Low-fidelity simulation models in urology resident's microsurgery training

Purpose: To evaluate the gain of microsurgical skills and competencies by urology residents, using low-fidelity experimental models. Methods: The study involved the use of training boards, together with a low-fidelity microsurgery simulator, developed using a 3D printer. The model consists in two silicone tubes, coated with a resin, measuring 10 cm in length and with internal and external diameters of 0.5 and 1.5 mm. The support for the ducts is composed by a small box, developed with polylactic acid. The evaluation of the gain of skills and competencies in microsurgery occurred throughout a training course consisting of five training sessions. The first sessions (S1-S4) took place at weekly intervals and the last session (S5) was performed three months after S4. During sessions, were analyzed: the speed of performing microsurgical sutures in the pre and post-training and the performance of each resident through the Objective Structure Assessment of Technical Skill (OSATS) and Student Satisfaction Self-Confidence tools in Learning (SSSCL). Results: There was a decrease in the time needed to perform the anastomosis (p=0.0019), as well as a progressive increase in the score in the OSATS over during sessions S1 to S4. At S5, there was a slightly decrease in performance (p<0.0001), however, remaining within the expected plateau for the gain of skills and competences. The SSSCL satisfaction scale showed an overall approval rating of 96.9%, with a Cronback alpha coefficient of 83%. Conclusions: The low-fidelity simulation was able to guarantee urology residents a solid gain in skills and competencies in microsurgery.

Portable model for vasectomy reversal training

ABSTRACT Objectives To validate an experimental non-animal model for training of vasectomy reversal. Materials and Methods The model consisted of two artificial vas deferens, made with silicon tubes, covered by a white resin, measuring 10 cm (length) and internal and external diameters of 0.5 and 1.5 mm, respectively. The holder of the ducts is made by a small box developed with polylactic acid, using a 3D print. The objective of the invention is to simulate the surgical field of vasovasostomy, when the vas deferens are isolated from other cord structures. For validation, it was verified the acquisition of microsurgical skills during its use, in a capacitation course with 5 urology residents from a Hospital of the region. Along the training sessions, it was analyzed the time (speed) of microsurgical sutures, and quantification of the performance using a checklist. Collected data were analyzed using de BioEstat®5.4 software. Results Medium time for the completion of microsurgical sutures improved considerably during the course, and reached a plateau after the third day of training (p=0.0365). In relation to the checklist, it was verified that during capacitation, there was significant improvement of the scores of each participant, that reached a plateau after the fourth day of training with the model (p=0.0035). Conclusion The developed model was able to allow the students that attended the course to gain skills in microsurgery, being considered appropriate for training vasectomy reversal.

Can a graft be placed over a flap in complex hypospadias surgery? An experimental study in rabbits

ABSTRACT Purpose: To develop a rabbit experimental study to test the hypothesis that surgical repair of hypospadias with severe ventral curvatures might be completed in one stage, if a graft, such as buccal mucosa, could be placed over the tunica vaginalis flap used in corporoplasty for ventral lengthening, with the addition of an onlay preputial island flap to complete the urethroplasty. Materials and methods: The experimental procedure with rabbits included a tunica vaginalis flap for reconstruction of the corpora after corporotomy, simulating a ventral lengthening operation. A buccal mucosa graft was placed directly on top of the flap, and the urethroplasty was completed with an onlay preputial island flap. Eight rabbits were divided into 4 groups, sacrificed at 2, 4, 8 and 12 weeks postoperatively, and submitted to histological evaluation. Results: We observed a large number of complications, such as fistula (75%), urinary retention (50%) and stenosis (50%). There were two deaths related to the procedure. Histological evaluation demonstrated a severe and persistent inflammatory reaction. No viable tunica vaginalis or buccal mucosa was identified. Conclusions: In this animal model, the association of a buccal mucosa graft over the tunica vaginalis flap was not successful, and resulted in complete loss of both tissues.

