutured in the midline, incorporating the umbilicus. RESULTS In a 30-year period, 43 PBS patients underwent this procedure with good cosmetic and long-term functional results. CONCLUSION This abdominoplasty technique is simple and presents good functional and cosmetic results in PBS patients.
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Affiliation(s)
- F T Dénes
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - R Park
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - R I Lopes
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil.
| | - P R M Moscardi
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - M Srougi
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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Dénes FT, Lopes RI. Response to commentary to "27 years of experience with the comprehensive surgical management of prune belly syndrome". J Pediatr Urol 2015; 11:279. [PMID: 26279103 DOI: 10.1016/j.jpurol.2015.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/17/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Francisco Tibor Dénes
- Uropediatric Unit, Division of Urology, University of São Paulo Medical School, Brazil.
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Cezarino BN, Lopes RI, Oliveira LM, Dénes FT, Srougi M. Diagnostic work-up and laparoscopic correction of an ectopic ureter. J Pediatr Urol 2015; 11:285-6. [PMID: 26143484 DOI: 10.1016/j.jpurol.2015.04.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 04/15/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION A duplex renal collecting system is a common congenital anomaly in children. Continuous dribbling (especially if after the toilet-training period) should raise suspicion of the presence of an ectopic ureter, which is most often associated with ureteral duplication. This video will demonstrate the complete diagnostic work-up necessary in these cases. CASE REPORT A 10-year-old girl presented with continuous dribbling. Ultrasonography and computerized tomography depicted a duplex system on the left side, with the upper pole ureter ectopically inserting into the vaginal cavity and good upper pole renal parenchyma. A careful urethrocystoscopy showed a topic right ureteral orifice and a topic lower pole left ureteral orifice. Retrograde pyelography was performed and displayed normal left lower pole anatomy. A vaginography was performed, which showed reflux to the ectopic ureter. Vaginoscopy clearly identified the ectopic ureteral orifice. A guide wire was introduced through this meatus and retrograde contrast injection confirmed the diagnosis of an ectopic ureter. RESULTS At laparoscopy, a larger upper pole ureter and a normal lower pole ureter on the left side were identified. A termino-lateral ureteroureteral anastomosis was performed. After the procedure, the child reported immediate resolution of urinary dribbling. CONCLUSION In order to optimize its surgical correction, efforts should be made to appropriate localization of the ectopic ureter.
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Affiliation(s)
- B N Cezarino
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, Brazil
| | - R I Lopes
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, Brazil.
| | - L M Oliveira
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, Brazil
| | - F T Dénes
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, Brazil
| | - M Srougi
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, Brazil
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Duarte RJ, Cristofani LM, Dénes FT, Filho VO, Tannuri U, Srougi M. Wilms Tumor: A Retrospective Study of 32 Patients Using Videolaparoscopic and Open Approaches. Urology 2014; 84:191-5. [DOI: 10.1016/j.urology.2014.02.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 01/26/2014] [Accepted: 02/03/2014] [Indexed: 10/25/2022]
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Dénes FT, Lopes RI, Oliveira LM, Tavares A, Srougi M. Modified Abdominoplasty for Patients With the Prune Belly Syndrome. Urology 2014; 83:451-4. [DOI: 10.1016/j.urology.2013.09.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 09/14/2013] [Accepted: 09/27/2013] [Indexed: 11/15/2022]
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Abstract
Tumors of the kidney, bladder, prostate, testis, and adrenal represent a large part of the adult urologic practice, but are relatively infrequent in children. The natural history and management of these tumors in the pediatric age is different from that of the adults. As result of the successful work of several clinical trial groups in recent decades, there has been a significant improvement in their cure rates. The aim of this article is to review their most significant clinical aspects, as well as to present an update in their management.
