Publications by authors named "Fabio C M Torricelli"

38 Publications

Editorial Comment: Fluid Intake and Dietary Factors and the Risk of Incident Kidney Stones in UK Biobank: A Population-based Prospective Cohort Study.

Int Braz J Urol 2021 Jul-Aug;47(4):894-895

Divisão de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, SP, Brasil.

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http://dx.doi.org/10.1590/S1677-5538.IBJU.2021.04.04DOI Listing
April 2021

Tranexamic acid in patients with complex stones undergoing percutaneous nephrolithotomy: a randomized, double-blinded, placebo-controlled trial.

BJU Int 2021 Feb 25. Epub 2021 Feb 25.

Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.

Objectives: To assess the efficacy and safety of single-dose tranexamic acid on the blood transfusion rate and outcomes of patients with complex kidney stones who have undergone percutaneous nephrolithotomy (PCNL).

Material And Methods: In a randomized, double-blinded, placebo-controlled trial, 192 patients with complex kidney stone (Guy's Stone Scores III-IV) were prospectively enrolled and randomized (1:1 ratio) to receive either one dose of tranexamic acid (1 g) or a placebo at the time of anesthetic induction for PCNL. The primary outcome measure was the occurrence rate of perioperative blood transfusion. The secondary outcome measures included blood loss, operative time, stone-free rate (SFR), and complications. ClinicalTrials.gov identifier: NCT02966236.

Results: The overall risk of receiving a blood transfusion was reduced in the tranexamic acid group (2.2% vs 10.4%, relative risk: 0.21, 95% confidence interval (CI): 0.03-0.76; P = 0.033, number-needed-to-treat: 12). Patients randomized to the tranexamic acid group showed higher immediate and three-month SFR compared with those in the placebo group (29% vs 14.7%, odds ratio [95% CI]: 2.37 [1.15-4.87], P = 0.019, and 46.2% vs 28.1%, odds ratio [95% CI]: 2.20 [1.20-4.02], P = 0.011, respectively). Faster hemoglobin recovery was demonstrated by patients in the tranexamic group (mean, 21.3 days, P = 0.001). No statistical differences were found in operative time and complications between groups.

Conclusions: Tranexamic acid administration is safe and reduces the need for blood transfusion by five times in patients with complex kidney stones undergoing PCNL. Moreover, tranexamic acid may contributes to better stone clearance rate and faster hemoglobin recovery without increasing complications. A single dose of tranexamic acid at the time of anesthetic induction could be considered standard clinical practice for patients with complex kidney stones undergoing PCNL.
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http://dx.doi.org/10.1111/bju.15378DOI Listing
February 2021

Bilateral simultaneous percutaneous nephrolithotomy versus staged approach: a critical analysis of complications and renal function.

Rev Assoc Med Bras (1992) 2020 Dec;66(12):1696-1701

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

Introduction: Patients with bilateral kidney stones and burdened by large stones are challenging cases for endourologists. Simultaneous bilateral percutaneous nephrolithotomy (sbPCNL) is an option; however, it may be accompanied by important morbidity. An alternative is a staged PCNL, operating one side each time. Herein, we compare the impact of sbPCNL and staged PCNL on complication rates and renal function.

Methods: Patients who underwent sbPCNL or staged bilateral PCNL with a frame time of 6 months were searched in our prospectively collected kidney stone database. Groups were compared for age, gender, body mass index (BMI), comorbidities (classification by the American Society of Anesthesiology - ASA), stone size, Guy's score, stone-free status, renal function, blood loss, blood transfusion rate, complication rate, and length of hospital stay.

Results: Twenty-six patients and 52 kidney units were enrolled. The mean operative time was 134.7 min. Only 11.3% of cases had complications, all of them minor (Clavien ≤ 2). Overall, the stone-free rate was 61.50%. Comparing the groups, there was a significantly longer operative time in the sbPCNL group (172.5 vs. 126.3 min; p=0.016), as well as a higher transfusion rate (12.5% vs. 5.6%; p=0.036). There was no statistically significant difference in creatinine levels between the groups. Regarding the stone-free rate, there was a significantly higher proportion of patients in the staged PCNL group (64.9% vs. 43.8%; p=0.012).

Conclusion: sbPCNL is a safe procedure; however, when compared to staged procedures it has a higher transfusion and lower stone-free rate.
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http://dx.doi.org/10.1590/1806-9282.66.12.1696DOI Listing
December 2020

Editorial comment: High pressure endoscopic irrigation: impact on renal histology.

Int Braz J Urol 2021 Mar-Apr;47(2):357-358

Divisão de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, SP, Brasil.

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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.0248.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857751PMC
December 2020

Impacted large ureteral stone: What is the best approach?

Int Braz J Urol 2021 Jan-Feb;47(1):71-72

Divisão de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil.

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http://dx.doi.org/10.1590/S1677-5538.IBJU.2019.0638.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7712679PMC
October 2020

Percutaneous nephrolithotomy in patients with spinal cord injury: should all these patients be automatically assigned a Guy's stone score of 4?

World J Urol 2020 Sep 15. Epub 2020 Sep 15.

Division of Urology, University of Sao Paulo Medical School, Av. Vereador Jose Diniz, 3300, conj. 208, Sao Paulo, SP, 04604-006, Brazil.

Purpose: To assess the complication and stone-free rates of PCNL in patients with spinal cord injury (SCI) and to evaluate whether this population should be assigned a Guy's stone score (GSS) of 4.

