RESUMO Um dos principais desafios no manejo clínico do câncer de próstata é identificar qual tumor é agressivo e precisa de tratamento invasivo. Assim, ser capaz de prever qual irá progredir para recorrência bioquímica é uma ótima estratégia para estratificar pacientes com câncer de próstata. Pensando nisso, criamos uma fórmula matemática que leva em consideração os dados clínicos e patológicos resultando em uma variável quantitativa, denominada densidade de PSA da lesão, que tem potencial para predizer recidiva bioquímica. Para testar se nossa variável é capaz de predizer recorrência bioquímica, usamos uma coorte de 219 pacientes com câncer de próstata, associando nossas variáveis e parâmetros clássicos como a recorrência bioquímica. PSA total, peso da lesão, volume e densidade de PSA clássico foram associados com recorrência bioquímica (p<0,05). O escore ISUP também foi associado à recorrência bioquímica na biópsia e na amostra cirúrgica (p<0,001). O aumento da densidade do PSA da lesão foi significativamente associado à recidiva bioquímica (p=0,03). As variáveis ??derivadas da fórmula, PSA 15% e PSA 152, também foram associadas positivamente à recorrência bioquímica (p=0,01 e p=0,002 respectivamente). A análise de regressão logística mostra que a densidade do PSA clássico, do PSA da lesão e PSA total, juntos, podem explicar até 13% dos casos de recorrência. A densidade de PSA da lesão por si só poderia explicar até 7% dos casos de recorrência. Em conclusão, esta nova abordagem matemática pode ser uma ferramenta útil para prever a recorrência da doença no câncer de próstata.

ABSTRACT A main challenge in the clinical management of prostate cancer is to identify which tumor is aggressive and needs invasive treatment. Thus, being able to predict which cancer will progress to biochemical recurrence is a great strategy to stratify prostate cancer patients. With that in mind, we created a mathematical formula that takes into account the patients clinical and pathological data resulting in a quantitative variable, called PSA density of the lesion, which has the potential to predict biochemical recurrence. To test if our variable is able to predict biochemical recurrence, we use a cohort of 219 prostate cancer patients, associating our new variable and classic parameters of prostate cancer with biochemical recurrence. Total PSA, lesion weight, volume and classic PSA density were positively associated with biochemical recurrence (p<0.05). ISUP score was also associated with biochemical recurrence in both biopsy and surgical specimen (p<0.001). The increase of PSA density of the lesion was significantly associated with the biochemical recurrence (p=0.03). Variables derived from the formula, PSA 15% and PSA 152, were also positive associated with the biochemical recurrence (p=0.01 and p=0.002 respectively). Logistic regression analysis shows that classic PSA density, PSA density of the lesion and total PSA, together, can explain up to 13% of cases of biochemical recurrence. PSA density of the lesion alone would have the ability to explain up to 7% of cases of biochemical recurrence. In conclusion, this new mathematical approach could be a useful tool to predict disease recurrence in prostate cancer.

RESUMO Objetivo: investigar os fatores de risco de conversão para cirurgia aberta na nefrectomia laparoscópica (NL) para urolitíase. Métodos: foram revisados os dados de todos os pacientes maiores de 18 anos de idade submetidos à NL entre janeiro de 2006 e maio de 2013 em nossa Instituição. Índice de Charlson, escore ASA, função renal pela equação e estágio de MDRD (Modification of Diet in Renal Disease), achados de tomografia computadorizada (TC) pré-operatória, complicações pela classificação de Clavien-Dindo e taxa de conversão foram analisados. Determinaram-se os fatores de risco para conversão por meio de regressão logística. Resultados: oitenta e quatro pacientes foram submetidos à LN, sendo que 16 (19%) tiveram seu procedimento convertido para cirurgia aberta devido à forte aderência do hilo renal aos órgãos adjacentes. Outras causas associadas à conversão foram sangramento excessivo (n=6) e lesão do intestino grosso (n=3). Na análise univariada, cirurgia renal prévia, borramento da gordura perirrenal, abscesso renal, abscesso perirrenal, abscesso pararrenal, fístula, aderência ao fígado ou baço e aderência ao intestino foram associados à conversão. Na análise multivariada, abscesso pararrenal e aderência ao intestino foram fatores de risco significativos para a conversão. Conclusão: abscesso pararrenal e aderência ao intestino demonstrados na TC pré-operatória são fatores de risco de conversão para cirurgia aberta em LN por urolitíase.