Cloacal Exstrophy: a complex disease

Introduction Cloacal exstrophy is a rare occurrence with an incidence of 1:200,000 to 1:400,000 live births. It represents one of the most challenging reconstructive endeavors faced by pediatric surgeons and urologists. Aside from the genitourinary defects, there are other associated anomalies of the gastrointestinal, musculoskeletal and neurological systems that require a multidisciplinary approach when counseling anxious parents. Material and Methods We present a video of a patient with cloacal exstrophy treated with 21 days of life. Surgery consisted of separation and tubularization of the cecal plate from the exstrophied bladder halves and colostomy construction. The bladder was closed primarily and umbilical scar reconstructed and used for ureteral and cistostomy drainage. A urethral catheter was used to guide bladder neck tubularization. A final epispadic penis was obtained and planned for further repair in a second step. Results The patient had an initial uneventful postoperative course and immediate outcome was excellent. The bladder healed nicely but patient presented with abdominal distension in the 5th day of postoperative setting requiring parenteral nutrition. The distal colon persisted with lower diameter although non obstructive, but causing difficulty for fecal progression. Continuous colostomy dilatation and irrigation were required. Conclusions Approximating the bladder halves in the midline at birth and primary bladder closure is a viable option, intestinal transit may be a issue of concern in the early postoperative follow-up. .

Keratinized versus non-keratinized preputial flap onlay urethroplasty: does it make any difference in the histological analysis? An experimental study in rabbits

Purpose To compare the histological characteristics of keratinized versus non-keratinized onlay island flaps in an experimental rabbit model. Materials and Methods Sixteen male rabbits were randomly allocated into two experimental groups: keratinized and non-keratinized onlay island flaps. A defect was created in the ventral aspect of the penile urethra. In the keratinized group, a longitudinal island flap was harvested from the external prepuce and rotated to cover the urethral defect. In the non-keratinized group a transverse island flap was harvested from the inner prepuce. The animals were sacrificed after 2, 4, 8 and 12 weeks. Results The flaps were viable in all animals, and no deaths were associated with the procedure. Two urethrocutaneous fistulas were identified, one in each experimental group. A similar pattern of fibrosis was identified in both groups. The keratinized epithelium of the external prepuce kept its histological aspect and keratin production. Both keratinized and non-keratinized groups presented a slight decrease on the epithelial thickness, however without a statistically significant difference between groups. Conclusions In this short-term rabbit model, we observed that the stratified squamous keratinized epithelium from the external prepuce kept its keratin production. There was no statistical influence of the flap type on the mean epithelial thickness. .

Medidas antropométricas como indicadores do estado nutricional em pacientes com espinha bífida submetidos a enterocistoplastia / Anthropometric measurements as an indicator of nutritional status in spina bifida patients undergoing enterocystoplasty

OBJECTIVE: To use anthropometric measurements to compare nutritional status in children with neurogenic bladder dysfunction secondary to meningomyelocele who underwent enterocystoplasty and those who did not undergo surgery. METHODS: A case-control study was conducted in 20 children, divided into two groups: those who had enterocystoplasty (Group A) and those who did not undergo surgery (Group B), matched for genre and age. Weight, height, arm circumference, and triceps skinfold thickness were the parameters used. Nutritional assessment was determined by calculating the indexes, based on age and genre. Classification was based on the percentile and the results were compared with the reference values. RESULTS: The mean age was 6.41 years in Group A and 6.35 years in Group B. The interval between surgery and evaluation was 11 months. The following measures were found for Group A: 80% of children were eutrophic, a percentage 30% greater than that in Group B; arm muscle circumference was adequate in 40% of patients, a percentage 20% greater than that in Group B; arm muscle area was adequate in 90%, a percentage 30% greater than that in Group B. Values in Group B were as follows: for triceps skinfold thickness, 60% of patients had values above the mean, a percentage 20% greater than that in Group A; for arm fat index, 60% of patients were above the mean value, 40% greater than in Group A. CONCLUSION: Patients who had undergone enterocystoplasty showed better nutritional status, while the control group presented higher fat indexes in anthropometric measures. However, the differences between groups were not statistically significant.