Methods: A case-control study was conducted, and electronic charts were reviewed to search for patients with SCI, bladder dysfunction, and kidney stones who had undergone PCNL. Control cases were randomly selected from among patients with complete staghorn calculus (GSS = 4).

Results: One hundred and seventeen patients were included. Patients with SCI had a significant shorter operative time (119 vs. 141 min; p = 0.018). There were no significant differences between the groups in terms of the patients' position, number of renal tracts, bleeding or transfusion rate; however, there was a significantly higher complication rate (23.1% vs. 7.8%; p = 0.009) and a longer hospital stay (5.8 vs. 3.1 days; p = 0.002) among patients with SCI. With regards to the stone-free rate in patients with different grades of GSS patients with SCI who had a GSS of 1 had a stone-free rate of 85.7%, while those with a GSS of 2, 3, or 4 had 50%, 50%, and 31.5%, respectively (p = 0.024). Only patients with a GSS of 4 in the SCI group had outcomes that were similar to those of control patients (31.5% vs. 31.6%).

Conclusion: Patients with SCI should not be automatically assigned GSS 4. Stone-free rate is related to stone burden in these patients, although they do show a higher complication rate and a longer hospital stay than non-neurological patients.
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http://dx.doi.org/10.1007/s00345-020-03443-1DOI Listing
September 2020

The impact of COVID-19 in medical practice. A review focused on Urology.

Int Braz J Urol 2021 Mar-Apr;47(2):251-262

Setor de Endourologia, Divisão de Urologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, SP, Brasil.

COVID-19 pandemic is a rapidly spreading virus that is changing the World and the way doctors are practicing medicine. The huge number of patients searching for medical care and needing intensive care beds led the health care system to a burnout status especially in places where the care system was already overloaded. In this setting, and also due to the absence of a specific treatment for the disease, health authorities had to opt for recommending or imposing social distancing to relieve the health system and reduce deaths. All other medical specialties non-directly related to the treatment of COVID-19 had to interrupt or strongly reduce their activities in order to give room to seriously ill patients, since no one knows so far the real extent of the virus damage on human body and the consequences of doing non deferrable procedures in this pandemic era. Despite not been a urological disease, the urologist needs to be updated on how to deal with these patients and how to take care of himself and of the medical team he works with. The aim of this article is to review briefly some practical aspects of COVID-19 and its implications in the urological practice in our country.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.99.08DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857770PMC
December 2020

Staghorn renal stones: what the urologist needs to know.

Int Braz J Urol 2020 Nov-Dec;46(6):927-933

Stevan B, Streem Center for Endourology & Stone Disease, Glickman Urological & Kidney Institute, The Cleveland Clinic, Cleveland, OH, USA.

Patients with staghorn renal stones are challenging cases, requiring careful preoperative evaluation and close follow-up to avoid stone recurrence. In this article we aim to discuss the main topics related to staghorn renal stones with focus on surgical approach. Most of staghorn renal stones are composed of struvite (magnesium ammonium phosphate) and are linked to urinary tract infection by urease-producing pathogens. Preoperative computed tomography scan and careful evaluation of all urine cultures made prior surgery are essential for a well-planning surgical approach and a right antibiotics choice. Gold standard surgical technique is the percutaneous nephrolithotomy (PCNL). In cases of impossible percutaneous renal access, anatrophic nephrolithotomy is an alternative. Shockwave lithotripsy and flexible ureteroscopy are useful tools to treat residual fragments that can be left after treatment of complete staghorn renal stone. PCNL can be performed in supine or prone position according to surgeon's experience. Tranexamic acid can be used to avoid bleeding. To check postoperative stone-free status, computed tomography is the most accurate imaging exam, but ultrasound combined to KUB is an option. Intra-operative high-resolution fluoroscopy and flexible nephroscopy have been described as an alternative for looking at residual fragments and save radiation exposure. The main goals of treatment are stone-free status, infection eradication, and recurrence prevention. Long-term or short-term antibiotic therapy is recommended and regular control imaging exams and urine culture should be done.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.99.07DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527092PMC
January 2021

Editorial Comment: Upper urinary tract stone compositions: the role of age and gender.

Int Braz J Urol 2020 Jan-Feb;46(1):81-82

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

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http://dx.doi.org/10.1590/S1677-5538.IBJU.2019.0278.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6968902PMC
January 2020

Renal Stone Features Are More Important Than Renal Anatomy to Predict Shock Wave Lithotripsy Outcomes: Results from a Prospective Study with CT Follow-Up.

J Endourol 2020 01 21;34(1):63-67. Epub 2019 Nov 21.

Division of Urology, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.

Lower pole kidney stones have been associated with poor shock wave lithotripsy (SWL) outcomes because of its location. However, the real impact of collecting system anatomy on stone clearance after SWL is uncertain. There is a lack of prospective well-controlled studies to determine whether lower pole kidney stones have inferior outcomes than nonlower pole kidney stones when treated with SWL. We prospectively evaluated patients with a single kidney stone of 5-15 mm undergoing SWL from June 12 through January 19. All patients were subjected to computed tomography before and 3 months after the procedure. Demographic data (age, gender, and body mass index), stone features (stone size, stone area, stone density, and stone-skin distance-SSD), and collecting system anatomy (infundibular length and width, and infundibulopelvic angle) were recorded. Outcomes (fragmentation and stone clearance rates) were compared between lower pole and nonlower pole cases. Then, a multivariate analysis including all variables was performed to determinate which parameters significantly impact on SWL outcomes. One hundred and twenty patients were included in the study. Mean stone size was 8.3 mm and mean stone density was 805 Hounsfield units. Overall stone fragmentation, success, and stone-free rates were 84.1%, 64.1%, and 34.1%, respectively. There were no significant differences in stone fragmentation (76.0% 71.4%;  = 0.624), success rate (57.6% 53.3%;  = 0.435), and stone-free rate (40.2% 35.7%;  = 0.422) in the lower nonlower pole groups, respectively. On multivariate analysis, only stone density ( < 0.001) and SSD ( = 0.006) significantly influenced fragmentation. Stone size ( = 0.029), stone density ( = 0.002), and SSD ( = 0.049) significantly influenced kidney stone clearance. Stone size, stone density, and SSD impact on SWL outcomes. Lower pole kidney stones have similar fragmentation and stone clearance compared with nonlower pole kidney stones.
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http://dx.doi.org/10.1089/end.2019.0545DOI Listing
January 2020

