PURPOSE: Laparoscopy has certainly brought considerable benefits to patients, but laparoscopic surgery requires a set of skills different from open surgery, and learning in the operating room may increase surgical time, and even may be harmful to patients. Several training programs have been developed to decrease these potential prejudices. PURPOSES: to describe the laparoscopic training program for urological residents of the "Hospital das Clinicas" of the Sao Paulo Medical School, to report urological procedures that are feasible in dry and wet labs, and to perform a critical analysis of the cost-benefit relation of advanced laparoscopic skills laboratory. MATERIALS AND METHODS: The laparoscopic skill lab has two virtual simulators, three manual simulators, and four laparoscopic sets for study with a porcine model. The urology residents during their first year attend classes in the virtual and manual simulator and helps the senior urological resident in activities carried out with the laparoscopic sets. During the second year, the urological resident has six periods per week, each period lasting four hours, to perform laparoscopic procedures with a porcine model. Results: In a training program of ten weeks, one urological resident performs an average of 120 urological procedures. The most common procedures are total nephrectomy (30%), bladder suture (30%), partial nephrectomy (10%), pyeloplasty (10%), ureteral replacement or transuretero anastomosis (10%), and others like adrenalectomy, prostatectomy, and retroperitoneoscopy. These procedures are much quicker and caused less morbidity. CONCLUSION: Laparoscopic skills laboratory is a good method for achieving technical ability.

Purpose: To compare the perioperative complication rate obtained with the transperitoneal laparoscopic radical prostatectomy (TLRP) and with the extraperitoneal LRP (ELRP) during the learning curve (LC). Materials and Methods: Data of the initial 40 TLRP (Group 1) were retrospectively compared with the initial 40 ELRP (Group 2). Each Group of patients was operated by two different surgeons. Results: The overall surgical time (175 min x 267.6 min; p < 0.001) and estimated blood loss (177.5 mL x 292.4 mL; p < 0.001) were statistically better in the Group 1. Two intraoperative complications were observed in Group 1 (5%) represented by one case of bleeding and one case of rectal injury, whereas four complications (10%) were observed in Group 2, represented by two cases of bleeding, one bladder and one rectal injuries (p = 0.675). Open conversion occurred once in each Group (2.5%). Overall postoperative complications were similar (52.5% x 35%; p = 0.365). Major early postoperative complications occurred in three and in one case in Group 1 and 2, respectively. Group 1 had two peritonitis (fecal and urinary), leading to one death in this group. Conclusions: No statistical differences in overall complication rates were observed. The transperitoneal approach presented more serious complications during the early postoperative time and this fact is attributed to the potential chance of intraperitoneal peritonitis not observed with the extraperitoneal route.

Objectives: Vesico-ureteric reflux (VUR) is a common cause of urinary tract infections in children, being less commonly diagnosed in adults. Several anti-reflux plasties have been used successfully for the treatment of such condition, such as Politano-Leadbetter, Cohen and Gregoir-Lich techniques, the latter being our preferred approach in open procedures. Here we describe our experience with laparoscopic Gregoir-Lich anti-reflux plasty (LGLP) in children and adults. Methods: The LGLP was used for the treatment of VUR in 15 patients (7 adults and 8 children). Four adults and 5 children had bilateral disease and both sides were treated at the same procedure. Data was collected prospectively and we analysed age at treatment, laterality, degree of VUR, previous anti-reflux procedures, operative time, number of detrusor stitches used in each side, intra-operative and post-operative complications, success rate and follow-up. Results: A total of 23 ureteral units were treated. VUR was graded as I in one unit, II in 4 units, III in 10 units, IV in 7 units and 1 unit was not classified, as it was diagnosed by radioisotopic cystography. Two children had failed previous endoscopic procedures. There were no open conversions. Two muccosal perforations occurred during the procedure and were successfully treated laparoscopically. Nineteen out of 21 ureteral units (90%) presented no VUR at the cystographic control, and no bladder dysfunction was identified on follow-up. Conclusions: The LGLP is a feasible, minimally invasive alternative for VUR that reproduces the open procedure. It has an excelent success rate and is not associated to bladder disfunction, even in bilateral procedures.

Objetivo: El reflujo vesicoureteral (RVU) es una causa común de infecciones del tracto urinario en niños, siendo diagnosticado con menos frecuencia en adultos. Se han utilizado varias técnicas antirreflujo para el tratamiento de dicha condición, como las técnicas de Politano-Leadbet-ter, Cohen y Gregoir-Lich, siendo ésta última nuestro abordaje preferido en cirugía abierta. Describimos nuestra experiencia con la plastia antirreflujo laparoscópica de Gregoir-Lich en niños y adultos. Métodos: La plastia de Gregoir-Lich laparoscópica fue utilizada en el tratamiento del RVU en 15 pacientes (7 adultos y 8 niños). Cuatro adultos y cinco niños respectivamente tenían reflujo bilateral, tratándose ambos lados en el mismo acto quirúrgico. Los datos fueron recogidos prospectivamente y se analizó edad en el momento el tratamiento, lado, grado de RVU, operaciones antirreflujo previas, tiempo operatorio, número de puntos del detrusor utilizados en cada lado, complicaciones intra y postoperatorias, tasa de éxitos y seguimiento. Resultados: Se trataron un total de 23 unidades ureterales. El RVU fue grado I en 1 uréter, II en 4, III en 10 y IV en 7, en un uréter no se asignó grado porque se diagnosticó mediante cistografía radioisotópica. Dos niños habían tenido operaciones endoscópicas previas que fracasaron. No hubo ninguna conversión a cirugía abierta. Hubo dos casos de perforación mucosa durante el procedimiento que fueron tratadas con éxito por vía laparoscópica. Diecinueve de las 21 unidades ureterales (90%) no presentaban RVU en el control mediante cistografía, y no se identificó disfunción vesical en el seguimiento. Conclusiones: La plastia laparoscópica de Gregoir-Lich es una alternativa factible, mínimamente invasiva para el RVU que reproduce el procedimiento abierto. Tiene un excelente porcentaje de éxitos y no se asocia con disfunción vesical, cruzó en procedimientos bilaterales.