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Affiliation(s)
- Francisco Tibor Dénes
- Uropediatric Unit, Division of Urology, Hospital das Clínicas, University of São Paulo , São Paulo , Brazil
| | - Ricardo Jordão Duarte
- Uropediatric Unit, Division of Urology, Hospital das Clínicas, University of São Paulo , São Paulo , Brazil
| | - Lílian Maria Cristófani
- Pediatric Onco-Hematology Unit, Department of Pediatrics, Hospital das Clínicas, University of São Paulo , São Paulo , Brazil
| | - Roberto Iglesias Lopes
- Uropediatric Unit, Division of Urology, Hospital das Clínicas, University of São Paulo , São Paulo , Brazil
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Sircili MH, Dénes FT, Tavares A, Costa EMF, Domenice S, Siqueira Cunha F, Srougi M, Mendonça B. 103 TRANSSEXUAL GENITAL SURGERY: COMPLICATIONS AND FUNCTIONAL RESULTS AFTER 13 YEARS OF EXPERIENCE. J Urol 2013. [DOI: 10.1016/j.juro.2013.02.1481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
PURPOSE Reporting on the laparoscopic technique for adrenal disease in children and adolescents has been limited. We review here our experience with laparoscopic adrenal surgery in children. PATIENTS AND METHODS 19 laparoscopic unilateral adrenalectomies were performed in 10 girls and 7 boys (mean age 3.9 years) during 1998-2011. The clinical diagnosis before surgery was virilizing tumor (n = 8), pheochromocytoma (n = 3), nonfunctioning solid adrenal tumor (n = 3), mixed adrenocortical tumor (n = 2), cystic adrenal mass (n = 1). Unilateral adrenal lesions were 20-65 mm at the longest axis on computerized tomography (12 right side, 7 left side). RESULTS The final clinicopathological diagnosis was cortical adenoma (n = 9), pheochromocytoma (n = 3, bilateral in two), neuroblastoma (n = 1), ganglioneuroblastoma (n = 1), ganglioneuroma (n = 1), adrenocortical carcinoma (n = 1), benign adrenal tissue (n = 1). Average operative time was 138.5 min (range 95-270). Blood transfusion was required in one case (5%). No conversion to open surgery was required and no deaths or postoperative complications occurred. Average hospital stay was 3.5 days (range 2-15). Average postoperative follow-up was 81 months (range 2-144). Two contralateral metachronic pheochromocytomas associated with von Hippel-Lindau syndrome occurred, treated with partial laparoscopic adrenalectomy (one without postoperative need of cortisone replacement therapy). CONCLUSIONS Laparoscopic adrenalectomy is a feasible procedure that produces good results. It can be used safely to treat suspected benign and malignant adrenal masses in children with minimal morbidity and short hospital stay.
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Affiliation(s)
- Roberto Iglesias Lopes
- Division of Urology, Hospital das Clínicas, University of São Paulo Medical School, Rua Dr. Enéas de Carvalho Aguiar, 455 - 7 andar, São Paulo, Brazil
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Sircili MHP, de Queiroz e Silva FA, Costa EM, Brito VN, Arnhold IJ, Dénes FT, Inacio M, de Mendonca BB. Long-Term Surgical Outcome of Masculinizing Genitoplasty in Large Cohort of Patients With Disorders of Sex Development. J Urol 2010; 184:1122-7. [DOI: 10.1016/j.juro.2010.05.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Indexed: 11/28/2022]
Affiliation(s)
- Maria Helena Palma Sircili
- Endocrinology Division, Hormone and Molecular Genetics Laboratory LIM/42, Endocrinology Discipline, Hospital das Clinicas da FMUSP, São Paulo, Brazil
| | | | - Elaine M.F. Costa
- Endocrinology Division, Hormone and Molecular Genetics Laboratory LIM/42, Endocrinology Discipline, Hospital das Clinicas da FMUSP, São Paulo, Brazil
| | - Vinicius N. Brito
- Endocrinology Division, Hormone and Molecular Genetics Laboratory LIM/42, Endocrinology Discipline, Hospital das Clinicas da FMUSP, São Paulo, Brazil
| | - Ivo J.P. Arnhold
- Endocrinology Division, Hormone and Molecular Genetics Laboratory LIM/42, Endocrinology Discipline, Hospital das Clinicas da FMUSP, São Paulo, Brazil
| | | | - Marlene Inacio
- Endocrinology Division, Hormone and Molecular Genetics Laboratory LIM/42, Endocrinology Discipline, Hospital das Clinicas da FMUSP, São Paulo, Brazil
| | - Berenice Bilharinho de Mendonca
- Endocrinology Division, Hormone and Molecular Genetics Laboratory LIM/42, Endocrinology Discipline, Hospital das Clinicas da FMUSP, São Paulo, Brazil
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Pinto MS, Mitre AI, Sheepmaker R, Nahas WC, Dénes FT, Coelho RF, David Neto E, Srougi M. Evaluation of cadaveric renal vein lengths and their extension loss with three types of ligature and section. J Endourol 2009; 23:995-1000. [PMID: 19456241 DOI: 10.1089/end.2008.0604] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE The right kidney has been less frequently used in live donor nephrectomy, because of the shorter length of the right renal vein (RRV) that is associated with technical difficulties and higher rates of venous thrombosis. In live open donor or deceased donor transplant nephrectomy, an additional cuff of the inferior vena cava is usually removed, but this is a more difficult and risky maneuver in laparoscopic nephrectomy. For this reason, laparoscopic right nephrectomy (LRN) for renal transplantation (RT) is not frequently performed in most medical