Publications by authors named "Fabio C Vicentini"

40 Publications

Treatment of renal lower pole stones: an update.

Int Braz J Urol 2022 Jan 20;48. Epub 2022 Jan 20.

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

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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.1023DOI Listing
January 2022

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

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

Renal manifestations of sarcoidosis: from accurate diagnosis to specific treatment.

Int Braz J Urol 2020 Jan-Feb;46(1):15-25

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

Sarcoidosis is a multisystem granulomatous disease characterized by epithelioid noncaseating granulomas associated with clinical and radiologic findings. The cause of this disease is still uncertain. Sarcoidosis affects mostly lungs and lymph nodes and is not usually considered a urological disease, therefore, this etiology may be overlooked in several urological disorders, such as hypercalcemia, hypercalciuria and nephrolithiasis. It affects all races and genders. This review aims to describe the urological manifestations of sarcoidosis and to elucidate how the disease may affect the management of numerous urological conditions.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2019.0042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6968907PMC
February 2020

Mini-percutaneous nephrolithotomy versus retrograde intrarenal surgery for the treatment of 10-20 mm lower pole renal stones: a systematic review and meta-analysis.

World J Urol 2020 Oct 7;38(10):2621-2628. Epub 2019 Dec 7.

Department of Nephrology-Urology, Hospital Regional de Alta Especialidad Del Bajío, San Carlos La Roncha, 37660, León, Guanajuato, Mexico.

Purpose: To compare the efficacy and safety of mini-percutaneous nephrolithotomy (mini-PCNL) versus retrograde intrarenal surgery (RIRS) for treatment of 10-20 mm lower pole renal stones.

Methods: A comprehensive literature search of PubMed, Scopus, the Cochrane Library, and Web of Science was conducted to identify all studies comparing mini-PCNL and RIRS for 10-20 mm lower pole renal stones before March 2019. Article selection proceeded according to the search strategy based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The meta-analysis was performed with the R program version 3.5.1.

Results: A total of five studies were included (two randomized controlled trials and three case-controlled trials) with a total of 587 patients included. The success rate was significantly higher in the mini-PCNL group (OR 1.67; 95% CI p = 0.05). Operative and fluoroscopy times were similar for both groups (MD 2.45; 95% CI p = 0.87 and MD 2.11; 95% CI p = 0.09, respectively). Concerning the hospital stay and overall complication rates, there were no differences between the two procedures (MD 41.94; 95% CI p = 0.18 and OR 1.76; 95% CI p = 0.11).

Conclusion: Our analysis showed that both procedures are safe for treatment of 10-20 mm lower pole renal stones with similar complication rates, operative times, fluoroscopy times and length of hospital stay, but mini-PCNL was significantly superior in effectiveness with a higher success rate. Based on these results, mini-PCNL may be included in the guidelines as a safe and effective alternative treatment for 10-20 mm lower pole stones.
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http://dx.doi.org/10.1007/s00345-019-03043-8DOI Listing
October 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

A comprehensive literature-based equation to compare cost-effectiveness of a flexible ureteroscopy program with single-use versus reusable devices.

Int Braz J Urol 2019 Jul-Aug;45(4):658-670

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

Purpose: To critically review all literature concerning the cost-effectiveness of flexible ureteroscopy comparing single-use with reusable scopes.

Materials And Methods: A systematic online literature review was performed in PubMed, Embase and Google Scholar databases. All factors potentially affecting surgical costs or clinical outcomes were considered. Prospective assessments, case control and case series studies were included.

Results: 741 studies were found. Of those, 18 were duplicated and 77 were not related to urology procedures. Of the remaining 646 studies, 59 were considered of relevance and selected for further analysis. Stone free and complication rates were similar between single-use and reusable scopes. Operative time was in average 20% shorter with digital scopes, single-use or not. Reusable digital scopes seem to last longer than optic ones, though scope longevity is very variable worldwide. New scopes usually last four times more than refurbished ones and single-use ureterorenoscopes have good resilience throughout long cases. Longer scope longevity is achieved with Cidex and if a dedicated nurse takes care of the sterilization process. The main surgical factors that negatively impact device longevity are lower pole pathologies, large stone burden and non-use of a ureteral access sheath. We have built a comprehensive fi nancial costeffective decision model to fl exible ureteroscope acquisition.

