Nefrostomia percutânea guiada por ultrassom: opção minimamenteinvasiva de acesso ao rim:[revisão] / Percutaneous nephrostomy guided by ultrasound: minimum invasive option of kidney access: [review]

A nefrostomia percutânea guiada por ultrassom é uma técnica de derivação urinária alta para pacientes com obstrução ureteral bilateral e uremiapós-renal. Este procedimento é mais frequentemente direcionado através de imagem radioscópica. Tivemos por objetivo descrever nossa técnica denefrostomia guiada por imagem ultrassonográfica como opção menos invasiva aprimorada após cinco anos de experiência. Paciente em pronação,administração de medicação pré-anestésica, inspeção ultrassonográfica com visão longitudinal do rim para localização do sistema coletor dilatado, demaneira que todo o rim seja visualizado na tela, demarcação na pele do local de punção adjacente ao probe no seu ponto médio. Realizou-se antissepsia,anestesia local com lidocaína, punção com agulha de Chiba sob visão do ultrassom no ponto demarcado com angulação de 15-30º com relação àimagem do probe no sentido de penetrar um cálice dilatado, observação ultrassonográfica da agulha dentro do sistema coletor, colocação fio-guia edilatadores e, por fim, cateter de polietileno com fixação à pele e conexão à bolsa coletora. A aplicação desta técnica com passos padronizados semostrou simples e rápida, de pronta aplicabilidade pelo urologista na prática diária, com baixo índice de complicações e com alto índice de sucesso.

Percutaneous nephrostomy guided by ultrasound is a high urinary derivation technique in post renal uremia and bilateral ureteral obstruction patients.This procedure is often guided by radioscopic imaging. Our goal is to describe our ultrasonographic guided nephrostomy method as a less invasive optionimproved in 5-year experience. Patients in prone position, infusion of pre-anestesic medication and ultrasonographic longitudinal kidney view to identifythe expanded collector system in a way that the entire kidney can be seen on screen. After antisepsis and asepsis, local anesthesia with lidocaineChiba?s needle punction under ultrasound view of pre-defined point in 15-30º angulation according to the probe image to penetrate a dilated collectingsystem, ultrasonographic view of the needle inside the collecting system, placement of the lead and dilators and then fix the polyethylene catheter tothe skin connected to a collecting bag. The use of this technique with standardized steps has been shown simple and fast, immediately applicable by the urologist with low complication and high success index.

Cardiovascular and metabolic syndrome risk among men with and without erectile dysfunction: case-control study.

CONTEXT AND OBJECTIVE: Erectile dysfunction has been associated with cardiovascular diseases. The aim here was to evaluate cardiovascular risk through the Framingham Risk Score (FRS) criteria, C-reactive protein (CRP) assays and presence of metabolic syndrome (MS) in men with and without erectile dysfunction diagnosed within a healthcare program. DESIGN AND SETTING: A retrospective case-control study was conducted. The patients were selected from a healthcare program at the Hospital Israelita Albert Einstein, between January and December 2007. METHODS: 222 men were retrospectively selected, and they were divided into two groups: men with erectile dysfunction (n = 111) and men without erectile dysfunction (n = 111). The patients were stratified according to the International Index of Erectile Function-Erectile Function domain (IIEF-EF domain). CRP and FRS were analyzed and the two groups were compared. RESULTS: The CRP levels were significantly higher among men with erectile dysfunction (P = 0.04). Patients with erectile dysfunction also had high FRS (P = 0.0015). CRP and FRS did not correlate with the severity of erectile dysfunction. The presence of metabolic syndrome was greater among men with erectile dysfunction (P < 0.05). The severity of erectile dysfunction was directly associated with metabolic syndrome. CONCLUSION: Men with erectile dysfunction presented higher cardiovascular risk according to the FRS criteria and CRP measurements. Severe erectile dysfunction seemed to have a correlation with metabolic syndrome.

Robotic assisted radical prostatectomy: a different treatment for prostate cancer? / Prostatectomia radical robô-assistida: um tratamento diferente para câncer de próstata?

Considering the Health Care System in Brazil, a developing country, and public healthcare policies, robotic surgery is a reality to very few citizens. Therefore, robotic assisted radical prostatectomy is far removed from the daily practice of the vast majority of Brazilian urologists. Scientific evidence of the superiority of robotic assisted radical prostatectomy does not presently justify public investments for widespread development of robotic centers. Maybe over time and with reductions in costs, robotic technology will become a more established practice, as observed in other countries, and more feasible for the Brazilian urological community.

Levando em conta o Sistema de Saúde do Brasil, um país em desenvolvimento, e as políticas de saúde pública, a cirurgia robótica é uma realidade disponível a poucos cidadãos. Assim, a prostatectomia radical robô-assistida está longe da prática diária da grande maioria dos urologistas brasileiros. As evidências científicas da superioridade da prostatectomia radical assistida por robôs não justificam, no momento, os investimentos públicos para o desenvolvimento disseminado de centros de robótica. Talvez mais tarde e com redução nos custos, a tecnologia da robótica torne-se uma prática mais estabelecida, como já observado em outros países, e fique, assim, mais viável para a comunidade urológica do Brasil.