institutions. We evaluate the difference between RRV and left renal vein (LRV) lengths in cadavers, as harvested for RT by three clamping methods. Our objective was to obtain information that could clarify when LRN for RT should be encouraged or avoided with regard to conventional surgery. MATERIALS AND METHODS Ninety adult fresh unfrozen cadavers were randomly divided into three groups of 30, according to the clamping device used: Satinsky, stapler, and Hem-o-lok clip. The abdominal viscera were removed through a median xyphopubic incision, and the veins were measured on the bench. Two lateral limits were used: The renal hilum and the tangential line of the renal poles. As for medial limits, the inferior vena cava or the laparoscopic clipping device on the RRV were used on the right side, while on the LRV, the medial border of the emergence of the adrenal vein was considered. After section of the renal vein, a slight traction of the extremity was applied for the measurement. All measurements were obtained three times using a metallic millimetric ruler, and the arithmetic mean was considered. The chi-square, one-way analysis of variance, and paired t tests were used for statistical analysis. Statistical significance was accepted at P <or= 0.05. RESULTS The groups of cadavers were homogeneous in demographic characteristics. Regardless of the clamping method and considering the useful length of the LRV, the RRV was statistically smaller. The evaluation of the vein length did not depend on the lateral limit considered. Independent of the clamping method, on both sides, the lengths after the vein section were larger than before the section, a fact attributed to traction. Use of a stapler and a single Hem-o-lok presented the same waste of vein length on the right side. On average, the RRV was 13.7% shorter than the LRV. CONCLUSIONS With the wide acceptance of laparoscopic live donor nephrectomy, the length difference between the veins of both kidneys is an important issue, and the right kidney is therefore used less than the left, compared with conventional surgery. This article represents the first step to quantify the anatomic length of renal veins in different situations. Certainly, more imagenologic or surgical studies should be carried out before decisions can be made for better selection of patients for LRN.
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Affiliation(s)
- Murilo Spinelli Pinto
- Division of Urology, Hospital das Clínicas, São Paulo University Medical School, São Paulo, Brazil
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de Bessa J, Dénes FT, Chammas MC, Cerri L, Monteiro EDS, Buchpiguel CA, Cerri GG, Srougi M. Diagnostic accuracy of color Doppler sonographic study of the ureteric jets in evaluation of hydronephrosis. J Pediatr Urol 2008; 4:113-7. [PMID: 18631905 DOI: 10.1016/j.jpurol.2007.10.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Accepted: 10/22/2007] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Hydronephrosis (HN) and obstruction are closely associated, but upper urinary tract dilatation can occur without significant obstruction. Despite some pitfalls, conventional ultrasonography and diuretic renography (DR) are the main means of evaluation of HN in children. Recent reports have demonstrated color Doppler ultrasonography (CDUS) to reliably identify ureteric jets in the bladder. The aim of this study was to evaluate this method as a diagnostic tool to distinguish obstructive from non-obstructive dilatations of the upper tract. METHODS We evaluated 51 patients (37 boys and 14 girls), aged 3 months to 14 years (median 4 years), who presented with unilateral grade III and IV hydronephrosis with suspicion of pyeloureteral junction obstruction. All patients underwent DR and evaluation of ureteric jets by transverse CDSG of the bladder within a maximum of 2 weeks. Obstruction was considered in the DR when the hydronephrotic unit showed a differential renal function of less than 40%, or when symptomatic intermittent renal colic was present in older children. The number of ureteric jets was counted over a 5-min period and the frequency calculated for each ureteral orifice. Relative jet frequency (RJF) was defined as frequency of the hydronephrotic side divided by total ureteric jet frequency. Receiver-operating characteristic (ROC) plots were constructed to determine the best cut-off for RJF, in order to identify renal units with obstructive hydronephrosis. RESULTS Twenty-three (45.1%) hydronephrotic units were considered obstructed. The mean RJF differed between obstructive (0.09+/-0.15) and non-obstructive hydronephrosis (0.42+/-0.11) (p<0.001). ROC analysis revealed that RJF <0.25 was the best threshold, and correctly discriminated obstruction in 91.2% of the children with a sensitivity of 87% (95% CI 78.6-98.2%) and specificity of 96.4% (95% CI 87.8-99%). The positive likelihood ratio was 24.3 and the area under the ROC curve was 0.92 (95% CI 0.86-0.98). CONCLUSIONS RJF <25% was found to be a good indicator of obstruction in children with unilateral hydronephrosis. CDUS evaluation of ureteric jets is an easy and non-invasive method that can be used as an initial diagnostic tool, and in follow-up cases, to differentiate obstructed from non-obstructed hydronephrosis in the pediatric population.