Urologic issues in pediatric transplant recipients.

Transl Androl Urol 2019 Apr;8(2):134-140

Division of Urology, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.

The limited supply of kidneys for pediatric transplantation leads to a large number of children in waiting transplant list. These patients have to be properly evaluated and prepared before organ transplantation to increase its success. The aim of this review is focus on urologic issues of pediatric kidney transplants such as preoperative evaluation and urinary tract abnormalities correction, surgical technique, and postoperative complications. All children that are candidates for kidney transplantation should be submitted to abdominal ultrasound. If bladder dysfunction is suspected, a more detailed evaluation is mandatory, including a voiding cystourethrography and urodynamic study. Patients with a poor bladder capacity and compliance will require bladder augmentation. Whenever possible the native ureter is recommended for that. Regarding kidney transplantation, recipient surgery can be safely performed through an extraperitoneal access, even in children weighting less than 10 kilograms. It allows adequate access to iliac vessels, aorta and vena cava. Graft survival continued to improve over the past decade and it is around 80% in 5 years. Postoperative complications such as urinary fistula may occur in less than 5% of cases, while vascular complications are reported in 1% to 2% of cases.
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http://dx.doi.org/10.21037/tau.2018.06.17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6503233PMC
April 2019

Low Dose Fluoroscopy During Ureteroscopy Does Not Compromise Surgical Outcomes.

J Endourol 2019 07;33(7):527-532

1 Department of Urology, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.

To evaluate whether reducing the dose of fluoroscopy to ¼ of standard dose during unilateral ureteroscopy for ureteral stone treatment would impact in a reduction of total radiation emitted and whether this strategy would impact operation time, stone-free rate, and complication rate. From August 2016 to August 2017, patients over 18 years submitted to ureteroscopy for ureteral stone between 5 and 20 mm were prospectively randomized for ¼ dose reduction or standard dose fluoroscopy. Patients with abnormal urinary anatomy such as horseshoe kidney, pelvic kidney, or duplex system were excluded from the study. Ninety-four patients were enrolled. The fluoroscopic dose reduction strategy to ¼ of the standard dose was able to significantly reduce the cumulative radiation emitted by C-arm fluoroscopy and the dose area product (3.6 ± 4.5 mGy 16.2 ± 19.3 mGy,  = 0.0001 and 0.23 ± 0.52 mcGycm 1.15 ± 2.74 mcGycm,  = 0.02, respectively). Fluoroscopy time was similar between groups (74.5 ± 84.8 seconds 88.3 ± 90 seconds,  = 0.44). There was no need to increase the fluoroscopy dose during any of the procedures. Surgical outcomes were not affected by fluoroscopic dose reduction strategy. Low dose fluoroscopy reduces the emitted radiation during ureteroscopy without compromising surgical outcomes.
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http://dx.doi.org/10.1089/end.2018.0722DOI Listing
July 2019

Robot - assisted laparoscopic local recurrence resection after radical prostatectomy.

Int Braz J Urol 2019 Jan-Feb;45(1):192

Serviço de Urologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil.

Introduction And Objective: Local prostate cancer recurrence is usually treated with salvage radiation (sRDT) with or without adjuvant therapy. However, surgical resection could be an option. We aim to present the surgical technique for robot - assisted laparoscopic resection prostate cancer local recurrence after radical prostatectomy (RP) and sRDT in 2 cases.

Patients And Method: First case depicts a 70 year - old man who underwent RP in 2001 and sRDT in 2004. Following adjuvant therapy, patient had biochemical recurrence. MRI showed a solid mass in the prostatic fossa close to vesicourethral anastomosis, measuring 2.1 cm and PET / CT revealed hyper caption significant uptake in the prostatic fossa. Second case is a 59 year - old man who underwent RP in 2010 and sRDT in 2011. Again, patient presented with biochemical recurrence. PET / CT showed hyper caption in the prostatic fossa. Biopsy conformed a prostate adenocarcinoma. Both patients underwent robot - assisted extended pelvic lymph nodes dissection and local recurrence resection. A standard 4 robotic arms port placement was utilized.

Results: Both procedures were uneventfully performed in less than 3 hours and there were no complications. Pathological examination showed a prostate adenocarcinoma Gleason 7 and 8 in the first and second case, respectively; surgical margins and lymph nodes were negative. After 6 months of follow-up, continence was not affected and both patients presented with PSA < 0.15 ng / mL.

Conclusion: Robot - assisted laparoscopic resection of prostate cancer local recurrence after RP and sRDT detected by PSMA PET / CT seems to be safe in experienced hands. It may postpone adjuvant therapy in selected cases.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2017.0503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6442126PMC
June 2019

Postgraduate course in minimally invasive urological surgery.