Her-2/neu expression in prostate adenocarcinoma: a systematic review and meta-analysis.

PURPOSE: HER-2/neu has been linked to the clinical progression of hormone independent prostate cancer. We performed a meta-analysis to investigate the prognostic impact of HER-2/neu over expression in patients with prostate adenocarcinoma, and its correlation with other pathological and clinical variables. MATERIALS AND METHODS: We searched the MEDLINE, Embase, CancerLit and ASCO abstract databases for published studies of HER-2/neu protein expression in primary prostate cancer tissue with a median followup of greater than 2 years and data on survival in patients with and without HER-2/neu over expression. We separately analyzed studies reporting HER-2/neu soluble receptor levels in patients with prostate cancer. RESULTS: We included 38 articles with a total of 5,976 patients. The overall RR of death in those with HER-2/neu over expression in the primary tumor was 1.63 (95% CI 1.47-1.82, p <0.0001). In the presence of over expression the recurrence RR was 1.87 (95% CI 1.59-2.21, p <0.0001). High HER-2/neu extracellular domain levels also correlated with death (RR 2.01, 95% CI 1.21-3.35, p = 0.007) and recurrence (RR 1.74, 95% CI 1.41-2.15, p <0.0001). CONCLUSIONS: There is a consistent association of HER-2/neu over expression and Gleason less than 7 with a higher RR of death and recurrence in patients with prostate cancer. Further clinical trials should test the hypothesis that HER-2/neu is a marker of a clinically worse outcome in patients with prostate cancer and a potential target for therapy.

Parachute technique for partial penectomy.

PURPOSE: Penile carcinoma is a rare but mutilating malignancy. In this context, partial penectomy is the most commonly applied approach for best oncological results. We herein propose a simple modification of the classic technique of partial penectomy, for better cosmetic and functional results. TECHNIQUE: If partial penectomy is indicated, the present technique can bring additional benefits. Different from classical technique, the urethra is spatulated only ventrally. An inverted "V" skin flap with 0.5 cm of extension is sectioned ventrally. The suture is performed with vicryl 4-0 in a "parachute" fashion, beginning from the ventral portion of the urethra and the "V" flap, followed by the "V" flap angles and than by the dorsal portion of the penis. After completion of the suture, a Foley catheter and light dressing are placed for 24 hours. CONCLUSIONS: Several complex reconstructive techniques have been previously proposed, but normally require specific surgical abilities, adequate patient selection and staged procedures. We believe that these reconstructive techniques are very useful in some specific subsets of patients. However, the technique herein proposed is a simple alternative that can be applied to all men after a partial penectomy, and takes the same amount of time as that in the classic technique. In conclusion, the "parachute" technique for penile reconstruction after partial amputation not only improves the appearance of the penis, but also maintains an adequate function.

Cardiovascular and metabolic syndrome risk among men with and without erectile dysfunction: case-control study / Risco cardiovascular e da síndrome metabólica entre homens com e sem disfunção erétil: estudo caso controle

CONTEXT AND OBJECTIVE: Erectile dysfunction has been associated with cardiovascular diseases. The aim here was to evaluate cardiovascular risk through the Framingham Risk Score (FRS) criteria, C-reactive protein (CRP) assays and presence of metabolic syndrome (MS) in men with and without erectile dysfunction diagnosed within a healthcare program. DESIGN AND SETTING: A retrospective case-control study was conducted. The patients were selected from a healthcare program at the Hospital Israelita Albert Einstein, between January and December 2007. METHODS: 222 men were retrospectively selected, and they were divided into two groups: men with erectile dysfunction (n = 111) and men without erectile dysfunction (n = 111). The patients were stratified according to the International Index of Erectile Function-Erectile Function domain (IIEF-EF domain). CRP and FRS were analyzed and the two groups were compared. RESULTS: The CRP levels were significantly higher among men with erectile dysfunction (P = 0.04). Patients with erectile dysfunction also had high FRS (P = 0.0015). CRP and FRS did not correlate with the severity of erectile dysfunction. The presence of metabolic syndrome was greater among men with erectile dysfunction (P < 0.05). The severity of erectile dysfunction was directly associated with metabolic syndrome. CONCLUSION: Men with erectile dysfunction presented higher cardiovascular risk according to the FRS criteria and CRP measurements. Severe erectile dysfunction seemed to have a correlation with metabolic syndrome.