ABSTRACT Objective: to investigate the risk factors for conversion to open surgery in laparoscopic nephrectomy (LN) for urolithiasis. Methods: we reviewed data on all patients over 18 years of age submitted to LN between January 2006 and May 2013 at our institution. We analyzed the Charlson's index, the ASA score, renal function by the equation and stage of MDRD (Modification of Diet in Renal Disease), preoperative computed tomography (CT) findings, complications by the Clavien-Dindo classification and conversion rate. We used logistic regression analysis to determine the risk factors for conversion. Results: eighty-four patients underwent LN, 16 (19%) sustaining convertion to open surgery due to the strong adhesion of the renal hilum to the adjacent organs. Other causes associated with conversion were excessive bleeding (n=6) and lesion of the large intestine (n=3). In the univariate analysis, previous renal surgery, perirenal fat blurring, renal abscess, perirenal abscess, pararenal abscess, fistula, adherence to the liver or spleen, and adherence to the intestine were associated with conversion. In the multivariate analysis, pararenal abscess and adherence to the intestine were significant risk factors for conversion. Conclusion: pararenal abscess and bowel adhesions demonstrated in the preoperative CT are risk factors for conversion to open surgery in LN due to urolithiasis.

ABSTRACT Objective: To show a video of a complete supine Percutaneous Nephrolithotomy (csPCNL) performed for the treatment of a staghorn calculus, from the surgeon's point of view. The procedure was recorded with a GoPro® camera, demonstrating the ten essential steps for a successful procedure. Materials and methods: The patient was a 38 years-old woman with 2.4cm of left kidney lower pole stone burden who presented with 3 months of lumbar pain and recurrent urinary tract infections. She had a previous diagnosis of polycystic kidney disease and chronic renal failure stage 2. CT scan showed two 1.2cm stones in the lower pole (Guy's Stone Score 2). She had a previous ipsilateral double J insertion due to an obstructive pyelonephritis. The csPCNL was uneventful with a single access in the lower pole. The surgeon had a Full HD GoPro Hero 4 Session® camera mounted on his head, controlled by the surgical team with a remote control. All of the mains steps were recorded. Informed consent was obtained prior to the procedure. Results: The surgical time was 90 minutes. Hemoglobin drop was 0.5g/dL. A post-operative CT scan was stone-free. The patient was discharged 36 hours after surgery. The camera worked properly and didn't cause pain or muscle discomfort to the surgeon. The quality of the recorded movie was excellent. Conclusion: GoPro® camera proved to be a very interesting tool to document surgeries without interfering with the procedure and with great educational potential. More studies should be conducted to evaluate the role of this equipment.

ABSTRACT Introduction: The urinary bladder diverticula (BD) secondary to benign prostatic hyperplasia (BPH) is a complication that can lead to urinary stasis, stone, urinary tract infection (UTI) and tumors. It's role in acute urinary retention (AUR) is not totally understood. Objectives: To determine the effect of BD size on AUR rates in patients with BPH candidates to surgery. Subjects and Methods: We performed a retrospective cohort study of 47 patients with BPH and BD who underwent BPH surgery associated to complete bladder diverticulectomy from 2006 to 2016. We analyzed risk factors for AUR in patients with BD using univariate, multivariate and correlation analysis. Results: There was a difference in the size of the diverticula, with 6.8 cm vs. 4.5 cm among patients with and without AUR respectively (p=0.005). The ROC curve showed a correlation between the size of BD and the risk of AUR. The value of 5.15 cm presented a sensitivity of 73% and a specificity of 72%. The area under the curve was 0.75 (p=0.01). Comparing groups with BD >5.0 cm vs. ≤5.0 cm, the AUR incidence was 74% and 27.8% respectively with an OR of 2.65 (1.20-5.85) (p=0.005). In the multivariate analysis, only the size of the diverticula reached statistical significance (p=0.012). Conclusions: The diameter of BD is an independent risk factor for AUR in patients with BPH and BD who are candidates to surgery. A diameter greater than 5.15 cm increases the risk of AUR.