OBJETIVO: Utilizar as medidas antropométricas para comparar o estado nutricional em crianças com bexiga neurogênica secundária à mielomeningocele submetidas a enterocistoplastia àquelas não submetidas à cirurgia. MÉTODOS: Estudo tipo caso-controle conduzido em 20 crianças, divididas em dois grupos, aquelas que realizaram enterocistoplastia (Grupo A) versus crianças não operadas (Grupo B), pareados por gênero e idade. Os parâmetros utilizados foram peso, altura, circunferência do braço e prega cutânea triciptal. A avaliação nutricional foi determinada calculando-se índices baseados na idade e no gênero. A classificação foi baseada em porcentagens, e os resultados foram comparados com valores de referência. RESULTADOS: A média da idade foi 6,41 anos no Grupo A e de 6,35 no Grupo B. O intervalo entre a cirurgia e a avaliação foi de 11 meses. As seguintes medidas foram encontradas para o Grupo A: 80% das crianças eram eutróficas, 30% maior do que no Grupo B; circunferência braquial foi adequada em 40% dos pacientes, 20% maior do que no Grupo B; a área do músculo do braço foi adequada em 90%, 30% maior do que no Grupo B. Os valores no Grupo B foram os seguintes: 60% apresentaram prega cutânea triciptal acima do valor médio, uma porcentagem 20% acima do que no Grupo A; para índice de gordura braquial, 60% dos pacientes estavam acima da média, 40% maior do que no Grupo A. CONCLUSÃO: Pacientes submetidos à enterocistoplastia demonstraram melhor estado nutricional enquanto o grupo controle apresentou índices de gordura mais elevados nas medidas antropométricas. Entretanto, a diferença entre os grupos não foi estatisticamente significativa.

The buccal mucosa fenestrated graft for Bracka first stage urethroplasty: experimental study in rabbits

To histologically evaluate, in an experimental study in rabbits, the integration process of the buccal mucosa fenestrated graft applied in the corpora cavernosa for Bracka first stage urethroplasty.

A urethral defect was surgically created in 16 male rabbits of the New Zealand breed through the excision of the penile urethra. The urethral defect was corrected by applying buccal mucosa fenestrated graft through two cruciform incisions in the distal portions of its longitudinal axis. The animals were sacrificed at 2, 4, 8 and 12 weeks post surgery and their genitals were subjected to clinical and histological assessment.

The buccal mucosa fenestrated graft showed complete uptake in all groups, with keratinization squamous metaplasia and mucosal proliferation of the fenestrated areas. The fenestrated graft area represented an increase in length of 25% in length in relation to the original standard graft.

The fenestrated buccal mucosa graft presented total integration to the adjacent epithelia with re-epithelization of the incision areas of the graft (fenestrations) and no significant inflammatory or scarring reactions when compared to other mucosa transplanted areas; therefore its application is viable in cases of extensive urethral defect whenever the donating area might be insufficient. .

Urethral duplication II-A Y type with rectal urethra: ASTRA approach and tunica vaginalis flap for first stage repair

INTRODUCTION: Urethral duplication is a rare congenital anomaly affecting mainly boys. Generally, the duplication develops on the sagittal plane; the accessory urethra may run dorsally or ventrally to the orthotopic one. We present a patient with urethral duplication in which the orthotopic urethra was patent in the penile segment but atresic in the bulbar and prostatic segment. The patient had urinary flow from the rectum and the ectopic urethra could be well identified by anal examination. MATERIALS AND METHODS: Age at surgery was 13 months. The procedure consisted of an ASTRA (anterior sagittal trans-ano-rectal) approach for dividing the urethra and rectum and was successful to move the urethra up to the perineal area. The rectum was reconstructed and the patient placed into a lithotomy position. A urethral catheter inserted in the penile urethra oriented us were the atresic urethra in bulbar area started. The scrotum was opened in the middle and the distance between the two urethral stumps proximal and distal defined the extension of no urethral tissue that consisted of 5 cm. We opened the right scrotal space and a tunica vaginalis flap was obtained and attached to the bulbar tissue for a two-stage urethroplasty strategy. RESULTS: Patient had a nice healing and the tunica vaginalis was nicely incorporated to the adjacent tissue, having the two urethral stumps well delineated. CONCLUSIONS: ASTRA approach in combination with a two-stage urethroplasty with tunica vaginalis dorsal flap proved to be an excellent combination for a rare case of urethral Y duplication having the main urethra into the rectum.