CONTEXTO E OBJETIVO: Disfunção erétil está associada a doenças cardiovasculares. O objetivo foi avaliar o risco cardiovascular através dos critérios de Framingham (FRS), da dosagem de proteína C-reativa e da presença de síndrome metabólica em homens com e sem disfunção erétil diagnosticados em um programa de saúde. TIPO DE ESTUDO E LOCAL: Estudo retrospectivo tipo caso-controle foi realizado. Os pacientes foram selecionados de um programa de saúde do Hospital Israelita Albert Einstein, no período de janeiro a dezembro de 2007. MÉTODOS: 222 homens foram retrospectivamente selecionados e divididos em dois grupos: homens com disfunção erétil (n = 111) e homens sem disfunção erétil (n = 111). Os pacientes foram estratificados de acordo com o Índice Internacional de Disfunção Erétil (International Index of Erectile Function, Erectile Function domain, IIEF-EF domain). A proteína C-reativa e o escore de Framingham foram analisados e os dois grupos foram comparados. RESULTADOS: O nível da proteína C foi significativamente maior entre homens com disfunção erétil (P = 0,04). Pacientes com disfunção erétil também tinham um escore de risco de Framingham alto (P = 0,0015). A proteína C e o escore de Framingham não se correlacionaram com o grau de gravidade da disfunção erétil. A presença de síndrome metabólica foi maior nos pacientes com disfunção erétil (P < 0,05). A gravidade da disfunção erétil esteve diretamente associada com a síndrome metabólica. CONCLUSÃO: Homens com disfunção erétil apresentaram maior risco cardiovascular de acordo com os critérios de Framingham e pela mensuração da proteína C-reativa. A disfunção erétil grave em homens parece ter correlação com a síndrome metabólica.

Parachute technique for partial penectomy

PURPOSE: Penile carcinoma is a rare but mutilating malignancy. In this context, partial penectomy is the most commonly applied approach for best oncological results. We herein propose a simple modification of the classic technique of partial penectomy, for better cosmetic and functional results. TECHNIQUE: If partial penectomy is indicated, the present technique can bring additional benefits. Different from classical technique, the urethra is spatulated only ventrally. An inverted "V" skin flap with 0.5 cm of extension is sectioned ventrally. The suture is performed with vicryl 4-0 in a "parachute" fashion, beginning from the ventral portion of the urethra and the "V" flap, followed by the "V" flap angles and than by the dorsal portion of the penis. After completion of the suture, a Foley catheter and light dressing are placed for 24 hours. CONCLUSIONS: Several complex reconstructive techniques have been previously proposed, but normally require specific surgical abilities, adequate patient selection and staged procedures. We believe that these reconstructive techniques are very useful in some specific subsets of patients. However, the technique herein proposed is a simple alternative that can be applied to all men after a partial penectomy, and takes the same amount of time as that in the classic technique. In conclusion, the "parachute" technique for penile reconstruction after partial amputation not only improves the appearance of the penis, but also maintains an adequate function.

Robotic assisted radical prostatectomy: a different treatment for prostate cancer?

Considering the Health Care System in Brazil, a developing country, and public healthcare policies, robotic surgery is a reality to very few citizens. Therefore, robotic assisted radical prostatectomy is far removed from the daily practice of the vast majority of Brazilian urologists. Scientific evidence of the superiority of robotic assisted radical prostatectomy does not presently justify public investments for widespread development of robotic centers. Maybe over time and with reductions in costs, robotic technology will become a more established practice, as observed in other countries, and more feasible for the Brazilian urological community.

Patient position and semi-rigid ureteroscopy outcomes.

INTRODUCTION: Two positions have been reported for ureteroscopy (URS): dorsal lithotomy (DL) position and dorsal lithotomy position with same side leg slightly extended (DLEL). The aim of the present study was to compare the outcomes associated with URS performed with patients in DL vs. DLEL position. MATERIALS AND METHODS: A total of 98 patients treated for ureteral calculi were randomized to either DL or DLEL position during URS, and were prospectively followed. Patients, stone characteristics and operative outcomes were evaluated. RESULTS: Of the 98 patients included in the study, 56.1% were men and 43.9% women with a mean age of 42.6 +/- 16.8 years. Forty-eight patients underwent URS in DL position and 50 in DLEL position. Patients' age, mean stone size and location were similar between both groups. Operative time was longer for the DL vs. DLEL group (81.0 vs. 62.0 minutes, p = 0.045), mainly for men (95.2 vs. 63.9 minutes, p = 0.023). Mean fluoroscopy use, complications and success rates were similar between both groups. CONCLUSIONS: Most factors associated with operative outcomes during URS are inherent to patient's condition or devices available at each center, and therefore cannot be changed. However, leg position is a simple factor that can easily be changed, and directly affects operative time during URS. Even though success and complication rates are not related to position, placing the patient in dorsal lithotomy position with an extended leg seems to make the surgery easier and faster.