ABSTRACT Introduction To present the current practice patterns on percutaneous nephrolithotomy (PCNL) in a developing country. Materials and Methods A survey was offered to Brazilian urologists during the II International Endourology Symposium held in Sao Paulo, in 2015. The first seven questions were related to demographic data while the 20 remaining were directed to urologists who performed PCNL. Results From 250 participants, 100 replied to the survey, 81% performed PCNL and 60.4% of performers had been in practice for less than 15 years. Eighty-one percent were trained in the prone position and 64% in supine. PCNL was learned during the residency in 66.7% and 2.5% had fellowship training. Prone position was the preferred decubitus for simple or complex calculi, though for obese patients there was no difference. Younger surgeons prefer supine while older surgeons prefer prone. The access was obtained by the surgeon in all cases, 96.3% use fluoroscopy and 3.7% prefer ultrasonography. Forty-seven percent use ultrasonic lithotripters and 4.1% laser. For kidney drainage, 71.6% place a nephrostomy tube. Double J stent is left in 77%. The postoperative image method was CT for 50%. Colonic injury was reported by 25%, predominantly in the senior group without statistically difference between positions. Conclusions From a selected group of urologists, we observe that Brazilian urologists usually gain their own access for PCNL guided by fluoroscopy. They predominantly prefer the prone position, use fascial dilators, ultrasonic lithotripters and place a nephrostomy tube when exiting the kidney. Fellowship programs, ultrasonography, flexible nephoscopy and tubeless procedures could be encouraged.

Main findings A 25-year-old hypertensive female patient was referred to our institution. Initial workup exams demonstrated a 2.8 cm cortical lower pole tumor in the right kidney. She underwent laparoscopic partial nephrectomy without complications. Histopathologic examination revealed a rare juxtaglomerular cell tumor known as reninoma. After surgery, she recovered uneventfully and all medications were withdrawn. Case hypothesis Secondary arterial hypertension is a matter of great interest to urologists and nephrologists. Renovascular hypertension, primary hyperadosteronism and pheocromocytoma are potential diagnosis that must not be forgotten and should be excluded. Although rare, chronic pyelonephritis and renal tumors as rennin-producing tumors, nephroblastoma, hypernephroma, and renal cell carcinoma might also induce hypertension and should be in the diagnostic list of clinicians. Promising future implications Approximately 5% of patients with high blood pressure have specific causes and medical investigation may usually identify such patients. Furthermore, these patients can be successfully treated and cured, most times by minimally invasive techniques. This interesting case might expand knowledge of physicians and aid better diagnostic care in future medical practice.

OBJECTIVES: We describe the results of over one hundred nephrectomies performed using a subcostal mini incision. INTRODUCTION: A major effort has been undertaken to encourage living donor renal transplantation. New techniques that use minimally invasive approaches to perform donor nephrectomy have been progressively accepted. Among these new procedures is the mini-incision approach. METHODS: We prospectively analyzed one hundred and seventeen consecutive donors that were subjected to subcostal mini-incision nephrectomy at a single center. Surgical time, warm and cold ischemia time, intraoperative complications, time until hospital discharge, presence of infection, bleeding, the need for a second operation, and death were analyzed. Eventual loss of donor renal function was indicated by increases in serum creatinine and proteinuria. RESULTS: The mean time of surgery was 180.5 ± 26.2 minutes. The mean warm ischemia time was 93 ±8.3 seconds, while the mean cold ischemia time was 85.9 (±23.5) minutes. We had one case with an intraoperative complication, and only two patients required another operation. An intra-abdominal abscess occurred in one patient (0.85%), proteinuria occurred in one patient (0.85%), and a transitory increase of creatinine levels occurred in two patients (1.7%). DISCUSSION: Reducing the length of the abdominal incision did not influence surgical time or result in an increase in intraoperative complications relative to our historical data or literature reports. Organ preparation was accomplished successfully with a brief warm ischemia time. Additionally, the mean hospital stay was short, and few surgical complications occurred. CONCLUSION: The use of a subcostal mini incision is both safe and similar to conventional techniques previously described in the literature.

