Publications by authors named "Bruno Nicolino Cezarino"

12 Publications

  • Page 1 of 1

Can extended upper pole ureterectomy prevent ureteral stump syndrome after proximal approach for duplex kidneys?

Int Braz J Urol 2021 Jul-Aug;47(4):821-826

Unidade de Urologia Pediátrica, Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, SP, Brasil.

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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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.0686DOI Listing
April 2021

Hidden incision ureterocystoplasty: step-by-step description of a novel technique.

Cent European J Urol 2020 15;73(4):575. Epub 2020 Oct 15.

Hospital das Clínicas, University of São Paulo Medical School, Pediatric Urology Unit, Division of Urology, São Paulo, Brazil.

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http://dx.doi.org/10.5173/ceju.2020.0241.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7848838PMC
October 2020

Laparoscopic hidden incision endoscopic surgery (hides) nephrectomy VS. Traditional laparoscopic nephrectomy: Non-inferior surgical outcomes and better cosmetic results.

J Pediatr Urol 2021 Jan 20. Epub 2021 Jan 20.

Pediatric Urology Unit, Division of Urology, Hospital Das Clínicas, University of São Paulo Medical School, Brazil.

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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http://dx.doi.org/10.1016/j.jpurol.2021.01.018DOI Listing
January 2021

Previously unseen 80L giant hydronephrosis.

Urol Case Rep 2020 Nov 23;33:101426. Epub 2020 Sep 23.

Divisão de Urologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.

Here we describe the case of a patient who was referred to our institution with an immense abdominal volume of unknown origin. The patient was unable to stand up and therefore was bedridden. A giant hydronephrotic kidney was diagnosed and total volume of urine removed was 80L. Nephrectomy was uneventful and, despite his acquired thoracic and abdominal deformities, he was able to recover completely. This is the largest reported hydroneprosis in the literature.
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http://dx.doi.org/10.1016/j.eucr.2020.101426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7574291PMC
November 2020

Prune perineum surgical correction - Treatment of a rare syndrome.

J Pediatr Urol 2020 10 19;16(5):723-724. Epub 2020 Aug 19.

Urology Unit, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.

Introduction: Prune Perineum Syndrome (PPS) is rare, with only three cases described in the literature. Treatment requires abdominal and pelvic surgeries. Our goal is to provide a video with steps of the surgical corrections of this syndrome.

Materials And Methods: We present a case of an 8 months-old boy with PPS. At our first evaluation, he had already been submitted to a colostomy with mucous fistula and a vesicostomy.

Results: By the time of this publication, he had been submitted to six surgical procedures. First, osteotomy, followed by colostomy, cystoscopic evaluation, cystoplasty, perineal and abdominal correction with a dual mesh, bilateral orchidopexy, treatment of the vesicocolonic fistula, sigmoidectomy and appendicectomy. He is 6 years old, walks with no assistance, has satisfactory abdominal tonus which allows him to void with Valsalva Maneuver. Clean intermittent catheterization is also performed. He had no UTI since his first surgery. Although submitted to several procedures, treatment is not yet concluded. A future urethral dilation together with a genitoplasty might improve his quality of life.

Conclusion: PPS is a very rare condition, with scarce literature concerning its treatment. Multiple procedures might be necessary to correct malformations and improve patient's quality of life.
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http://dx.doi.org/10.1016/j.jpurol.2020.08.013DOI Listing
October 2020

Single-stage Abdominoplasty Using Groin Flaps Without Osteotomies: Management of Exstrophy-epispadias Complex.

Urology 2018 Oct 19;120:266. Epub 2018 Jul 19.

Divisao de Urologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil.

Background And Objective: The optimal treatment for children born with exstrophy-epispadia complex is still a matter of debate. 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%). 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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http://dx.doi.org/10.1016/j.urology.2018.07.001DOI Listing
October 2018

Transperitoneal laparoscopic pyeloplasty in children: does upper urinary tract anomalies affect surgical outcomes?

Int Braz J Urol 2018 Mar-Apr;44(2):370-377

Unidade de Urologia Pediátrica, Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brasil.

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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http://dx.doi.org/10.1590/S1677-5538.IBJU.2017.0224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6050553PMC
May 2018

Editorial Comment: Laparoscopic pectopexy: initial experience of single center with a new technique for apical prolapse surgery.

Int Braz J Urol 2017 Sep-Oct;43(5):910

Serviço de Urologia do Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil.

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http://dx.doi.org/10.1590/S1677-5538.IBJU.2017.0070.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5678523PMC
January 2018

Retroperitoneoscopic pyelolithotomy: a good alternative treatment for renal pelvic calculi in children.

Int Braz J Urol 2016 Nov-Dec;42(6):1248

Departamento de Urologia, Faculdade de Medicina da Universidade de São Paulo, SP, Brasil.