Patient position and semi-rigid ureteroscopy outcomes

Introduction: Two positions have been reported for ureteroscopy (URS): dorsal lithotomy (DL) position and dorsal lithotomy position with same side leg slightly extended (DLEL). The aim of the present study was to compare the outcomes associated with URS performed with patients in DL vs. DLEL position. Material and Methods: A total of 98 patients treated for ureteral calculi were randomized to either DL or DLEL position during URS, and were prospectively followed. Patients, stone characteristics and operative outcomes were evaluated. Results: Of the 98 patients included in the study, 56.1 percent were men and 43.9 percent women with a mean age of 42.6 ± 16.8 years. Forty-eight patients underwent URS in DL position and 50 in DLEL position. Patients' age, mean stone size and location were similar between both groups. Operative time was longer for the DL vs. DLEL group (81.0 vs. 62.0 minutes, p = 0.045), mainly for men (95.2 vs. 63.9 minutes, p = 0.023). Mean fluoroscopy use, complications and success rates were similar between both groups. Conclusions: Most factors associated with operative outcomes during URS are inherent to patient's condition or devices available at each center, and therefore cannot be changed. However, leg position is a simple factor that can easily be changed, and directly affects operative time during URS. Even though success and complication rates are not related to position, placing the patient in dorsal lithotomy position with an extended leg seems to make the surgery easier and faster.

Video-assisted double-barreled wet colostomy: a new minimally invasive simultaneous diversion to patients after pelvic radiation therapy.

INTRODUCTION: A wet colostomy can be done when the simultaneous diversion of fecal and urine streams are necessary. Laparoscopic access is gaining space in urinary diversion procedures. The aim of the present study was to present the technique and results of the first case reported of a video-assisted double-barreled wet colostomy. PATIENT AND METHODS: In this article, we report a case of a 50-year-old woman with actinic complex urinary and fecal fistula, treated through a retroperitoneoscopic double-barreled wet colostomy. Only the left kidney had function, so she was treated by video endoscopic retroperitoneal dissection of the left ureter, preplanned transverse 5-cm incision for exteriorization of left colon and ureter, extracorporeal section of the left colon with a linear stapler, extracorporeal antireflux ureterocolonic anastomosis, and maturation of the stoma 10 cm proximal to the end of the proximal colonic loop. RESULTS: Operative time was 135 minutes. No transfusion was required nor had intraoperative complications occurred. Oral intake was initiated in postoperative day 2, and the patient was discharged postoperative day 6 without complications. Normal activities were recovered after 21 days. In a 3-month follow-up, there were no infectious complications, and good urinary drainage was observed. She was satisfied and adapted to the stoma. CONCLUSIONS: Video-assisted double-barreled wet colostomy is a feasible procedure. The same goals of the open procedure were achieved, offering the advantages of the laparoscopic approach.

Video-assisted colonic conduit: a new minimally invasive urinary diversion to patients after pelvic radiotherapy.

PURPOSE: To report preliminary results of the first case of video-assisted colonic conduit. A 42-year-old woman had undergone external beam radiotherapy for squamous cell carcinoma of the cervix and developed a vesicovaginal fistula with small capacity bladder. Intraoperative option for urinary diversion was colonic conduit. METHODS: A 4 trocar transperitoneal approach was chosen and isolation of both ureters was performed. A 5 cm incision between xiphoid and umbilicus was carried out. A 15 cm colonic segment was isolated with linear stapler maintaining blood supply. Intestinal transit was then reconstructed. Leadbetter ureterointestinal anastomoses were performed with ureteral splints. Drainage, colostomy maturation, and closure of incisions were carried out conventionally. RESULTS: Operative time was 195 minutes; blood loss was 90 mL; no intraoperative or postoperative complications were observed. Length of hospital stay was 7 days and time to full recovery 3 weeks. CONCLUSIONS: Video-assisted colonic conduit is feasible and have promising results concerning reduction of surgical morbidity.

Comparative results of two techniques to treat stress urinary incontinence: synthetic transobturator and aponeurotic slings.

INTRODUCTION AND HYPOTHESIS: This study aims to analyze comparatively the efficacy and safety of synthetic transobturatory and aponeurotic retropubic slings, in the treatment of stress urinary incontinence (SUI) in women. METHODS: Patients were separated in a randomized way. Twenty-one patients were submitted to the operatory correction by the transobturatory sling technique, whereas 20 patients were operated by the retropubic sling technique. All patients were submitted to complete physical exam and urodynamic test. The "T" test and the Mann-Whitney U test were applied to establish comparisons between the two groups. Patients were followed-up for 12 months. RESULTS: Healing rate was 90.5% (19/21) and 95% (19/20), respectively after 12 months. The transobturatory group presented lesser complications rate than the retropubic group. CONCLUSIONS: The transobturatory and the aponeurotic slings techniques were equally effective for the treatment of SUI. The transobturatory sling has shown fewer complications and lesser surgical time than the aponeurotic sling technique.

Prospective comparative study between retroperitoneoscopic and hand-assisted laparoscopic approach for radical nephrectomy.

