Contribuições à técnica cirúrgica em transplante renal: Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo / Contributions to the surgical tecniques of kidney transplantation: Clinic Hospital of São Paulo University School of Medicine

Não é infreqüente ouvir que, em transplante renal, inovações de impacto no âmbito cirúrgico já não são mais prováveis. No entanto, soluções de alto impacto econômico ainda surgem com freqüência e muitas delas têm surgido no Brasil, contribuindo significativamente para a mudança de conduta cirúrgica em transplante renal a nível mundial. A técnica cirúrgica do transplante renal propriamente dita está bem estabelecida há anos, sendo muito parecida entre os diversos serviços de transplante. Já no que se refere ao tratamento cirúrgico das complicações do transplante e dos pacientes com doenças associadas à insuficiência renal crônica dialítica (IRCD), observamos considerável controvérsia e variação nas condutas. Este estudo pretende oferecer um panorama sobre as técnicas cirúrgicas utilizadas no transplante renal, as complicações decorrentes deste procedimento e os resultados obtidos pelo Serviço de Transplante Renal do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo...

Is not rare to hear that, on kidney transplantation, improvements on surgical aspects are not probable anymore. Although, solutions with high economical impact arises frequently and, many of them, in Brazil, contributing, significantly, for changes on surgical conduct on kidney transplantation worldwide. The surgical techniques for kidney transplantation are well established and do not change between the groups of transplants. Although, the surgical treatment of complicated outcomes and of patients with diseases related to chronic renal failure is still controversial. This study aims to offer a general overview about the surgical techniques of kidney transplantation, complications inherent to this procedure and the results obtained by the Kidney Transplantation Team of Clinic Hospital of São Paulo University Medical School.

Primary reconstruction is a good option in the treatment of urinary fistula after kidney transplantation

OBJECTIVES: urinary fistula is a morbid complication after renal transplantation leading to graft losses and patient death. We review and update our data on urinary fistula after renal transplantation and the outcome after surgical and conservative management. MATERIALS AND METHODS: the charts of 1046 renal transplants were reviewed. Transplants were performed through an extended inguinotomy; vascular anastomoses to the iliac vessels and urinary reconstruction accomplished through the Gregoir technique. Fistulae were diagnosed by urinary leaks through the incision or by the occurrence of a collection in the iliac fossa. Patient was treated surgically or conservatively according to the characteristics of the fistula and patient clinical status. RESULTS: Thirty one fistulae were diagnosed (2.9 percent). Twenty nine leaks due to ureteral necrosis and 2 due to reimplantation fault. The incidence of leaks among cadaver and live donor transplants was 3.22 percent and 2.63 percent, respectively (p = 0.73). Among diabetic and non diabetic patients the incidence of urinary leaks was 6.4 percent and 2.6 percent, respectively (p = 0.049). Treatment consisted in anastomosis of the graft ureter or pelvis with the ureter of the recipient in 17 cases with success in 13 (76.5 percent). Prolonged bladder drainage was employed in 7 cases and the fistula healed in 4 (57 percent). Ureteral reimplantation was performed in 3 cases and did not work in any of them. Ureteral ligature plus nephrostomy was employed in two cases and worked in one (50 percent). Percutaneous nephrostomy and ureteral stenting with double J catheter were employed in one case each and worked in both. CONCLUSIONS: The anastomosis of the graft ureter with the ureter of the recipient is a good method for treating urinary fistulae after renal transplantation when local and systemic conditions are good. Ureteral ligature associated to nephrostomy should be applied in cases of unfavorable local conditions or clinically unstable patients.

Likelihood of retrograde double-J stenting according to ureteral obstructing pathology