Transl Androl Urol 2018 Apr;7(2):274-279

Institute of Education and Research, Hospital Sírio Libanês, São Paulo, Brazil.

Background: Minimally invasive surgeries are increasingly common as the first option for most urological diseases. However, laparoscopic techniques are difficult to master, especially for surgeons who were not trained during their residency programs. Therefore, postgraduate courses are important for such matters. This study aims to evaluate the results of postgraduate courses in minimally invasive urological surgery.

Methods: A specific questionnaire was used to evaluate the impact of the course on urologists' professional activities. The questionnaire also evaluated demographic data and previous surgical experience. The postgraduate course was divided into 10 monthly modules, each one with 36 hours of activities, from March to December. All students of the laparoscopic postgraduate course from the last five years were enrolled in the study.

Results: Forty-one students were included in the study. Thirty-nine students were male (95.1%), and the mean age was 39.5 years (range, 30-60 years). Students from all regions of the country were enrolled. Thirty (73.2%) students had minor laparoscopic experience. All students improved their laparoscopic skills and were able to include new procedures in their daily surgical practice. Eleven students (26.8%) had no laparoscopic experience, and all of them started to perform laparoscopic procedures. The median level of impact on professional life was 75 points (range, 0-100 points).

Conclusions: The postgraduate course is an appropriate way to acquire urological laparoscopic skills. The annual course allowed improvement and initiation of laparoscopic procedures, which significantly impacted urologists' daily activities.
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http://dx.doi.org/10.21037/tau.2018.03.18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5911530PMC
April 2018

Supine percutaneous nephrolitotripsy in septuagenarian and octogenarian patients: outcomes of a case-control study.

Can J Urol 2018 04;25(2):9245-9249

Division of Urology, Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil.

Introduction: Currently, there is a paucity of data evaluating the outcomes of supine percutaneous nephrolithotomy (PCNL) in septuagenarian and octogenarian patients. In this study we aim to compare the outcomes of supine PCNL in elderly patients with those of younger population.

Material And Methods: A matched case-control study was performed from January 2009 through December 2015 using our prospectively collected kidney stone database. Case group was composed of patients with age greater than 70 years. Control group included patients with less than 70 years old. Patients were randomly matched based on Guy's Stone Score as a surrogate of case complexity.

Results: Fifty-four patients were enrolled in this study, 18 cases and 36 controls. There were no significant differences in gender and body mass index between groups. There were significantly more ASA 3 patients in septuagenarian and octogenarian patients (p = 0.012). Mean Charlson comorbidity index was significantly higher in septuagenarian and octogenarian patients (p = 0.041). Regarding PCNL technique, there were no differences in number of accesses, number of supra-costal accesses, and operative time. There was no significant difference in stone-free rate, nephrostomy tube time, complication rate, mean decrease in hemoglobin level, and need of blood transfusion. Hospital stay time (days) was longer in case group (4.0 +/- 1.7 versus 2.4 +/- 1.1 days; p = 0.002).

Conclusion: Septuagenarian and octogenarian patients have similar complication and stone-free rates compared to younger patients, although they demand a longer length of hospital stay.
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April 2018

Sporadic primary hyperparathyroidism and stone disease: a comprehensive metabolic evaluation before and after parathyroidectomy.

BJU Int 2018 02 28;121(2):281-288. Epub 2017 Nov 28.

Section of Endourology, Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.

Objectives: To characterize the stone risk and the impact of parathyroidectomy on the metabolic profile of patients with primary hyperparathyroidism (PHPT) and urolithiasis.

Patients And Methods: We analysed the prospectively collected charts of patients treated at our stone clinic between January 2001 and January 2016 searching for patients with PHPT and urolithiasis. Imaging evaluation of the kidneys, bones and parathyroid glands was assessed. We analysed the demographic data, serum and urinary variables before and after parathyroidectomy. We used a paired t-test, Fisher's test, Spearman's test and anova in the statistical analysis.

Results: A total of 51 patients were included. The mean patient age was 57.1 ± 12.1 years and 82.4% were women. Before parathyroidectomy, mean calcium and parathyroid hormone (PTH) levels were 11.2 ± 1.0 mg/dL and 331 ± 584 pg/dL, respectively. Hypercalcaemia was present in 84.3% of patients. All eight patients with normal calcium levels had elevated PTH levels. Only two patients did not have PTH above the normal range, although both had elevated calcium levels. The most common urinary disorders were low urinary volume (64.7%), hypercalciuria (60.8%), high urinary pH (41.2%) and hypocitraturia (31.4%). After parathyroidectomy, the number of patients with hypercalcaemia (n = 4; 7.8%), elevated PTH (n = 17; 33.3%) and hypophosphataemia (n = 3; 5.9%) significantly decreased (P < 0.001). The number of urinary abnormalities decreased and there was a reduction in urinary calcium (P < 0.001), pH (P = 0.001) and citrate levels (P = 0.003).

Conclusion: Individuals with PHPT and nephrolithiasis frequently have elevated baseline PTH and calcium levels. Low volume, hypercalciuria, high urinary pH, and hypocitraturia are the most frequent urinary disorders. Parathyroidectomy is effective in normalizing serum calcium and PTH levels, although other urinary metabolic may persist. Patients should be monitored for the need for citrate supplementation.
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http://dx.doi.org/10.1111/bju.14072DOI Listing
February 2018

Leiomyosarcoma of the inferior vena cava: Survival rate following radical resection.

Oncol Lett 2017 Oct 2;14(4):3909-3916. Epub 2017 Aug 2.