OBJECTIVE: No consensus has yet been established regarding the best minimally invasive access for radical ablation of renal tumors. Our objective was to prospectively compare the surgical results and oncologic management of two currently used endoscopic techniques. MATERIALS AND METHODS: Over a four-year period, 50 patients with renal tumors and clinical stage T1b-T2, smaller than 12 cm, underwent a radical nephrectomy at two reference institutions, 25 underwent retroperitoneoscopic radical nephrectomy (RRN) and 25 a hand-assisted laparoscopic radical nephrectomy (HALRN). Mean follow-up of both cohorts was 50 months. Operative parameters and oncological management were compared. RESULTS: The mean operative time was 180 min in RRN and 108 min in HALRN (p < 0.001). The time required to access the renal pedicle in RRN was 30 min. and in HALRN 40 min., Learning curve was shorter in HALRN than RRN. Mean blood loss was 100 mL in RRN and 242 mL in HALRN. Mean incision size for specimen retrieval in RRN was 6.5 cm and in HALRN 7.5 cm. One patient with intra operative occurrence of ascites and subsequent pathological stage pT2N0M0 grade 3 operated via HALRN, had neoplasic implants in the Hand-port incision 3 months after surgery followed by death 4 months after recurrence. One patient, with pathological stage pT3N0M0 grade 3 in RRN had metastasis after 36 months. CONCLUSION: Both, RRN and HALRN techniques are accepted minimally invasive options for endoscopic radical nephrectomy with equivalent long term oncological outcome in the treatment of renal tumors.

Prospective comparative study between retroperitoneoscopic and hand-assisted laparoscopic approach for radical nephrectomy

OBJECTIVE: No consensus has yet been established regarding the best minimally invasive access for radical ablation of renal tumors. Our objective was to prospectively compare the surgical results and oncologic management of two currently used endoscopic techniques. MATERIAL AND METHODS: Over a four-year period, 50 patients with renal tumors and clinical stage T1b-T2, smaller than 12 cm, underwent a radical nephrectomy at two reference institutions, 25 underwent retroperitoneoscopic radical nephrectomy (RRN) and 25 a hand-assisted laparoscopic radical nephrectomy (HALRN). Mean follow-up of both cohorts was 50 months. Operative parameters and oncological management were compared. RESULTS: The mean operative time was 180 min in RRN and 108 min in HALRN (p < 0.001). The time required to access the renal pedicle in RRN was 30 min. and in HALRN 40 min., Learning curve was shorter in HALRN than RRN. Mean blood loss was 100 mL in RRN and 242 mL in HALRN. Mean incision size for specimen retrieval in RRN was 6.5 cm and in HALRN 7.5 cm. One patient with intra operative occurrence of ascites and subsequent pathological stage pT2N0M0 grade 3 operated via HALRN, had neoplasic implants in the Hand-port incision 3 months after surgery followed by death 4 months after recurrence. One patient, with pathological stage pT3N0M0 grade 3 in RRN had metastasis after 36 months. CONCLUSION: Both, RRN and HALRN techniques are accepted minimally invasive options for endoscopic radical nephrectomy with equivalent long term oncological outcome in the treatment of renal tumors.

Male infertility related to an aberrant karyotype, 46,XY,9ph,9qh+.

OBJECTIVE: To report a man with primary infertility and variant karyotype. DESIGN: Case report. SETTING: Private practice. PATIENT(S): A 37-year-old man with 4 years of primary infertility due to oligoasthenozoospermia. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): G- and C-banding. Polymerase chain reaction for SRY, DBY, RBMY, DAZ, AMELX, and AMELY. RESULT(S): G-band analysis of the proband revealed a 46,XY,9ph,9qh+ karyotype. C-banding confirmed increase in the heterochromatin in one chromosome 9 and inversion in the other. CONCLUSION(S): The morphologic difference between the homologous chromosomes 9 may have been responsible for an error in crossing-over, leading to aberrant spermatozoa and consequently to infertility.

Diagnosis and treatment of acute antibody-mediated rejection in renal transplant: the role of C4d and donor-specific antibody identification / Diagnóstico e tratamento da rejeição aguda mediada por anticorpo no transplante renal: papel do C4d e da pesquisa de anticorpo específico contra o doador