Conclusions: The cost-effectiveness of a fl exible ureteroscopy program is dependent of several aspects. We have developed a equation to allow a literature-based and adaptable decision model to every interested stakeholder. Disposable devices are already a reality and will progressively become the standard as manufacturing price falls.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2018.0880DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6837614PMC
September 2019

Endoscopic guided PCNL in the prone split-leg position versus supine PCNL: a comparative analysis stratified by Guy's stone score.

Can J Urol 2019 02;26(1):9664-9674

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

Introduction: The optimal patient positioning for percutaneous nephrolithotomy (PCNL) based on the complexity of stone burden is not yet defined. Thus, we aimed to evaluate the intraoperative parameters, effectiveness and complications of patients undergoing PCNL between the endoscopic-guided prone split-leg PCNL (ePSL) and the supine PCNL by stratifying patients according to Guy's stone score (GSS).

Materials And Methods: A retrospective chart review was conducted of patients undergoing PCNL at two high-volume tertiary referral centers. At one center, patients underwent PCNL using the ePSL technique, while at the second center, patients underwent PCNL in supine. Patient demographics and stone characteristics, operative details, complications and effectiveness were compared between groups. The impact of obesity was also investigated.

Results: Of 830 subjects, a total of 449 (54%) underwent PCNL in ePSL and 381 (46%) in supine. The ePSL group had a greater mean age and body mass index. No statistical differences were found in gender, serum chemistry and Charlson comorbidity index. After stratifying patients by GSS, the differences in baseline stone burden between PSL and supine lost significance and both groups could be compared. Complications were not statistically different between both groups. Univariate analysis demonstrated that multiple tracts and lower pole access were more prevalent in supine. In addition, for GSS1-3, ePSL was correlated with reduced operative time, radiation exposure, length of hospital stay and need for secondary procedure. Multivariate analysis correlated ePSL with lower radiation exposure and need for secondary procedures (p = 0.01). In comparison to the whole trial population, the same tendencies were appreciated for obese cohort.

Conclusions: This is the first report focusing on the performance differences between ePSL and supine PCNL stratified by GSS. Both techniques are safe, with a low rate of complications. For GSS1-3, ePSL reduces radiation exposure and requires less need for both multiple access and secondary procedure.
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February 2019

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

Differences in the percutaneous nephrolithotomy practice patterns among Latin American urologists with and without endourology training.

Int Braz J Urol 2018 May-Jun;44(3):512-523

Hospital Regional de Alta Especialidade do Bajío, México.

Purpose: Although the worldwide percutaneous nephrolithotomy (PCNL) practice patterns determined via a survey sent to members of the Endourological Society have been published, differences in PCNL practice patterns among Latin American urologists based on endourological or lithiasis training have not been published. To determine the PCNL practice patterns among Latin American urologists with and without training in endourology.

Materials And Methods: The SurveyMonkey® web platform was used to develop a 27- item survey on PCNL for the treatment of renal stones, and the survey was sent via e-mail and other electronic media to 2000 urologists from 15 Latin American countries. Endourology-trained (group 1) and nontrained urologists (group 2) were analyzed. The group results were compared using the chi-squared and Fisher's exact tests. SPSS version 20 for Windows was used for all analyses.

Results: A total of 331 urologists responded to the survey (rate of 16.55%): 221 (66.7%) in group 1 and 110 (33.2%) in group 2). In groups 1 and 2, 91.9% and 63.2% performed PCNL, respectively; 85.1% and 58.5% used preoperative tomography, respectively; 12.7% and 4.7% used preoperative nephrolitometry nomograms, respectively; 45.2% and 32.1% used endoscopic combined intrarenal surgery, respectively; 68.3% and 38.7% used multiple percutaneous tract realization, respectively; and 19.9% and 5.7% used minimally invasive PCNL, respectively (all p=0.0005).

Conclusions: Statistically significant differences were observed in PCNL practice patterns of Latin American urologists with and without training in endourology. Specific training in endourology significantly influence the practice patterns of Latin American urologists.
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http://dx.doi.org/10.1590/s1677-5538.ibju.2017.0599DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5996812PMC
July 2018

In Vitro Evaluation of Single-Use Digital Flexible Ureteroscopes: A Practical Comparison for a Patient-Centered Approach.

J Endourol 2018 03 5;32(3):184-191. Epub 2018 Jan 5.

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

Objective: To compare the manufacturing and in vitro performance characteristics of two single-use flexible ureteroscopes with a permanent optical flexible ureteroscope.

Materials And Methods: Two single-use flexible ureteroscopes, LithoVue (Boston Scientific) and Pusen (1rs. generation; Zhuhai Pusen Medical Technology Company Limited, China), were tested and compared with a permanent Flex-X ureteroscope (Karl Storz, Germany) in terms of technical characteristics, optics, deflection mechanism, and additional parameters which could potentially affect surgical technique.