Department of General Surgery, Clinics Hospital, University of São Paulo Medical School, Cerqueira César, SP 05403-000, Brazil.

Leiomyosarcoma (LMS) of inferior vena cava (IVC) is a rare neoplasm affecting approximately 1/100,000 people. The prognosis is poor and potential curative intent occurs through challenging operations, such as vena cava resection, occasionally multivisceral when required, and vascular reconstruction. There are few retrospective series regarding this retroperitoneal neoplasm, and the aim of the present study was to discuss the experience at the São Paulo Cancer Institute and Clinics Hospital of University of São Paulo Medical School, São Paulo, Brazil. The current study is a retrospective review of 7 patients treated in the two tertiary hospitals between 2005 and 2013. Oncological and operative aspects were discussed, primarily regarding surgical aspects highlighting resection, vascular reconstruction, and the overall survival and recurrence rates. All the patients were treated with radical intent, 4 of whom underwent multivisceral resection, with the kidney being the most resected organ. The location of the IVC tumor was described using Kulaylat's description and the median tumor size was 10 cm. Vascular reconstruction was necessary in 4 patients. The overall survival rate at 3 and 5 years was 100, and 25%, respectively. The disease-free survival rate at 3 and 5 years was 57 and 20%, respectively. In conclusion, IVC LMS is a rare and severe retroperitoneal neoplasm, with multivisceral resections remaining a surgical challenge. The treatment requires numerous experienced surgeons and the impact of microscopic free margins remains unclear. Vascular reconstruction depends on several aspects regarding primarily the topography of the tumor.
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http://dx.doi.org/10.3892/ol.2017.6706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5651407PMC
October 2017

Complete Calcified Ureteral Stent: A Combined 1-Session Approach.

Urology 2017 12 31;110:259-261. Epub 2017 Aug 31.

Division of Urology, Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.

Objective: To demonstrate a successful 1-session approach to a complete calcified ureteral stent, preserving the affected kidney without complications.

Patient And Methods: A 33-year-old man presented at our service with an increased urinary frequency, afebrile urinary tract infection, and left lumbar pain. He underwent a ureterolithotripsy with ureteral stenting 3 years ago. After that intervention, he was lost to follow-up. A noncontrast computed tomography scan revealed a complete calcified ureteral stent (FECal V). After careful preoperative planning, the patient was submitted to a combined 1-step approach including left semirigid ureteroscopy, left percutaneous nephrolithotomy, and an open cystolithotomy in supine decubitus. This video demonstrates the surgical steps of the procedure for a FECal V (completely calcified) stent removal.

Results: Operative time was 240 minutes. The calcified stent was completely removed. A 6 Fr ureteral catheter and a 16 Fr nephrostomy tube were left at the end of the procedure. No double-J stent was used to avoid the same kind of complication. The patient had no peri- or postoperative complications. A computed tomography scan was performed in the first postoperative day (POD) and revealed 2 small residual fragments (7 mm and 6 mm). The ureteral catheter was removed on the first POD, and the nephrostomy tube on the second POD. The patient was discharged from hospital on the third POD. The patient is now scheduled to a flexible ureteroscopy to treat the small residual fragments.

Conclusion: Forgotten ureteral stent is a surgical challenge, requiring multiple approaches and advanced urologic techniques. Our video illustrates that a less invasive and combined 1-step procedure to preserve the kidney is both safe and feasible, when performed by an experienced surgeon.
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http://dx.doi.org/10.1016/j.urology.2017.06.051DOI Listing
December 2017

Author Reply.

Urology 2017 12 28;110:261. Epub 2017 Sep 28.

Division of Urology, Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.

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http://dx.doi.org/10.1016/j.urology.2017.06.053DOI Listing
December 2017

Supracostal punctures in supine percutaneous nephrolithotomy are safe.

Can J Urol 2017 Apr;24(2):8749-8753

Division of Urology, Department of Surgery, University of Sāo Paulo Medical School, Sāo Paulo, Brazil.

Introduction: The feasibility and safety of supracostal punctures in supine percutaneous nephrolithotomy (PCNL) are still controversial. In this study we aim to compare success and complication rates from prone and supine PCNL with at least one supracostal puncture.

Material And Methods: We reviewed our electronic database for all supracostal PCNLs performed in our institution from February 2008 to September 2013. Patients were enrolled in the study if at least one supracostal puncture was required during surgery. Patients' demographics data, stone characteristics, intra and postoperative data, and success on first postoperative day CT were compared.

Results: A total of 132 procedures were included in the analysis. Twenty-eight PCNLs were performed in supine position (21.2%), while 104 were done in prone position (78.8%). Patient's demographics and distribution of stones based on Guy's Score were similar between groups. Mean operative time and blood transfusion rate were not statistically different. There was no significant difference in the success rate (63.5% prone versus 71.4% supine, p = 0.507). Major complication rate (Clavien ≥ 3) was 16.3% in the prone group versus 3.6% in the supine group (p = 0.119).

Conclusions: Supracostal punctures are safe and feasible in supine PCNL. It does not add additional risks and might provide equivalent success rates when compared to prone PCNLs.
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April 2017

What is the quickest scoring system to predict percutaneous nephrolithotomy outcomes? A comparative study among S.T.O.N.E score, guy's stone score and croes nomogram.

Int Braz J Urol 2017 Nov-Dec;43(6):1102-1109

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

Objective: To compare the application time and the capacity of the nomograms to predict the success of Guy's Stone Score (GSS), S.T.O.N.E. Nephrolithometry (STONE) and Clinical Research Office of the Endourological Society nephrolithometric nomogram (CROES) of percutaneous nephrolithotomy (PCNL), evaluating the most efficient one for clinical use.

