Clip residual posterior a prostatectomía radical laparoscópica y radioterapia. Presentación de caso

RESUMEN La prostatectomía radical laparoscópica y la robótica son dos opciones de tratamiento para el cáncer de próstata. Estos procedimientos, aunque avanzados, no están exentos de riesgos. Unas de las complicaciones poco comunes, pero con suficientes casos reportados en la literatura, son las migraciones de los clips hemostáticos usados en la cirugía. Se presenta el caso de un paciente de 56 años de edad, operado de prostatectomía radical laparoscópica con preservación de nervios, el cual padeció de síntomas obstructivos bajos producto de un cuerpo extraño vesical más síntomas irritativos vesicouretrales, producto de radioterapia. Al paciente se le extrajo, 45 días después de la radioterapia, un clip plástico calcificado, tres años después de haber sido operado ( un año antes se le habían extraído cinco clips). Por lo inusual y delicado del caso y como alerta sobre la precaución que se debe tomar al combinar un cuerpo extraño vesical con la radioterapia y al utilizar estos dispositivos durante el acto quirúrgico, se decidió esta presentación.

ABSTRACT Laparoscopic and robotic radical prostatectomy are two treatment options for prostate cancer. These procedures, although advanced, are not without risks. Some of the rare complications, but with enough cases reported in the literature, are the migrations of the hemostatic clips used in surgery. A case of a 56-years-old patient, who underwent nerve-sparing laparoscopic radical prostatectomy, who suffered from lower obstructive symptoms as a result of a bladder foreign body plus irritative vesicourethral symptoms, as a result of radiotherapy was presented. The patient had a calcified plastic clip removed 45 days after radiotherapy, three years after surgery (five clips had been removed a year earlier). Due to the unusual and delicate nature of the case and as a warning about the precaution that should be taken when combining a bladder foreign body with radiotherapy and when using these devices during the surgical act, this presentation was presented.

Evaluation of demographic, radiological and intraoperative factors for assessment of postoperative pain and complications in surgical removal of impacted mandibular third molar: a prospective study / Evaluación de factores demográficos, radiológicos e intraoperatorios para la evaluación del dolor postoperatorio y las complicaciones en la extracción quirúrgica del tercer molar mandibular impactado: un estudio prospectivo

Third molars usually erupt within the age of 17 ­ 21years. Usually, due to the evolution of human jaws, the size is decreasing leading to the impacted tooth. An impacted tooth may lead to external resorption of the adjacent tooth, trismus, infection, etc. Many studies have been reported in the literature for evaluating the surgical difficulty and postoperative complications secondary to impacted third molars. This study includes a sample of 100 subjects evaluated for the surgical difficulty and postoperative complications. Various demographic, radiological, and intraoperative factors were evaluated which may lead to postoperative complications. Factors responsible for postoperative sequelae were also evaluated with complications. Postoperative pain after 4 hours and 7 days was assessed to mark the factors commonly responsible. Pain at 7th postoperative day was significant involving factors like fully impacted, horizontal impaction, level C, no/very little retromolar space, and root contact. Postoperative complications were not reported in this study.

Los terceros molares suelen erupcionar entre los 17 y los 21 años de edad. Por lo general, debido a la evolución de las mandíbulas humanas, el tamaño disminuye, lo que conduce al diente impactado. Un diente impactado puede conducir a la reabsorción externa del diente adyacente, trismo, infección, etc. Se han reportado muchos estudios en la literatura para evaluar la dificultad quirúrgica y las complicaciones postoperatorias secundarias a terceros molares impactados. Este estudio incluye una muestra de 100 sujetos evaluados por la dificultad quirúrgica y las complicaciones postoperatorias. Se evaluaron diversos factores demográficos, radiológicos e intraoperatorios que pueden conducir a complicaciones postoperatorias. También se evaluaron los factores responsables de las secuelas postoperatorias con las complicaciones. Se evaluó el dolor postoperatorio después de 4 horas y 7 días para marcar los factores comúnmente responsables. El dolor al séptimo día postoperatorio fue significativo e involucró factores como impacto total, impactación horizontal, nivel C, espacio retromolar nulo o muy pequeño y contacto con la raíz. En este estudio no se informaron complicaciones posoperatorias.