Tratamento de hidrocele por escleroterapia com álcool absoluto / Treatament of hydrocele by sclerotherapy using absolute alcohol

Introdução: A hidrocele é uma das doenças urológicas mais comuns. Até hoje o tratamento mais aceito e mais utilizado é cirúrgico, no entanto, o uso de substâncias esclerosantes vem ganhando maior importância no tratamento desta afecção. Objetivo: Apresentar os resultados iniciais obtidos com o uso do ácool absoluto na escleroterapia de hidrocele. Método: Foram estudados aleatoriamente dez pacientes, no período de março 99 a setembro de 2000, com idade variando entre 45 e 72 anos e prole constituída, com diagnóstico clínico de hidrocele da túnica vaginal e tratados por este método. Resultados; Ao final, 100 por cento dos pacientes estavam curados: seis deles (60 por cento) necessitavam apenas de uma sessão; dois (20 por cento) de duas e dois (20 por cento) de três. Considerações Finais: Os procedimentos foram realizados a nível ambulatorial, permitindo que os pacientes retornassem precocemente às suas atividades habituais, demonstrando que além de pouco invasivos, também evitam os custos de um procedimento cirúrgico e seus encargos, confirmando os benefícios desta técnica

Incidência de escabiose emalunos duma escola pública de Belém-Pará / Incidence of scabies in students of public school in Belém-Pará

Introdução: A escabiose é a dermatozoonose mais prevalente. É transmitida por contato pessoal, não tem predileção por raça, sexo ou idade e é fortemente influenciado por fatores sócio-econômicos e culturais. Objetivo: Determinar a incidência de escabiose em alunos da rede pública. Método: Foram realizados exame clínico-dermatológico e aplicado questionário sócio-econômico a 100 alunos do ensino médio da rede pública de Belém. Resultados: Entre os alunos examinados 23 por cento apresentaram escabiose, demonstrando que esta é endêmica em nosso meio, sendo o ambiente escolar propício para sua disseminação. Houve uma nítida predominância sobre o sexo feminino, com 31,1 por cento da mulheres e, apenas, 10,2 por cento dos homens.60,8 por cento dos alunos acometidos coabitam com cinco ou mais pessoas, acentuando a transmissibilidade da doença, e 70 por cento possui renda familiar igual ou inferior a dois salários mínimos, confirmando que fatores sócio-econômicos estão fortemente ligados a escabiose. Considerações Finais: A escabiose apresentou alta incidência nos alunos examinados, alertando a classe médica e vigilância sanitária sobre a importância da prevenção controle e tratamento desta doença

Uso de retalho miocutâneo em linfadenectomia inguinal extensa / Use of miocutaneous flap in extensive groin lymphadenectomy

O manejo das metástase linfáticas é o tempo mais importante dos pacientes com câncer de pênis. O tratamento por linfadenectomia, implica em morbidade elevada e, a retirada de grande extensão de tecidos da região inguinal, constitui-se um problema neste cirurgia. O uso de retalhos miocutâneos tem sido descrito para o fechamento primário da região inguinal nesses casos, diminuindo com isso as complicações e o tempo de internamento. Apresenta-se um caso clínico de um paciente, 36 anos, portador de um caso de câncer de pênis, submetido à linfadenectomia extensa onde utilizou-se retalho miocutâneo do músculo tensor da fáscia lata para cobertura da ferida operatória. O resultado final foi satisfatório alcando os objetivos cosméticos e funcionais esperados