Materials And Methods: We studied 48 patients who underwent PCNL by the same surgeon between 2010 and 2011. We calculated GSS, STONE and CROES based on preoperative non-contrast computed tomography (CT) images and clinical data. A single observer, blinded to the outcomes, reviewed all images and assigned scores. We compared the application time of each nomogram. We used an analysis of variance for repeated measures and multiple comparisons by the Tukey test. We compared the area under the ROC curve (AUC) of the three nomograms two by two to determine the most predictive scoring system.

Results: The immediate success rate was 66.7% and complications occurred in 16.7% of cases. The average operative time was 122 minutes. Mean application time was significantly lower for the GSS (27.5 seconds) when compared to 300.6 seconds for STONE and 213.4 seconds for CROES (p<0.001). There was no significant difference among the GSS (AUC=0.653), STONE (AUC=0.563) and CROES (AUC=0.641) in the ability to predict immediate success of PCNL.

Conclusions: All three nomograms showed similar ability to predict success of PCNL, however the GSS was the quickest to be applied, what is an important issue for routine clinical use when counseling patients who are candidates to PCNL.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2016.0586DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734073PMC
March 2018

Robot - assisted laparoscopic retroperitoneal lymph node dissection in testicular tumor.

Int Braz J Urol 2017 Jan-Feb;43(1):171

Instituto do Câncer do Estado de São Paulo (ICESP), SP, Brasil.

Introduction And Objective: Retroperitoneal lymph node dissection (RPLND) is indicated for patients with non-seminomatous germ cell tumor (NSGCT) with residual disease after chemotherapy. Although the gold standard approach is still the open surgery, few cases of robot-assisted laparoscopic RPLND have been described. Herein, we aim to present the surgical technique for robot-assisted laparoscopic RPLND.

Patient And Method: A 30 year-old asymptomatic man presented with left testicular swelling for 2 months. Physical examination revealed an enlarged and hard left testis. Alpha-fetoprotein (>1000ng/mL) and beta-HCG (>24.000U/L) were increased. Beta-HCG increased to >112.000U/L in less than one month. The patient underwent a left orchiectomy. Pathological examination showed a mixed NSGCT (50% embryonal carcinoma; 30% teratoma; 10% yolk sac; 10% choriocarcinoma). Computed tomography scan revealed a large tumor mass close to the left renal hilum (10x4x4cm) and others enlarged paracaval and paraortic lymph nodes (T2N3M1S3-stage III). Patient was submitted to 4 cycles of BEP with satisfactory response. Residual mass was suggestive of teratoma. Based on these findings, he was submitted to a robot-assisted RPLND.

Results: RPLND was uneventfully performed. Operative time was 3.5 hours. Blood loss was minimal, and there were no intra- or postoperative complications. The patient was discharged from hospital in the 1st postoperative day. Pathological examination showed a pure teratoma. After 6 months of follow-up, patient is asymptomatic with an alpha-fetoprotein of 2.9ng/mL and an undetectable beta-HCG.

Conclusion: Robot-assisted laparoscopic RPLND is a feasible procedure with acceptable morbidity even for post chemotherapy patients when performed by an experienced surgeon.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5293403PMC
http://dx.doi.org/10.1590/S1677-5538.IBJU.2015.0436DOI Listing
July 2017

Impact of laparoscopic surgery training laboratory on surgeon's performance.

World J Gastrointest Surg 2016 Nov;8(11):735-743

Fabio C M Torricelli, Joao Arthur B A Barbosa, Giovanni S Marchini, Department of Surgery, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo SP04604-006, Brazil.

Minimally invasive surgery has been replacing the open standard technique in several procedures. Similar or even better postoperative outcomes have been described in laparoscopic or robot-assisted procedures when compared to open surgery. Moreover, minimally invasive surgery has been providing less postoperative pain, shorter hospitalization, and thus a faster return to daily activities. However, the learning curve required to obtain laparoscopic expertise has been a barrier in laparoscopic spreading. Laparoscopic surgery training laboratory has been developed to aid surgeons to overcome the challenging learning curve. It may include tutorials, inanimate model skills training (box models and virtual reality simulators), animal laboratory, and operating room observation. Several different laparoscopic courses are available with specific characteristics and goals. Herein, we aim to describe the activities performed in a dry and animal-model training laboratory and to evaluate the impact of different kinds of laparoscopic surgery training courses on surgeon's performance. Several tasks are performed in dry and animal laboratory to reproduce a real surgery. A short period of training can improve laparoscopic surgical skills, although most of times it is not enough to confer laparoscopic expertise for participants. Nevertheless, this short period of training is able to increase the laparoscopic practice of surgeons in their communities. Full laparoscopic training in medical residence or fellowship programs is the best way of stimulating laparoscopic dissemination.
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http://dx.doi.org/10.4240/wjgs.v8.i11.735DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5124702PMC
November 2016

The challenge of cystine and struvite stone formers: clinical, metabolic and surgical assessment.

Int Braz J Urol 2016 Sep-Oct;42(5):977-985. Epub 2016 Sep 1.

Seção de Endourologia, Divisão de Urologia do Hospital das Clínicas da Universidade de São Paulo Faculdade de Medicina de São Paulo, Brasil.

Purpose: To compare the clinical, metabolic, and calculi characteristics of cystine and struvite stone patients after percutaneous nephrolithotripsy (PCNL).