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Affiliation(s)
- José de Bessa
- Uropediatric Unit, Division of Urology, Medical School, Sao Paulo University, Sao Paulo, Brazil.
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Abstract
PURPOSE We describe 2 cases of laparoscopic nephrectomy for unilateral Wilms tumor in children who underwent preoperative chemotherapy. MATERIALS AND METHODS Two children with unilateral nonmetastatic Wilms tumor included in the International Society of Pediatric Oncology 2001 protocol were preoperatively treated with vincristine/actinomycin D and subsequently underwent laparoscopic nephrectomy and lymph node sampling. A 5 and 10 mm trocar transperitoneal approach was used in each case. The tumor was extracted without morcellation through a 4 cm Pffannensteil incision. RESULTS The 2 tumors were completely removed as well as lymph node samples. Intraoperative bleeding was minimal (50 ml). The postoperative period was free of complications and patients were discharged home after 3 days. CONCLUSIONS Laparoscopic nephrectomy for Wilms tumor is feasible in children after chemotherapy. It is a safe procedure and it allows the complete surgical approach required to treat this tumor. Longer followup is necessary to evaluate long-term results and more cases are necessary to compare the results of laparoscopic techniques with those of open surgical procedures.
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Affiliation(s)
- S Arap
- Division of Urology, The Medical School Hospital of the University of São Paulo, São Paulo, Brazil.
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Abstract
Laparoscopy has gained acceptance as the ideal method of surgical treatment of the internal [figure: see text] genital organs in patients with intersex disorders. The intersexual states for which laparoscopy is needed are female and male pseudohermaphroditism, true hermaphroditism, and Turner's syndrome. In these patients, the indications for laparoscopy are the removal of normal gonads and ductal structures that are contrary to the assigned gender and the removal of dysgenetic gonads that are nonfunctional and that present potential for malignancy. In addition to being a minimally invasive surgery, one of the main advantages of this method is the lack of scars, a fact much appreciated by patients and their parents. Generally, gonadectomy is a straightforward operation because the gonads present with an accessible pedicle. Laparoscopic orchidopexy has been standardized and can be performed in patients in whom the testis must be relocated to the scrotum. The removal of ductal structures is also easily performed in most cases, whereas hysterectomy with resection of the vagina may present some difficulties owing to the location of these structures. In patients with a long vaginal component of the urogenital sinus, the distal segment must be removed by a retrograde perineal access, usually performed simultaneously with genitoplasty. Endocrinologists must be aware of the application of this method of treatment in intersex patients, and urologists proficient in laparoscopic techniques must extend their field of work in this area.