Results: Pusen was the lightest ureteroscope while the LithoVue had the longest working length. LithoVue had a higher resolution power than the other two ureteroscopes at all distances tested (p < 0.001). Pusen showed higher resolution than Flex-X (p < 0.01). Field of view was wider for LithoVue (87°), followed by Flex-X (85°) and Pusen (75°). Color representation was superior for Flex-X than LithoVue and then Pusen. LithoVue outperformed Pusen and Flex-X for all settings with instruments in terms of deflection loss (p < 0.01). Pusen had the highest irrigation flow (52 mL/min) with an empty working channel (p < 0.01). LithoVue and Pusen showed similar flow rates with a 200 μm (21 mL/min) and 365 μm laser fiber (7 mL/min) and 1.3F basket (18 mL/min), being superior to Flex-X (p < 0.01). With the 1.9F basket, LithoVue had superior flow rate (7 mL/min) than Pusen (3.5 mL/min) and Flex-X (4 mL/min; p = 0.01).

Conclusion: LithoVue outperformed the other ureteroscopes in terms of optical resolution, field of view, deflection capacity, and irrigation flow with larger instruments. Pusen is the lighter scope and showed better results in terms of irrigation when no instruments are in place. Flex-X was superior in terms of color representation.
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http://dx.doi.org/10.1089/end.2017.0785DOI Listing
March 2018

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

Use of the Uro Dyna-CT in endourology - the new frontier.

Int Braz J Urol 2017 Jul-Aug;43(4):762-765

Departamento de Urologia, Centro do Cálculo Renal do Hospital 9 de Julho, São Paulo, Brasil.

We describe the use of the Uro Dyna-CT, an imaging system used in the operating room that produces real-time three-dimensional (3D) imaging and cross-sectional image reconstructions similar to an intraoperative computerized tomography, during a percutaneous nephrolithotomy and a contralateral flexible ureteroscopy in a complete supine position. A 65 year-old female patient had an incomplete calyceal staghorn stone in the right kidney and a 10mm in the left one. The procedure was uneventful and the intraoperative use of the Uro Dyna-CT identified 2 residual stones that were not found by digital fluoroscopy and flexible nephroscopy at the end of surgery, helping us to render the patient stone-free in one procedure, which was confirmed by a postoperative CT scan. Prospective studies will define the real role of the Uro Dyna-CT for endourological procedures, but its use seems to be a very promising tool for improving stone free rates and decreasing auxiliary procedures, especially for complex cases.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2016.0413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5557454PMC
November 2017

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

Outcomes of surgical treatment of ureteral strictures after laser ureterolithotripsy for impacted stones.

Can J Urol 2015 Dec;22(6):8079-84

Endourology and Lithiasis Section, Division of Urology, Hospital das Clinicas, University of São Paulo, School of Medicine, Sao Paulo, Brazil.

Introduction: To evaluate the outcomes of ureteral strictures treatment after endoureterotomy using the holmium laser or open/laparoscopic surgery.

Material And Methods: From a database of 1101 patients that underwent semi-rigid holmium laser ureterolithotripsy from 2003 to 2013, we performed a search for patients treated for ureteral stricture. Parameters analyzed included patient demographic, stone burden, and ureteral stricture characteristics. Treatment included holmium laser endoureterotomy for stenosis ≤ 1 cm and open/laparoscopic repair for stenosis > 1 cm or for failed endoscopic treatment. Outcomes and complications were assessed. Success was defined as symptom improvement and radiographic obstruction resolution.

Results: Of all the patients, 32 (2.8%) evolved with ureteral stenosis and all had impacted calculi at the time of surgery. Twenty-two patients with complete follow up were studied. After a mean follow up of 18.5 months (range 3-70), the success rates for endoureterotomy and open/laparoscopic stricture repair group were 50% and 82%, respectively. The hospitalization period was significantly shorter for patients who had undergone endoureterotomy (2.7 +/- 1.4 days versus 4.8 +/- 1.4 days; p = 0.003). Only minor complications occurred in both groups.

Conclusion: The rate of ureteral stricture after holmium laser ureterolithotripsy for impacted calculi is higher than reported for non-impacted stones. Holmium laser endoureterotomy for stenosis shorter than 1 cm treated half of the cases. Open/laparoscopic repair had good outcomes in cases of longer stenosis.
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December 2015

Percutaneous nephrolithotomy in patients with solitary kidney: a critical outcome analysis.