Material And Methods: Between January/2006-July/2013, 11 cystine stone patients were treated in our clinic. Of those, 3 were excluded due to incomplete follow-up. Eight cystine stone patients (2 with bilateral disease; 10 renal units-RU) were considered for further analysis. A cohort of 8 struvite stone formers (10RU) was matched having the same age, gender, body mass index (BMI) and Guys stone score. Analyzed parameters comprised demographic data, serum/urinary metabolic evaluation and surgical outcomes.

Results: Both groups had 6 female patients. Groups were similar in regards to age, gender, BMI, stone burden, and serum creatinine (p=NS). All patients had PCNL as the first surgical treatment modality. Stone free rate (SFR) after the first PCNL tended to be lower (0%) in the cystine compared to the struvite group (40%)(p=0.08). Final SFR after secondary procedures increased to 70% in cystine and 80% in struvite patients (p=1.0); mean number of procedures to achieve stone free status was higher in the first group (3.57 vs. 2.0;p=0.028). Hypocitraturia was found in all patients, but struvite cases presented with lower mean urinary citrate levels (p=0.016). Other common abnormalities were elevated urinary pH (cystine 75% and struvite 62.5%;p=1.0) and low urinary volume (62.5%,37.5%;p=0.63).

Conclusion: Multiple interventions and suboptimal stone free rates are trait of the significant stone burden of struvite and cystine patients. Underlying metabolic abnormalities characterized by increased urinary pH, hypocitraturia and low urinary volume are often encountered in both populations.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5066895PMC
http://dx.doi.org/10.1590/S1677-5538.IBJU.2015.0741DOI Listing
September 2016

Percutaneous Nephrolithotomy in Immunocompromised Patients: Outcomes from a Matched Case-Control Study.

J Endourol 2016 12 5;30(12):1326-1331. Epub 2016 Oct 5.

1 Division of Urology, Department of Surgery, University of Sao Paulo Medical School , Sao Paulo, Brazil .

Objective: To compare the outcomes of percutaneous nephrolithotomy (PCNL) in immunocompromised patients with those of PCNL in healthy population.

Patients And Methods: A matched case-control study was performed from January 2009 through December 2014 using our prospectively collected kidney stone database. Patients with positive serology to human immunodeficiency virus (HIV), hepatitis C (cellular immune dysfunction), and patients on high dose of immunosuppressive drugs for treatment of autoimmune diseases composed the case group. Control group included patients with kidney stones and no other comorbidity. Patients were randomly matched based on Guy's score as a surrogate of case complexity.

Results: Sixty-two patients were enrolled in this study, 21 cases and 42 controls. There were no significant differences in age, gender, and body mass index between groups. Regarding PCNL technique, there were no differences in patient positioning, number of accesses, and operative time. Complication rate was higher in the case group (38.1% vs 14.3%; p = 0.032); however, major complications, defined by Clavien score ≥3, were not statistically different (4.8% vs 2.4%; p = 0.611). There was a tendency of more postoperative urinary tract infection in the case group (19% vs 4.8%; p = 0.069). Mean decrease in hemoglobin level (3.3 vs 2.4 mg/dL; p = 0.037) and blood transfusion rate (23.8% vs 4.8%; p = 0.036) was significantly higher in the case group. Immunocompromised patients had a 2.8-fold increased risk of complications (odds ratio [OR] = 2.0, 95% confidence interval [CI] 1.01, 7.74) and a 5.8-fold increased risk of blood transfusion (OR = 5.8, 95% CI 1.29, 26.55). There were no differences in stone-free rate, nephrostomy tube time, and length of hospital stay.

Conclusion: Immunocompromised patients are at higher risk for complications such as bleeding after PCNL.
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http://dx.doi.org/10.1089/end.2016.0496DOI Listing
December 2016

Semi-rigid ureteroscopic lithotripsy versus laparoscopic ureterolithotomy for large upper ureteral stones: a meta - analysis of randomized controlled trials.

Int Braz J Urol 2016 Jul-Aug;42(4):645-54

Departamento de Urologia do Hospital das Clínicas da Universidade de São Paulo Faculdade de Medicina São Paulo, SP, Brasil.

Introduction: To provide a systematic review and meta-analysis of randomized controlled trials (RCT) comparing semi-rigid ureteroscopic lithotripsy (URS) with laparoscopic ureterolithotomy (LU) for the treatment of the large proximal ureteral stone.

Materials And Methods: A systematic literature review was performed in June 2015 using the PubMed, Scopus, and Web of Science databases to identify relevant studies. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria.

Results: Six RCT including 646 patients were analyzed, 325 URS cases (50.3%) and 321 LU cases (49.7%). URS provided a significantly shorter operative time (weighted mean difference [WMD] = -31.26 min; 95%CI -46.88 to -15.64; <0.0001) and length of hospital stay (WMD = -1.48 days; 95%CI -2.78 to -0.18; p=0.03) than LU. There were no significant differences in terms of overall complications (OR = 0.78; 95%CI 0.21-2.92; p=0.71) and major complications - Clavien ≥3 - (OR = 1.79; 95%CI 0.59-5.42; p=0.30). LU led to a significantly higher initial stone-free rate (OR = 8.65; 95%CI 4.18-17.91; p<0.00001) and final stone-free rate (OR = 6.41; 95%CI 2.24-18.32; p=0.0005) than URS. There was a significantly higher need for auxiliary procedures in URS cases (OR = 6.58; 95%CI 3.42-12.68; p<0.00001).