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Affiliation(s)
- F T Dénes
- Division of Urology, University of São Paulo School of Medicine Hospital, São Paulo, Brazil
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Abstract
OBJECTIVE To evaluate the results of the laparoscopic technique in the treatment of adrenal pheochromocytoma. METHOD Ten patients, 7 men and 3 women, between 10 and 67 years of age (mean 48) with pheochromocytoma underwent transperitoneal laparoscopic adrenalectomy and were evaluated retrospectively, based on clinical, laboratory, and pathological diagnosis. In all cases there was a solid unilateral adrenal tumor, 5 on the left side and 5 on the right side, whose greater diameter varied from 7 to 80 mm (mean 32). Nine of the 10 patients were chronically hypertensive or had already had hypertensive crises. One patient was normotensive, but presented metabolic alterations suggestive of adrenergic hyperfunction. RESULTS No deaths occurred in this series. There were two (20%) conversions to open surgery, one due to venous bleeding and one due to the difficulty of dissection behind the vena cava in a patient presenting a partially retro-caval tumor. Surgical time in the 8 non-converted cases ranged from 70 to 215 minutes (mean 136). One patient (10%) received blood transfusion, and another (10%) presented two complications - acute renal failure and a subcutaneous infection. Both had been converted to open surgery. None of the non-converted cases was transfused or presented complications. Hospital discharge occurred between the 2nd and 11th post-operative day (mean 3). The pathological exam of the surgical specimens confirmed the diagnoses of pheochromocytoma in all 10 cases, one of them associated with an aldosterone-producing cortical tumor. CONCLUSIONS Laparoscopic adrenalectomy for selected patients presenting pheochromocytoma is feasible and provides good results.
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Affiliation(s)
- L N Castilho
- Division of Urology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo
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Dénes FT, Arap S. [Vesicoureteral reflux in children]. J Pediatr (Rio J) 1995; 71:183-8. [PMID: 14688999 DOI: 10.2223/jped.775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The association between vesicoureteral reflux and urinary tract infection represents a significant threat to the kidney, in the form of pyelonephritic scarring. The physiopathologic events that allow the upward migration of bacteria and their inoculation in the renal tissue, causing irreversible damage if not adequately treated, are reasonably understood. Reflux nephropathy is a major cause of childhood hypertension and renal insufficiency. Early diagnosis of reflux, and identification of the pyelonephritic aggression are important for successful therapy. Long-term chemoprophylaxis,to prevent urinary tract infection and renal scarring is the adequate form of treating low-grade vesicoureteric reflux, since spontaneous cure is expected in most of these cases. Although the same approach can be employed in high-grade reflux, surgery is a favorable alternative, with high rates of primary success,reducing the need of long-term medication and the exposure of the kidney to recurring pyelonephritic aggression. The retrograde flow of urine from the bladder to the upper urinary tract is an abnormal situation in the human being, known as vesicoureteral reflux (VUR). It results either from an intrinsic anatomical deficiency of the vesicoureteral junction or from an increased bladder pressure, due to mechanical or dysfunctional vesicourethral obstruction. The recognition of the association between VUR, urinary tract infection (UTI) and renal scars has led to an increased study of this disease in the last two decades.
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Affiliation(s)
- F T Dénes
- Divisão de Urologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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Dénes FT, Brito AH, Cutait R. Transureterocalicostomy: an alternative internal diversion technique. J Urol 1995; 153:404-6. [PMID: 7815599 DOI: 10.1097/00005392-199502000-00035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We report a case of an infiltrating retroperitoneal tumor that completely enveloped and obstructed the mid third of the left ureter. After resection of the tumor, including a 10 cm. long segment of ureter, the upper left ureter was successfully diverted to the upper calix of the right ectopic kidney (transureterocalicostomy). To our knowledge our report represents the first case of such surgery.
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Affiliation(s)
- F T Dénes
- Department of Urology, Hospital Sírio-Libanes, São Paulo, Brazil
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Abstract
The authors report 4 cases of urinary tract malakoplakia. This rare disease of unknown etiopathogenesis can present with a benign character in the bladder, but when the upper urinary tract is affected, loss of renal function can occur. Treatment aims to control the primary infection, as well as enhance intracellular bactericidal activity, which seems to be compromised in these cases. Cytoreductive surgery may be indicated when this treatment fails.
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Dénes FT, Arap S. [Percutaneous nephrostomy]. Rev Hosp Clin Fac Med Sao Paulo 1986; 41:6-10. [PMID: 3823732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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36
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Abstract
A case of retroperitoneal fibrosis satisfactorily treated with indwelling double J catheters is presented. This method, although reserved for special cases, is an adequate alternative treatment as it allows efficient long-term drainage of kidneys without aggressive surgical dissection of ureters.
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Arap S, Borrelli M, Padovani Júnior H, Gromatzky C, Dénes FT. [Spontaneous rupture of a renal angiomyolipoma]. Rev Hosp Clin Fac Med Sao Paulo 1985; 40:258-60. [PMID: 3836480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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38
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Abstract
Although rare, the prolapsed ureterocele constitutes a urologic emergency that can rapidly evolve to severe conditions due to congestion and necrosis, and to obstruction of the urinary tract. A simple external resection resolves the emergency, allowing a postoperative investigation of the whole urinary tract to be performed, in order to adequately prepare urinary reconstruction.