Cutaneous ureterostomy with definitive ureteral stent as urinary diversion option in unfit patients after radical cystectomy / Ureterostomia cutânea como opção de derivação urinária em pacientes em condições clínicas após cistectomia radical

PURPOSE: Simple diversions are underutilized, mostly for unfit, bedridden, and very self-limited patients requiring palliative surgical management due to life-threatening conditions. Experience with cutaneous ureterostomy (CU) as palliative urinary diversion option for unfit bladder cancer patients is reported. METHODS: We retrospectively reviewed clinical and operative parameters of 41 patients who underwent CU following RC in three specialized Cancer Centers from July/2005 to July/2010. Muscle-invasive disease (clinical Stage T2/worse), multifocal high-grade tumor, and carcinoma in situ refractory to intravesical immunotherapy were the main indications for RC. Double-J ureteral stents were used in all patients and replaced every 6 months indefinitly. Peri-operative morbidity and mortality were evaluated. RESULTS: Median age was 69 years (interquartile range - IQR 62, 76); 30 (73%) patients were men. Surgery in urgency setting was performed in 25 (61%) of patients, most due to severe bleeding associated with hemodynamic instability; 14 patients (34%) showed an American Society of Anesthesiologists score 4. Median operative time was 180 minutes (IQR 120, 180). Peri-operative complications occurred in 30 (73%) patients, most Clavien grade I and II (66.6 %). There was no per-operative death. Re-intervention was necessary in 7 (17%) patients. Overall survival was 24% after 9.4 months follow-up. CONCLUSIONS: CU with definitive ureteral stenting represents a simplified alternative for urinary diversion after palliative cystectomy in unfit patients. It can be performed quickly, with few early and late postoperative complications allowing RC in a group of patients otherwise limited to suboptimal alternatives. Future studies regarding the quality of life are warranted.

OBJETIVO: Relatar a experiência do emprego da ureterostomia cutânea (UC) como forma de derivação urinária definitiva em pacientes portadores de neoplasia vesical avançada, em más condições clínicas e que necessitam de tratamento paliativo. MÉTODOS: Foram analisados retrospectivamente os parâmetros clínicos e operatórios de 41 pacientes submetidos a cistectomia radical e UC em três centros oncológicos especializados. A UC foi a derivação urinária escolhida quando os pacientes não apresentavam condições clínicas de serem submetidos a outro tipo de derivação . Foram avaliados a morbidade peri-operatória e a sobrevida global. RESULTADOS: A idade média dos pacientes foi de 69 anos (intervalo interquartil - IQR 62, 76); 30 (73%) pacientes eram do sexo masculino. Vinte e cinco pacientes (61%) foram submetidos a cirurgia de urgência sendo a maioria devido a hemorragia grave associada a instabilidade hemodinâmica. O tempo cirúrgico médio foi de 180 minutos (IQR 120, 180). As complicações peri-operatórias ocorreram em 30 (73%) pacientes sendo a maioria classificadas como "Clavien" graus I e II (66,6%). Não houve óbito per-operatório. A reabordagem cirúrgica foi necessária em 7 (17%) dos pacientes e a sobrevida global foi de 24% após 9,4 meses de seguimento. CONCLUSÕES: A UC com implante de "stent" ureteral é uma alternativa simples de derivação urinária, após cistectomia paliativa, em pacientes sem condições clínicas de serem submetidos a procedimentos cirúrgicos mais complexos. A UC é um procedimento rápido e apresenta taxas de complicações aceitáveis. Essa alternativa cirúrgica permite melhorar a qualidade de vida dos pacientes portadores de tumores vesicais localmente avançados.