Int Braz J Urol 2015 May-Jun;41(3):496-502

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

Purpose: To describe our experience with percutaneous nephrolithotomy (PCNL) in patients with solitary kidneys and analyze factors that can impact on intra-operative bleeding and postoperative complications.

Materials And Methods: We reviewed our stone database searching for patients with solitary kidney who underwent PCNL from Jan-05 through Oct-13. Demographic data, stone characteristics, and intra- and postoperative outcomes were recorded. Spearman correlation was performed to assess which variables could impact on bleeding and surgical complications. Linear and logistic regressions were also performed.

Results: Twenty-seven patients were enrolled in this study. The mean age and BMI were 45.6 years and 28.8Kg/m(2), respectively; 45% of cases were classified as Guys 3 (partial staghorn or multiple stones) or 4 (complete staghorn) - complex cases. Stone-free rate was 67%. Eight (29.6%) patients had postoperative complications (five of them were Clavien 2 and three were Clavien 3). On univariate analysis only number of tracts was associated with increased bleeding (p=0.033) and only operative time was associated with a higher complication rate (p=0.044). Linear regression confirmed number of access tracts as significantly related to bleeding (6.3, 95%CI 2.2-10.4; p=0.005), whereas logistic regression showed no correlation between variables in study and complications.

Conclusions: PCNL in solitary kidneys provides a good stone-free rate with a low rate of significant complications. Multiple access tracts are associated with increased bleeding.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4752142PMC
http://dx.doi.org/10.1590/S1677-5538.IBJU.2014.0343DOI Listing
December 2015

Difference of opinion--In the era of flexible ureteroscopy is there still a place for Shock-wave lithotripsy? Opinion: NO.

Int Braz J Urol 2015 Mar-Apr;41(2):203-6

Endourology and Lithiasis Section, Division of Urology, Hospital das Clinicas, University of São Paulo, School of Medicine, São Paulo, Brazil.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4752081PMC
http://dx.doi.org/10.1590/S1677-5538.IBJU.2015.02.04DOI Listing
October 2015

Peripyelitis: A risk factor for urinary fistula after tubeless PCNL.

Int Braz J Urol 2015 Jan-Feb;41(1):177-8

Department of Urology, University of São Paulo Medical School, Sao Paulo, Brazil.

A 43 years-old man presented to our stone clinic complaining of back pain for the last 3 months. He had significant past medical history for nephrolithiasis: he had undergone unsuccessful SWL for left renal calculi five years ago and also presented with several episodes of pyelonephritis in the last months, requiring hospitalization for intravenous antibiotics. Initial laboratory work-up revealed normal serum creatinine (0.92 mg/dL) and hemoglobin levels (15.3 g/dL); urine culture was negative. Abdominal computed tomography (CT) revealed a 140 mm2 stone in the left renal pelvis with 1500 Hounsfield Units (Figure-1a); thickening of the urothelium surrounding the stone was suspected after contrast infusion (Figure-1b) and confirmed in the excretory phase (Figure-1c).
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4752072PMC
http://dx.doi.org/10.1590/S1677-5538.IBJU.2015.01.24DOI Listing
August 2015

Impact of renal anatomy on shock wave lithotripsy outcomes for lower pole kidney stones: results of a prospective multifactorial analysis controlled by computerized tomography.

J Urol 2015 Jun 15;193(6):2002-7. Epub 2014 Dec 15.

Division of Urology, Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil; Stevan B. Streem Center for Endourology and Stone Disease, Glickman Urological and Kidney Institute (MM), Cleveland Clinic, Cleveland, Ohio.

Purpose: We evaluated which variables impact fragmentation and clearance of lower pole calculi after shock wave lithotripsy.

Materials And Methods: We prospectively evaluated patients undergoing shock wave lithotripsy for a solitary 5 to 20 mm lower pole kidney stone between June 2012 and August 2014. Patient body mass index and abdominal waist circumference were recorded. One radiologist blinded to shock wave lithotripsy outcomes measured stone size, area and density, stone-to-skin distance, infundibular length, width and height, and infundibulopelvic angle based on baseline noncontrast computerized tomography. Fragmentation, success (defined as residual fragments less than 4 mm in asymptomatic patients) and the stone-free rate were evaluated by noncontrast computerized tomography 12 weeks postoperatively. Univariate and multivariate analysis was performed.