OBJECTIVES: To evaluate the likelihood of retrograde double-J stenting in urgent ureteral drainage according to obstructing pathology. MATERIALS AND METHODS: From July 2002 to January 2003, 43 consecutive patients with ureteral obstruction who needed urgent decompression were evaluated at our institution, where we performed a total of 47 procedures. Emergency was defined as ureteral obstruction associated with infection, obstructive acute renal failure, or refractory pain. Ureteral obstruction was defined as intrinsic and extrinsic based on etiology and evaluated by ultrasound. Patients submitted to previous double-J stenting were excluded. Failures in retrograde ureteral stenting were treated with percutaneous nephrostomy. Results were analyzed with Fisher's exact test and regression analysis. RESULTS: Failure in retrograde ureteral stenting occurred in 9 percent (2/22) and 52 percent (13/25) of the attempts in patients with intrinsic and extrinsic obstruction respectively (p < 0.001). Failures in stenting extrinsic obstructions occurred due to lack of identification of the ureteral meatus in 77 percent and impossibility of catheter progression in 23 percent (p < 0.05). All attempts of retrograde catheter insertion failed in obstructions caused by prostate or bladder pathologies (6/6). Inability to identify the ureteral meatus was the cause of all failures. CONCLUSION: Retrograde double-J stenting has a low probability of success in extrinsic ureteral obstruction caused by prostate or bladder disease. Such cases might be best managed with percutaneous nephrostomy.

Surgical complications after renal transplantation in grafts with multiple arteries

INTRODUCTION: Renal transplantation with multiple arteries appears, in literature, associated to a major index of surgical complications. This study compared the surgical complications and short-term outcome renal transplants with multiple arteries and single artery grafts. MATERIALS AND METHODS: The data of 64 renal transplants with multiple arteries performed between January 1995 and December 1999 were compared to the ones of 292 transplants with single renal artery. The aspects analyzed were number of arteries of the graft, donor type, vascular reconstruction technique, the occurrence of surgical complications, the incidence of delayed graft function, graft function 1 month after transplantation, graft loss and the patients' deaths. RESULTS: The incidence of surgical complications in grafts with multiple arteries and single renal artery was respectively: vascular - 3.1 percent and 3.1 percent; urological - 6.3 percent and 2.7 percent and other surgical complications - 15.6 percent and 10.6 percent, respectively. The incidence of lymphoceles was 3.1 percent in grafts with a single artery and 12.5 percent in grafts with more than 1 artery (p = 0.0015). The incidence of delayed graft function in grafts with multiple arteries and with a single renal artery was respectively 35.1 and 29.1 percent (p = 0.295). Mean serum creatinine at the 30th postoperative day was 2.46 and 1.81 in grafts with multiple and with 1 artery, respectively (p=0.271). CONCLUSIONS: Kidney transplantation using grafts with single and multiple arteries present similar indexes of surgical complications and short-term outcome; lymphoceles were more frequent among grafts with multiple arteries.

Racial differences in prostate cancer prevalence / Análise da prevalência de câncer de próstata entre as diversas etnias

Objetivo: Analisar descritivamente as diferenças etnicas na prevalência de câncer de próstata no Brasil. Materiais e métodos: Entre 1922 e 1997, 1773 homens foram submetidos a toque retal (TR), dosagem de PSA e questionário padrão (AUA-IPSS). Foram classificados etnicamente em amarelos (45 casos), brancos (1180 casos) e negróides (210 casos). Em 347 homens não foi possível definir a etnia. Os pacientes foram orientados a submeter-se a biópsia de próstata quando o PSA e/ou o TR estivessem alterados. Avaliou-se também o estádio clínico e escore de Gleason na ocasião do diagnóstico, sendo que as etnias foram comparadas quanto à prevalência de câncer. Resultados:Foram feitas 346 biópsias e diagnosticados 51 tumores (14,7 porcento de positividade nas biópsias). Dos tumores, 4 (7,8 porcento) apresentavam PSA normal, 16 (31,4 porcento) PSA entre 4,1 ng/ml e 10 ng/ml e 31 (60,8 porcento), PSA>10 ng/ml. A prevalência de câncer em brancos foi de 2,4 porcento e em negróides de 5,5 porcento (p<0,05). A média de idade para brancos foi de 62,3 ± 0,4 anos e para negróides 62,4 ± 0,7 anos (p>0,05). O PSA mediano para brancos foi 3 ng/ml e para negróides 3,3 ng/ml (p>0,05). Os negróides apresentaram maior prevalência de TR alterado (18,9 porcento versus 11,7 porcento, p<0,05). A instrução mediana de brancos foi 3 e a de negróides 2 (p<0,05). A prevalência de tumores clinicamente localizados foi de 61,3 porcento. Conclusões: A prevalência de câncer de próstata em negróides é maior do que em brancos (5,5 porcento versus 2,4 porcento). O PSA mediano foi similar em ambas etnias. Os negróides apresentaram maior prevalência de toque retal alterado (18,9 porcento versus 11,7 porcento).