Objective: To evaluate the incidence of antibody-mediated rejection after the C4d and donor specific antibody detection was provided by Luminex in renal transplantation biopsies; to compare acute antibody-mediated rejection characteristics as related to acute cellular rejection; to evaluate the impact on the incidence of acute antibody mediated rejection after the utilization of cross match test by flux cytometry and the detection of pre-transplantation donor specific antibody in patients with previous history of exposition to alloantigens. Methods: One hundred twenty-four renal transplanted patients were evaluated through the detection of C4d in early biopsies of those presenting graft dysfunction and the detection of antibody against donor when C4d was positive. The acute antibody mediated rejection was treated by plasmapheresis and intravenous immunoglobulin. Results: The incidence of acute rejection was 18.8%, being the acute cellular rejection 14.9% and acute antibody mediated rejection 6.6%. When both were compared, the acute antibody-mediated rejection were earlier than the acute cellular rejection (12.5 versus 59.9 days, p = NS), being more frequent in female patients (75 versus 29%, p = 0.05), with deceased donors (75 versus 33%, p = 0.09), with higher dialysis time (87.7 versus 47.4, p = 0.03), greater number of transfusion episodes (4.6 versus 1.4, p = 0.02), greater panel reaction activity (28.0 versus 4.8, p = 0.03) and more frequently in re-transplanted patients (50 versus 5.6%, p = 0.02). Delayed graft function was more frequent in antibody mediated rejection (100 versus 50%, p = 0.02). All patients with acute cellular rejection reversed graft function after treatment, with 100% graft survival after one year. Among patients with acute antibody-mediated rejection, the treatment with plasmapheresis and immunoglobulin was efficient in reducing the titers of donor specific antibody (2605 versus 202 mfi, p < 0.001), but 3/8 of patients evolved to graft loss, making graft survival of 62.5% (p < 0.001). Conclusions: The routine use of detecting C4d and donor specific antibody increased the incidence of acute rejection. Acute antibody-mediated rejection presented clinical profile and therapeutic response different from acute cellular rejection, identifying a worse prognosis as well as therapeutic success.

Objetivo: Avaliar a incidência da rejeição mediada por anticorpo depois de instituída a pesquisa de C4d em biópsias de rim transplantado e pesquisa de anticorpo específico de doador pelo Luminex; comparar as características da rejeição aguda mediada por anticorpo em relação à rejeição aguda celular; avaliar o impacto na incidência de rejeição aguda mediada por anticorpo após utilizar a prova cruzada por citometria de fluxo e pesquisa de anticorpo específico de doador pré-transplante em pacientes com histórico de exposição prévia à aloantígenos. Métodos: Foram avaliados 124 pacientes transplantados renais, com pesquisa de C4d em biópsias precoces em pacientes com disfunção do enxerto e pesquisa de anticorpo contra o doador quando o C4d foi positivo. A rejeição aguda mediada por anticorpo foi tratada com plasmaferese e imunoglobulina intravenosa. Resultados: Foi encontrada uma incidência de rejeição aguda de 18,8%, com frequência de episódios de rejeição aguda celular de 14,9% e de rejeição aguda mediada por anticorpo de 6.6%. Quando comparados com rejeição aguda celular, os episódios de rejeição aguda mediada por anticorpo foram mais precoces (12,5 versus 59,9 dias, p = NS), sendo mais frequentes em pacientes femininas (75% versus 29%, p = 0,05), com doadores falecidos (75% versus 33%, p = 0.09), com maior tempo de diálise (87,7 versus 47,4, p = 0,03), maior número de transfusões (4,6 versus 1,4, p = 0,02), maior atividade contra painel (28,0 versus 4,8, p = 0,03) e mais frequentemente retransplantados (50 versus 5,6%, p = 0,02). Função retardada do enxerto foi mais frequente nos pacientes com rejeição aguda mediada por anticorpo (100 versus 50%, p = 0,02). Todos os pacientes com rejeição aguda celular reverteram a função do enxerto após o tratamento, com sobrevida do enxerto, em um ano, de 100%. Entre os pacientes com rejeição aguda mediada por anticorpo, o tratamento com plasmaferese e imunoglobulina foi eficiente em reduzir os títulos de anticorpo específico de doador (2.605 versus 202 mpi, p < 0,001), mas 3/8 pacientes evoluíram para perda do enxerto, conferindo sobrevida do enxerto de 62,5% (p < 0,001). Conclusões: O uso rotineiro da pesquisa de C4d e anticorpo doador específico aumentou a incidência de rejeição aguda. A rejeição aguda mediada por anticorpo apresentou perfil clínico e resposta terapêutica diferentes da rejeição aguda celular, conferindo-lhe pior prognóstico e pior resposta terapêutica.

Bladder involvement in systemic lupus erythematosus / Envolvimento vesical no lúpus eritematoso sistêmico