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Abstract
We report 2 patients in whom regression of ureteral obstruction due to recurrent idiopathic retroperitoneal fibrosis was obtained with steroids. Steroids are a valid alternative to surgery in the initial treatment of biopsy-proven benign (idiopathic) retroperitoneal fibrosis.
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Abstract
Two cases of vesical haemangioma and a review of the literature are presented. In one of the cases association with cutaneous "Blue Rubber Bleb Nevus" has been found. Vesical haemangioma is a benign tumour, probably of congenital origin, that occurs in young patients. The first symptom is generally haematuria, and diagnosis is confirmed by cystoscopy. The treatment of choice is partial cystectomy, and the most common histologic form is cavernous haemangioma.
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Abstract
We report a case of squamous keratinizing metaplasia of the upper urinary tract. This benign pathology is very rare and difficult do differentiate from other space occupying lesions of the upper urinary tract. Its aetiopathogenesis is still not well understood, but whenever early diagnosis is made, conservative treatment can be employed.
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Dénes FT, Borrelli M, de Góes GM. [Intraoperative exploration in surgery of staghorn lithiasis]. Rev Paul Med 1983; 101:217-21. [PMID: 6677982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Borrelli M, Mitre AI, Alfer Júnior W, Dénes FT, Wroclawski ER, Castilho LN, de Góes GM. [Surgical treatment of priapism using Al-Ghorab's technic]. Rev Paul Med 1983; 101:27-8. [PMID: 6879028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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45
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Abstract
The authors present two cases of ureteral endometriosis. Urinary tract endometriosis has been frequently described affecting mainly the bladder. In the ureter, it is a rare pathology, of difficult identification. Treatment aims at ureteral disobstruction together with eradication of endometrial foci. This is accomplished by surgical, radiotherapeutic and chemotherapeutic means.
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Abstract
Due to better methods of diagnosis, an increasing number of children with renovascular hypertension are being discovered. The disease itself has variable clinical manifestations, and an adequate laboratorial workup, including arteriography and renin assays, is mandatory in suspected cases. Treatment depends on the prognostic values of the renin assays and surgery cures 80% of the patients, either by nephrectomy or by revascularization techniques. Among these, renal autotransplantation gives better exposure of the operative field, and therefore better results. In most cases, systemic infection seems to be the main cause of the inflammatory reaction within the arterial wall that causes obstruction.
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Netto NR, Dénes FT, de Góes GM. [The triad syndrome in an adult patient]. Rev Paul Med 1979; 93:72-5. [PMID: 40298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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48
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Abstract
A rare case of benign pelvic neurilemmoma with bladder infiltration and ureteral obstruction is presented. This neurally originated tumor may occur anywhere in the body, but involvement of the urinary tract is rare. Management depends upon location and other clinical findings, and in this case, since complete removal was impossible, urinary derivation was employed as a palliative treatment.
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49
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Abstract
The efficiency of cavernospongiosum shunt in the management of priapism was evaluated in 10 patients. Technical details such as the "Z" perineal incision and the opening followed by closure of the contralateral corpus cavernosum, at the time of corpora evacuation, can improve the local exposure and permits a more complete drainage of the corpus cavernosum, but did not improve our results when they were compared with other techniques for treatment of priapism. Penile flaccidity and preservation of sexual potency occurred in 6 (60%) and 5 (50%) patients, respectively, and no surgical complications were observed. Immediate penile flaccidity and regaining of physiologic erection were, however, not complete even in the successfully treated patients. The cavernospongiosum shunt does not seem to represent the definitive form of treating priapism. New knowledge about mechanisms involved in priapism has to be obtained, in order to improve the approach and the prognosis of this disabling condition.
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50
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Abstract
Treatment of penile fracture, due to the low number of cases, still lacks adequate documentation. The authors present two cases of such pathology, which were treated conservatively, and presented penile deformities in the late follow up. Both conservative and surgical management are discussed; since surgery in these cases has low mortality and clinical treatment can be followed by various sequelae, the authors favour the former, stressing that it is mandatory in cases with urinary obstruction, progressive infiltration of cutaneous laceration.
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