Results: A total of 100 patients were enrolled in the study. Mean stone size was 9.1 mm. Overall fragmentation, success and stone-free rates were 76%, 54% and 37%, respectively. On logistic regression body mass index (OR 1.27, 95% CI 1.11-1.49, p = 0.004) and stone density (OR 1.0026, 95% CI 1.0008-1.0046, p = 0.005) significantly impacted fragmentation. Stone size (OR 1.24, 95% CI 1.07-1.48, p = 0.039) and stone density (OR 1.0021, 95% CI 1.0007-1.0037, p = 0.012) impacted the success rate while stone size (OR 1.24, 95% CI 1.04-1.50, p = 0.029), stone density (OR 1.0015, 95% CI 1.0001-1.0032, p = 0.046) and infundibular length (OR 1.1035, 95% CI 1.015-1.217, p = 0.015) impacted the stone-free rate. The best outcomes were found in patients with a body mass index of 30 kg/m(2) or less, stones 10 mm or less and 900 HU or less, and an infundibular length of 25 mm or less. The coexistence of significant unfavorable variables led to a stone-free rate of less than 20%.

Conclusions: Obese patients with higher than 10 mm density stones (greater than 900 HU) in the lower pole of the kidney with an infundibular length of greater than 25 mm should be discouraged from undergoing shock wave lithotripsy.
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http://dx.doi.org/10.1016/j.juro.2014.12.026DOI Listing
June 2015

How are we protecting ourselves from radiation exposure? A nationwide survey.

Int Urol Nephrol 2015 Feb 15;47(2):271-4. Epub 2014 Nov 15.

Departament of Surgery, Federal University of Espirito Santo, UFES, Vitória, Espírito Santo, Brazil,

Purpose: We performed a nationwide survey of Brazilian urologists to study behaviors toward radiation exposure and the use of protective and monitoring equipment.

Methods: A 13-question e-mail questionnaire was sent to 4,526 Brazilian urologists; the questions addressed demographic characteristics, radiation exposure, and the utilization of shielding devices and dosimeters. The reasons why these devices were not used were also investigated.

Results: A total of 332 completed questionnaires were analyzed (7.3 %); the median age of the respondents was 43.3 ± 10.8 years. Lead aprons and thyroid protection are utilized in every procedure by 84.4 and 53.89 % of respondents, respectively. Protective eyeglasses are never used by 72.12 % of the respondents. Older urologists were more likely not to use adequate protection. Of the urologists who responded, 76.42 % never use dosimeters.

Conclusion: This study shows an unsatisfactory utilization of radiation-shielding devices and dosimeters, revealing a low compliance to the as low as reasonably achievable principle among Brazilian urologists.
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http://dx.doi.org/10.1007/s11255-014-0882-zDOI Listing
February 2015

Preoperative planning with noncontrast computed tomography in the prone and supine position for percutaneous nephrolithotomy: a practical overview.

J Endourol 2015 Jan;29(1):6-12

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

Objective: To evaluate kidney/adjacent organs positional changes in patients undergoing percutaneous nephrolithotomy (PCNL) using noncontrast computed tomography (NCCT) in prone and supine positions.

Methods: Patients scheduled PCNL were prospectively enrolled in the study and underwent NCCT in supine and in prone position (with boosters). Two imaginary lines for the posterior calyx of upper/mid/lower poles of both kidneys in prone and supine decubitus were considered and compared. Line I (LI): drawn horizontally in the coronal plane in contact with the posterior edge of the kidney. Line II (LII): drawn from the antero-lateral edge of the vertebra through the middle of the posterior calyx (ideal puncture line). Renal depth (d) was measured from LI to the anterior extremity of the vertebra. The maximum access angle (a) considered the window available in the axial plane to perform a secure approach to each calyx.

Results: Thirty-seven patients were analyzed; 56.7% were female; mean BMI was 28.3±4.9 kg/m(2). For the right kidney, prone position was associated with more organs crossed by LI (54.1% vs 18.9%; p<0.01) and LII (56.8% vs 27%; p=0.03) in the upper calyx. For the left kidney, LII crossed more organs in prone in the upper calyx (54.1% vs 29.7%; p=0.03). Both kidneys showed a tendency to be deeper in the supine position, which provided a wider access angle.

Conclusions: Supine NCCT is not accurate to plan PCNL access in prone position. Prone decubitus is associated with more potential organ injuries in the upper pole. In supine, the kidney situates deeper in the abdomen but the access angle is wider than in prone.
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http://dx.doi.org/10.1089/end.2014.0299DOI Listing
January 2015

Utility of the Guy's stone score based on computed tomographic scan findings for predicting percutaneous nephrolithotomy outcomes.