OBJECTIVES: To evaluate the prevalence of cholecystopathy in chronic renal patients awaiting kidney transplants. INTRODUCTION: The prevalence and management of cholelithiasis in renal transplant patients is not well established. METHODS: A total of 342 chronic renal failure patients on the waiting list for a kidney transplant were studied. Patients were evaluated for the presence of cholelithiasis and related symptoms, previous cholecystectomies and other abdominal surgeries, time on dialysis, and general data (gender, age, number of pregnancies, and body mass index). RESULTS: Cholelithiasis was found in 41 out of 342 patients (12%). Twelve of these patients, all symptomatic, had previously undergone cholecystectomies. Five out of 29 patients who had not undergone surgery were symptomatic. Overall, 17 patients (41.5%) were symptomatic. Their mean age was 54 (range 32-74) years old; 61% were female, and their mean body mass index was 25.4. Nineteen (76%) out of 25 women had previously been pregnant, with an average of 3.6 pregnancies per woman. CONCLUSIONS: The frequency of cholelithiasis was similar to that reported in the literature for the general population. However, the high frequency of symptomatic patients points toward an indication of routine pre-transplant cholecystectomy to avoid serious post-transplant complications.

OBJECTIVE: The aim of this study was to report a single center experience of organ and tissue transplantation INTRODUCTION: This is the first report of organ and tissue transplantation at the Hospital das Clínicas of the University of Sao Paulo Medical School. METHODS: We collected data from each type of organ transplantation from 2002 to 2007. The data collected were patient characteristics and actuarial survival Kaplan-Meier curves at 30 days, one year, and five years RESULTS: There were a total of 3,321 transplants at our institution and the 5-year survival curve ranged from 53% to 88%. CONCLUSION: This report shows that solid organ and tissue transplants are feasible within the institution and allow us to expect that the quality of transplantation will improve in the future.

CONTEXTO: Ainda existe controvérsia quanto ao uso e a forma de utilização de profilaxia antimicrobiana da infecção urinária associada ao cateterismo uretral no pós-transplante renal. OBJETIVO: Determinar se os pacientes desenvolvem infecção urinária durante o período de cateterismo uretral de curta duração após o transplante renal, sem usar a profilaxia antimicrobiana de rotina. TIPO DE ESTUDO: Estudo prospectivo. LOCAL: Unidade de Transplante Renal do Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brasil. PACIENTES: 20 pacientes submetidos a transplante renal não-complicado, com trato urinário normal e sem fatores de risco para infecção urinária. Idade variando de 15 a 65 anos de idade. VARIÁVEIS ESTUDADAS: Nos pacientes submetidos a transplante renal, durante o período de cateterismo uretral ( 4 a 5 dias ), urina vesical, urina da bolsa coletora do sistema de drenagem fechado e material do meato uretral, foram coletados diariamente para exame de cultura. RESULTADOS: Houve um predomínio de bactérias Staphylococcus sp coagulase negativa e S. viridans na flora do meato uretral normal e nos primeiros dois dias de cateterismo uretral. Após o segundo dia de cateterismo uretral, houve predomínio de E. coli e E. faecalis. Infecção urinária não ocorreu durante o período de cateterismo uretral. No seguimento, apenas uma paciente (7%) desenvolveu bacteriúria assintomática causada por E. coli após a retirada do cateter uretral. CONCLUSÕES: Não ocorrem infecção urinária durante o período de cateterismo uretral no pós-transplante renal. Portanto, não há necessidade de profilaxia antimicrobiana nesses pacientes para prevenir a infecção urinária.

CONTEXT: There is still controversy as to the use and dosage of antimicrobial prophylaxis of the urinary infection associated with urethral catheterization in the post renal transplant period. OBJECTIVE: To determine whether patients develop urinary infection during short-term urethral catheterization after renal transplant without routine antimicrobial prophylaxis. DESIGN: Prospective study. SETTING: Kidney Transplantation Unit. SAMPLE: 20 patients submitted to non-complicated kidney transplant, with a normal urinary tract and no risk factors present regarding urinary infection. Aged 15 to 65 years. MAIN MEASUREMENTS: Before the transplant, material from the urethral meatus and urine were collected for culture. After the transplant, in the period during which the patient was with short-term urethral catheterization (4 to 5 days), material from the urethral meatus and urine from the bladder and the collecting bag were taken daily from all recipients for culture. RESULTS: There was a predominance of coagulase-negative Staphylococcus and S. viridans in the normal urethral meatus flora and in the first two days of urethral catheterization. After the second day, there was a predominance of E. coli and E. faecalis. Urinary infection did not occur during the period of urethral catheterization. In the follow up only one female patient (7%) had asymptomatic bacteriuria caused by E.coli after the withdrawal of the urethral catheter. CONCLUSIONS: Infection urinary does not occur during the period of urethral catheterization in kidney post-transplant patients. Thus, antimicrobial prophylaxis is not recommended for these patients to prevent urinary infection.