Introduction: Nephrolitiasis, once considered an adult disease, has become increasingly prevalent in children, with na increase from 6% to 10 % annually in past 25 years. Kidney stones in pediatric population can result from metabolic diseases in up to 50% of children affected. Other factors associated with litiasis are infection, dietary factors, and anatomic malformations of urinary tract. Standard treatment procedures for pediatric population are similar to adult population. Extracorporeal shock wave lithotripsy (ESWL), ureterorenoscopy (URS), percutaneous nepfrolithotomy (PCNL), as well as laparoscopic and retroperitoneoscopic approaches can be indicated in selected cases. The advantages of laparoscopic or retroperitoneoscopic approaches are shorter mean operation time, no trauma of renal parenchyma, lower bleeding risk, and higher stone-free rates, especially in pelvic calculi with extrarenal pelvis, where the stone is removed intact.

Patient And Methods: A 10 year-old girl presented with right abdominal flank pain, macroscopic hematuria,with previous history of urinary infections.. Further investigation showed an 1,5 centimeter calculi in right kidney pelvis. A previous ureterorenoscopy was tried with no success, and a double J catheter was placed. After discussing options, a retroperitoneoscopic pielolithotomy was performed.

Results: The procedure occurred with no complications, and the calculi was completely removed. The foley catheter was removed in first postoperative day and she was discharged 2 days after surgery. Double J stent was removed after 2 weeks.

Conclusions: Retroperitoneoscopic pielolithotomy is a feasible and safe procedure in children, with same outcomes of the procedure for adult population.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5117984PMC
http://dx.doi.org/10.1590/S1677-5538.IBJU.2015.0242DOI Listing
July 2017

Reoperative Laparoscopic Ureteropelvic Junction Obstruction Repair in Children: Safety and Efficacy of the Technique.

J Urol 2017 03 24;197(3 Pt 1):798-804. Epub 2016 Oct 24.

Division of Urology, University of São Paulo School of Medicine, São Paulo, Brazil.

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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http://dx.doi.org/10.1016/j.juro.2016.10.062DOI Listing
March 2017

Laparoscopic Pyeloplasty in children with Horseshoe Kidney.

Int Braz J Urol 2017 Mar-Apr;43(2):375

Divisão de Urologia do Departamento de Cirurgia, Universidade de São Paulo, SP, Brasil.

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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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5433381PMC
http://dx.doi.org/10.1590/S1677-5538.IBJU.2016.0042DOI Listing
August 2017

Diagnosis of neonatal group B Streptococcus sepsis by nested-PCR of residual urine samples.

Braz J Microbiol 2008 Jan 1;39(1):21-4. Epub 2008 Mar 1.

Laboratório de Investigação Médica, Departamento de Pediatria, Faculdade de Medicina da Universidade de São Paulo , São Paulo, SP , Brasil.

Group B streptococcus (GBS) remains the most common cause of early-onset sepsis in newborns. Laboratory gold-standard, broth culture methods are highly specific, but lack sensitivity. The aim of this study was to validate a nested-PCR and to determine whether residue volumes of urine samples obtained by non invasive, non sterile methods could be used to confirm neonatal GBS sepsis. The nested-PCR was performed with primers of the major GBS surface antigen. Unavailability of biological samples to perform life supporting exams, as well as others to elucidate the etiology of infections is a frequent problem concerning newborn patients. Nevertheless, we decided to include cases according to strict criteria: newborns had to present with signs and symptoms compatible with GBS infection; at least one of the following biological samples had to be sent for culture: blood, urine, or cerebrospinal fluid; availability of residue volumes of the samples sent for cultures, or of others collected on the day of hospitalization, prior to antibiotic therapy prescription, to be analyzed by PCR; favorable outcome after GBS empiric treatment. In only one newborn GBS infection was confirmed by cultures, while infection was only presumptive in the other three patients (they fulfilled inclusion criteria but were GBS-culture negative). From a total of 12 biological samples (5 blood, 3 CSF and 4 urine specimen), eight were tested by culture methods (2/8 were positive), and 8 were tested by PCR (7/8 were positive), and only 4 samples were simultaneously tested by both methods (1 positive by culture and 3 by PCR). In conclusion, although based on a restricted number of neonates and samples, our results suggest that the proposed nested-PCR might be used to diagnose GBS sepsis as it has successfully amplified the three types of biological samples analyzed (blood, urine and cerebrospinal fluid), and was more sensitive than culture methods as PCR in urine confirmed diagnosis in all four patients. Moreover, PCR has enabled us to use residue volumes of urine samples collected by non invasive, non sterile methods, what is technically adequate as GBS is not part of the normal urine flora, thus avoiding invasive procedures such as suprapubic bladder punction or transurethral catheterization. At the same time, the use of urine instead of blood samples could help preventing newborns blood spoliation.
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http://dx.doi.org/10.1590/S1517-83822008000100005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3768362PMC
January 2008