Urology 2014 Jun 5;83(6):1248-53. Epub 2014 Mar 5.

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

Objective: To evaluate the ability of the Guy's stone score (GS) to predict the success rates and complications on the basis of the computed tomographic (CT) scan findings for renal stones treated with percutaneous nephrolithotomy (PCNL).

Methods: From 2008 to 2012, a total of 147 consecutive patients (155 renal units) who underwent PCNL in a completely supine position were prospectively evaluated. All patients underwent a CT scan preoperatively, and the stones were classified according to the GS. All PCNLs were analyzed to determine the association between the GS and treatment outcomes on the basis of CT findings and complications, according to the Clavien criteria.

Results: Of the 155 PCNLs, 27% were classified as GS1, 28.4% as GS2, 27% as GS3, and 17.6% as GS4. Only the largest diameter of the stones differed among the groups (GS1=21.4, GS2=26.5, GS3=31.4, and GS4=50.5 mm; P<.001). After stratification according to the GS, the groups differed significantly regarding their operative times (GS1=63±28.5, GS2=101.4±40.8, GS3=127.6±47.6, and GS4=153.3±56 minutes; P<.001), tubeless rates (GS1=54.8%, GS2=45.4%, GS3=28.6%, and GS4=7.4%; P<.001), blood transfusion rates (GS1=0%, GS2=2.3%, GS3=4.8%, and GS4=22.2%; P=.01), complications (GS1=4.8%, GS2=9.1%, GS3=26.2%, and GS4=44.4%; P<.001), immediate success rates (GS1=95.2%, GS2=79.5%, GS3=59.5%, and GS4=40.7%; P<.001), and number of auxiliary procedures (GS1=0.05±0.32, GS2=0.28±0.6, GS3=0.35±0.66, and GS4=0.43±0.59; P=.031). The final success rates after the auxiliary procedures were similar among the groups (GS1=97.6%, GS2=86.4%, GS3=90.5%, and GS4=74.5%; P=.19).

Conclusion: The GS based on CT findings accurately predicted success rates and complications after PCNL for renal stones.
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http://dx.doi.org/10.1016/j.urology.2013.12.041DOI Listing
June 2014

Secondary hypertension caused by massive renal lymphangiomatosis.

Urology 2013 Aug;82(2):e11-2

Division of Nephrology, Department of Medicine, University of São Paulo School of Medicine, São Paulo, Brazil.

Renal lymphangiomatosis is a rare disease characterized by lymphatic vessel proliferation. We present a case of an adult patient with chronic flank pain, hypertension, and a right kidney mass. The magnetic resonance imaging findings were consistent with unilateral renal lymphangiomatosis. Technetium-99m dimercaptosuccinic acid renal scintilography revealed decreased ipsilateral renal function. From these findings, the patient underwent right nephrectomy, which resulted in complete remission of his hypertension and pain.
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http://dx.doi.org/10.1016/j.urology.2013.04.043DOI Listing
August 2013

Modified complete supine percutaneous nephrolithotomy: solving some problems.

J Endourol 2013 Jul 8;27(7):845-9. Epub 2013 Jun 8.

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

Background And Purpose: Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for patients with renal stones larger than 2 cm. In this article, we aim to describe our modified technique with the patient in a complete supine position for PCNL (csPCNL).

Patients And Methods: A total of 117 patients (120 renal units) who underwent csPCNL for large stones from November 2008 to November 2011 were prospectively evaluated. One surgeon worked in two different institutions and performed all operations. All patients underwent CT preoperatively, and the stones were classified according to the Guy score. Patients were placed in the supine decubitus position with the posterior axillary line located just outside the border of the surgical table, and the flank was extended to increase the space between the last rib and the iliac crest. The csPCNL was performed without a rolled towel under the flank, and the patients remained in the same position during the entire procedure. Success was evaluated based on CT findings at the end of follow-up.

Results: There was no failure of access. The median operative time was 100 (20-240) minutes. The immediate and final success rates were 72.5% and 90.4%, respectively. The complication rate was 16.8% (12.7% of Clavien I or II and 4.1% of Clavien III or IV). There were no colon injuries or deaths. The median hospital stay was 48 (24-840) hours.

Conclusion: Modified csPCNL is a safe and effective procedure with excellent outcomes and a low rate of major complications. It provides a good area for renal puncture and surgical instrumentation.
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http://dx.doi.org/10.1089/end.2012.0725DOI Listing
July 2013