Conclusions: Outcomes with LU for larger proximal ureteral calculi are favorable compared to semi-rigid URS and should be considered as a first-line alternative if flexible ureteroscopy is not available. Utilization of flexible ureteroscopy in conjunction with semi-rigid ureteroscopy may impact these outcomes, and deserves further systematic evaluation.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5006758PMC
http://dx.doi.org/10.1590/S1677-5538.IBJU.2015.0696DOI Listing
July 2017

Specific training for LESS surgery results from a prospective study in the animal model.

Int Braz J Urol 2016 Jan-Feb;42(1):90-5

Instituto de Ensino e Pesquisa do Hospital Sírio Libanês, São Paulo, Brasil.

Objective: to prospectively evaluate the ability of post-graduate students enrolled in a laparoscopy program of the Institute for Teaching and Research to complete single port total nephrectomies.

Materials And Methods: 15 post-graduate students were enrolled in the study, which was performed using the SILStm port system for single-port procedures. All participants were already proficient in total nephrectomies in animal models and performed a left followed by a right nephrectomy. Analyzed data comprised incision size, complications, and the time taken to complete each part of the procedure. Statistical significance was set at p<0.05.

Results: All students successfully finished the procedure using the single-port system. A total of 30 nephrectomies were analyzed. Mean incision size was 3.61 cm, mean time to trocar insertion was 9.61 min and to dissect the renal hilum was 25.3 min. Mean time to dissect the kidney was 5.18 min and to complete the whole procedure was 39.4 min. Total renal hilum and operative time was 45.8% (p<0.001) and 38% (p=0.001) faster in the second procedure, respectively. Complications included 3 renal vein lesions, 2 kidney lacerations and 1 lesion of a lumbar artery. All were immediately identified and corrected laparoscopically through the single-port system, except for one renal vein lesion, which required the introduction an auxiliary laparoscopic port.

Conclusion: Laparoscopic single-port nephrectomy in the experimental animal model is a feasible but relatively difficult procedure for those with intermediate laparoscopic experience. Intraoperative complications might be successfully treated with the single-port system. Training aids reducing surgical time and improves outcomes.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4811231PMC
http://dx.doi.org/10.1590/S1677-5538.IBJU.2014.0658DOI Listing
March 2017

Urological complications, vesicoureteral reflux, and long-term graft survival rate after pediatric kidney transplantation.

Pediatr Transplant 2015 Dec 3;19(8):844-8. Epub 2015 Oct 3.

Division of Urology, University of Sao Paulo Medical School, Sao Paulo, Brazil.

To describe a single-center experience with kidney transplantation and then study some donor and recipient features that may impact on graft survival and urological complication rates. We reviewed our database searching for pediatric patients who underwent kidney transplantation from August 1985 through November 2012. Preoperative data and postoperative complications were recorded. Graft survival rates were analyzed and compared based on the type of donor, donor's age from deceased donors, and recipients' ESRD cause. Kaplan-Meier curves with log rank and Wilcoxon tests were used to perform the comparisons. There were 305 pediatric kidney transplants. The mean recipient's age was 11.7 yr. The mean follow-up was 11.0 yr. Arterial and venous thrombosis rates were 1.6% and 2.3%, respectively, while urinary fistula and symptomatic vesicoureteral reflux were diagnosed in 2.9% and 3.6% of cases, respectively. Deceased kidney transplantation had a lower graft survival rate than living kidney transplantation (log rank, p = 0.005). Donor's age (p = 0.420) and ESRD cause (p = 0.679) were not significantly related to graft survival rate. In long-term follow-up, type of donor, but not donor's age, impacts on graft survival rate. ESRD cause has no impact on graft survival rate, showing that well-evaluated recipients may have good outcomes.
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http://dx.doi.org/10.1111/petr.12591DOI Listing
December 2015

Robotic Salvage Lymph Node Dissection After Radical Prostatectomy.

Int Braz J Urol 2015 Jul-Aug;41(4):819; discussion 820

Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, SP, Brasil.

Introduction And Objective: Radical prostatectomy is a first-line treatment for localized prostate cancer. However, in some cases, biochemical recurrence associated with imaging-detected nodal metastases may happen. Herein, we aim to present the surgical technique for salvage lymph node dissection after radical prostatectomy.

Materials And Methods: A 70 year-old asymptomatic man presented with a prostate-specific antigen (PSA) of 7.45 ng/mL. Digital rectal examination was normal and trans-rectal prostate biopsy revealed a prostate adenocarcinoma Gleason 7 (3+4). Pre-operative computed tomography scan and bone scintigraphy showed no metastatic disease. In other service, the patient underwent a robotic-assisted radical prostatectomy plus obturador lymphadenectomy. Pathologic examination showed a pT3aN0 tumor. After 6 months of follow-up, serum PSA was 1.45 ng/mL. Further investigation with 11C--Choline PET/CT revealed only a 2-cm lymph node close to the left internal iliac artery. The patient was counseled for salvage lymph node dissection.

Results: Salvage lymph node dissection was uneventfully performed. Operative time was 1.5 hour, blood loss was minimal, and there were no intra- or postoperative complications. The patient was discharged from hospital in the 1st postoperative day. After 12 months of follow-up, his PSA was undetectable with no other adjuvant therapy.

Conclusion: Robotic salvage pelvic lymph node dissection is an effective option for treatment of patients with biochemical recurrence after radical prostatectomy and only pelvic lymph node metastasis detected by C11-Choline PET/CT.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4757015PMC
http://dx.doi.org/10.1590/S1677-5538.IBJU.2014.0614DOI Listing
March 2016