Objective: To study bladder involvement in systemic lupus erythematosus patients through clinical and laboratorial evaluation, ultrasonography, radiological and endoscopic examination. Methods: Thirty-nine patients, either outpatients or inpatients at the Department of Rheumatology of Hospital das Clínicas da Faculdade de Medicina from Universidade de São Paulo were evaluated as to clinical and laboratorial data. All patients were submitted to ultrasonographic evaluation of the upper urinary tract, radiological and endoscopic examinations of the middle and lower urinary tracts. Results: Mean age of patients varied between 13 and 62 years (median = 29 years). Thirty-six were females and three were males. The disease varied from 6 months to 22 years (median three years and one month). Clinical and laboratory activity of the disease was present in 30 patients. Twenty-two patients had the diagnosis of lupus established for three years or more. Twenty-five patients were asymptomatic and all had received corticosteroids for treatment at least once. Twenty-three received antimalarial drugs; ten received cytostatics, and seven patients received non-steroid anti-inflammatory drugs. Upper urinary tract ultrasonography was normal in all cases but one with staghorn calculus associated with neurogenic bladder secondary to neurological involvement by the disease. Vesicoureteral reflux was observed in two cases. Other two patients had significant post-voiding residual urine, both with neurogenic bladder secondary to nervous system involvement by lupus. The average bladder maximum capacity in an awaken patient was 342 mL, and was decreased in 18.9% of cases. This subgroup of patients presented a greater frequency of urinary symptoms and greater use of cytostatic drugs (Z > Z5%). A pathognomonic cystoscopic pattern of bladder involvement in systemic lupus erythematosus could not be established. Cystoscopic aspects similar to those seen in the initial or minor forms of interstitial cystitis were present in 43.2% of patients. This finding was more frequent when cytostatic drugs were used for treating the disease. Conclusions: There was bladder involvement in systemic lupus erythematosus, even in asymptomatic patients, demonstrated by the occurrence of cystoscopic abnormalities or by reduced bladder maximum capacity associated with the presence of suprapubic pain, urinary irritation symptoms and the use of cytostatic drugs.

Objetivo: Estudar o envolvimento vesical em pacientes com lúpus eritematoso sistêmico (LES) por meio de avaliações clínica, laboratorial, ultrassonográfica e de estudos radiológico e endoscópico. Métodos: Trinta e nove pacientes ambulatoriais ou internados no Serviço de Reumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo foram avaliados clínica e laboratorialmente. Todos foram submetidos à avaliação do trato urinário superior por meio da ultrassonografia, e a exames radiológicos e endoscópicos para a avaliação dos tratos médio e inferior. Resultados: A idade dos pacientes variou de 13 a 62 anos (mediana = 29 anos). Trinta e seis pacientes eram do sexo feminino e três do sexo masculino. O tempo de doença variou de seis meses a 22 anos (mediana = três anos e um mês). Trinta pacientes apresentavam atividade da doença na ocasião do estudo. O diagnóstico de lúpus havia sido estabelecido havia três anos ou mais em 22 pacientes. Vinte e cinco pacientes eram assintomáticos em relação às queixas urinárias e todos haviam feito uso de corticoides em alguma fase do tratamento. Vinte e três receberam antimaláricos; dez, citostáticos e sete anti-inflamatórios não-hormonais. A ultrassonografia do trato urinário superior foi normal em todos os casos, exceto um que apresentou cálculo coraliforme associado à bexiga neurogênica devido a envolvimento neurológico pelo lúpus. Refluxo vésico-ureteral foi demonstrado em dois pacientes e, em outros dois casos, observava-se grande resíduo pós-miccional secundário à lesão neurológica pela doença de base. A média da capacidade vesical máxima com paciente desperto foi de 342 ml e, em 18,9% dos casos este parâmetro estava diminuído. Este subgrupo apresentou maior incidência de manifestações urinárias e maior frequência de emprego de citostáticos (Z > Z5%). Não se caracterizou padrão diacrítico de participação vesical na doença. Em 43,2% dos pacientes, detectaram-se aspectos cistoscópicos semelhantes aos descritos para a forma precoce ou menor de cistite intersticial, guardando dependência apenas com o emprego de citostáticos no tratamento do lúpus eritematoso sistêmico. Conclusões: Demonstrou-se o envolvimento vesical no lúpus eritematoso sistêmico, mesmo em pacientes assintomáticos e que se manifestou pela ocorrência de alterações cistoscópicas e pela diminuição da capacidade vesical máxima em paciente desperto, estando esta associada à presença de dor suprapúbica à repleção vesical e manifestações irritativas urinárias, bem como ao uso de citostáticos.

Histological aspects of the bladder in systemic lupus erythematosus / Aspectos histopatológicos da bexiga no lúpus eritematoso sistêmico

Objectives: to study pathological data from bladders of systemic lupus erythematosus patients, correlate them to clinical events and the use of therapeutic drugs, and compare them to bladder histopathological findings in individuals not affected by systemic lupus erythematosus. Methods: thirty-nine out or inpatients of the Department of Rheumatology at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, diagnosed with systemic lupus erythematosus were clinically and cystoscopically evaluated. Bladder biopsy was also performed. As a normal parameter, bladders taken from 20 corpses collected at the Death Verification Department of São Paulo city, without autolysis or evidence of urinary tract or autoimmune disease were also histologically studied. This group was considered as a Control Group. A correlation among clinical, cystoscopic and histopathological data was carried out. Results: the patients mean age was 29 years (range 13-62). Thirty-six were females and three were males. Twenty-five patients were asymptomatic during the study period. In the Control Group the age range was 20-65 years. Nineteen were females (95%) and one was male (5%). Cystoscopic examination of the group with systemic lupus erythematosus showed interstitial pattern in 16 cases (41.0%) and normal in 15 (38.5%). The bladder was normal in four patients (10.3%). Chronic unspecific cystitis was observed in 18 (46.2%) patients. In the remaining, several alterations were found, including bladder vasculitis in seven patients (17.9%). The mean number of mast cells in the bladder area was 2.223/mm2. In the Control Group, unspecific cystitis was found in three cases (15.0%). No other abnormalities were found. The mean number of mast cells in this group was 0.777/mm2 (±2.7). Chronic unspecific cystitis, bladder vasculitis and the mean number of mast cells were compared with each other and no statistical differences were found (p > 0.05). There were statistically significant differences between the two groups regarding chronic unspecific cystitis and bladder vasculitis (Z = 2.078 > Z5% = 1.645 and Z = 1.777 > Z5% = 1.645) and also mean number of mast cells (Z = 2.387 > Z5% = 1.673). There were statistically significant differences between the proportion of mast cell infiltrate and presence of suprapubic pain as well as use of antimalarial drugs. The other analysis did not show statistically significant differences. There was no statistical evidence of dependence among the events: cystoscopy with interstitial pattern and chronic unspecific cystitis (p > 0.237); cystoscopy with interstitial pattern and bladder vasculitis(p > 0.325); cystoscopy with interstitial pattern and mast cell infiltrate (p > 0.277). Conclusions: the bladder in systemic lupus erythematosus may be involved even in the absence of clinical manifestations. The involvement of the bladder in systemic lupus erythematosus was characterized mainly by the finding of chronic unspecific cystitis, bladder vasculitis and mast cell infiltrate. The presence of chronic unspecific cystitis was significantly greater in patients with the disease than in the Control Group, and the same occurred with bladder vasculitis. The number of mast cells/mm2 was higher than normal in patients with systemic lupus erythematosus. This finding was associated to suprapubic pain upon bladder repletion and to use of antimalarial drugs.

Video game as a preoperative warm-up for laparoscopic surgery / Jogo de video game como aquecimento pré-operatório para cirurgia laparoscópica

Objective: The aim of the present study was to assess the influence of video game as warm-up before dry-lab laparoscopic activities. Methods: Eleven medical students participated in this prospective randomized crossover study. Students were divided into two groups. Students in Group 1 had to execute an interrupted suture with the dominant hand using a standardized technique (non-video game group). Students in Group 2 performed the same suture, but after playing a video game match (video game group). After this initial task, groups were crossed. The time spent to complete each task was recorded, and the participants and observers had to judge the performance for each laparoscopic exercise. These variables were used as a measure of performance. Results: Mean time for laparoscopic surgery in this subset of inexperienced laparoscopic students was similar between non-video game versus video game groups (254.6 ± 187.7 versus 255.8 ± 183.6; p = 0.875). Subjective impression of observers regarding students? performance was also similar (p = 0.662), but subjective impression of the participant about his own performance was different between both groups, with 64.7 versus 20.0% of participants that considered their performance good for video game versus non-video game groups (p = 0.044). Conclusions: In conclusion, video games used as warm-up for laparoscopic practice seem to make inexperienced surgeons more confident and comfortable with the procedures, even though objective measures, as operative time and observers impression of surgeons performance do not seem to be affected by video game warm-up.

Objetivo: Avaliar o efeito de um jogo de video game como aquecimento pré-operatório para o cirurgião laparoscópico. Métodos: Foi realizado um estudo prospectivo cruzado com 11 estudantes de medicina e médicos residentes com pouca experiência em laparoscopia. Um grupo realizou suturas laparoscópicas em caixa preta sem aquecimento inicial, enquanto outro realizou aquecimento por meio de jogos de video game. Os grupos foram cruzados em um segundo momento. Resultados: O tempo médio para confecção de sutura laparoscópica foi semelhante entre os grupos Direto versus Video game (254,6 ± 187,7 versus 255,8 ± 183,6; p = 0,875). A impressão subjetiva dos avaliadores sobre o grau de dificuldade para a realização da tarefa também foi semelhante entre os grupos (p = 0,662). Em relação à percepção do cirurgião quanto ao grau de dificuldade para a realização do procedimento cirúrgico, observou-se que os cirurgiões do grupo Video game versus Direto tiveram uma percepção subjetiva de maior facilidade para a realização do exercício, sendo que a porcentagem de exercícios considerados de dificuldade baixa ou moderada foi de 64,7 versus 20,0% entre os grupos (p = 0,044). Conclusões: O emprego de jogo de video game como aquecimento para a cirurgia laparoscópica em cirurgiões pouco experientes parece torná-los mais receptivos para as dificuldades do procedimento, embora não altere o tempo para a realização dos procedimentos e nem a percepção alheia do grau de dificuldade.