OBJECTIVES: The aim of this retrospective study is to compare surgical complications and long-term survival in children with Wilms' tumor (WT) and tumor thrombus receiving or not preoperative chemotherapy MATERIALS AND METHODS: Review of the charts of 155 children with WT treated between 1983 and 2005, and analysis of 16/155 (10.3%) children with WT who presented cavoatrial tumor extension, being 8/16 IVC and 8/16 atrial thrombus RESULTS: Median age was 54 months. 2/16 had cardiac failure as the first symptom. 11/16(7 IVC and 4 atrial extension) (67%) were submitted to preoperative chemotherapy with vincristine plus actinomycin D, and 5/16(1 IVC and 4 atrial) (33%) underwent initial nephrectomy and thrombus resection. So, 11 patients were submitted to preoperative VCR/ACTD and 2/11 (18.1%) had complete regression of the thrombus, 6/11(54.5%) partial regression and 3/11 (27%) had no response. Among the partial responders, nephrectomy with thrombus removal was performed in all, including one patient with previous intracardiac involvement, without extracorporeal circulation procedures. In two of the three non-responders, cardiopulmonary bypass was necessary for thrombus removal. There were no surgical related deaths. Long-term survival is 91% in the group submitted to preoperative chemotherapy and 100% in the group who had surgery as first approach CONCLUSION: Preoperative chemotherapy was able to reduce thrombus extension in 8/11 (73%) treated patients and cardiopulmonary bypass was avoided in 2 patients with atrial thrombus. Surgical resection of tumor and thrombus was successful in all cases, receiving or not preoperative chemotherapy and overall survival was similar in both groups.

We report a successful surgical intervention to repair bilateral ureteral strictures in a child with juvenile dermatomyositis (JDM) and ureteral calcinosis. This is the fourth reported case in medical literature. A 9-year-old-girl with severe JDM, a rare connective tissue disease characterized by skin and muscles vasculitis, was under immunosuppressive therapy. In the course of the disease, she presented recurrent urinary tract infections. Bilateral ureteral dilation was detected by ultrasound (US) and intravenous pyelogram (IVP). CT scan showed bilateral ureteral calculus. Ureteroscopy revealed bilateral ureteral calcinosis, confirmed by histopathological analysis. Bilateral double-J stents were placed, resulting in transient improvement of ureteral dilation and infection, but only the surgical removal of abnormal ureteral portions was successful. In conclusion, endourological approach is recommended for diagnosis of urinary tract involvement by JDM because radiological evaluation can be misleading. The immunosuppressive treatment and the resection of damaged ureteral segments have allowed the control of urinary complications.

Objetivo: cálculos urinários atingem de 5 a 10% da população em alguma fase da vida. Destes casos, somente 2 a 3% são crianças. O tratamento da litíase urinária na faixa pediátrica, com o uso de métodos minimamente invasivos, representa uma alternativa cada vez mais atraente. O presente trabalho objetiva apresentar resultados de litotripsia extracorpórea como tratamento minimamente invasivo de litíase urinária na infância. Métodos: no período de setembro de 1991 a setembro de 2000, foram tratadas e acompanhadas 87 crianças, sendo que seis delas tinham dois cálculos; portanto foram tratados 93 cálculos urinários. Foi utilizado o equipamento de litotripsia extracorpórea por ondas de choque, da Dornier-Philips. Resultados: os cálculos piélicos, caliciais superiores e médios foram fragmentados e eliminados na porcentagem de 87,7% e 77,8%, respectivamente. Os cálculos localizados no cálice inferior foram eliminados em 64,7%. Dos três casos de cálculo coraliforme, somente um ficou livre do cálculo (33,3%). Os dez pacientes com cálculo ureteral ficaram livres de litíase (100%). Os cálculos vesicais foram tratados e eliminados em 60% dos casos. Conclusão: a litotripsia extracorpórea demonstrou ser uma forma eficiente de tratamento de cálculos piélicos, caliciais, ureterais e vesicais em crianças. Cálculos coraliformes não tiveram bons resultados quando tratados por meio de litotripsia extracorpórea. Os resultados deste método foram influenciados pela localização e tamanho dos cálculos.

Objective: urolithiasis affects between five and 10% of the human population during their lifetime, only 2-3% of whom are children. Therapy of urolithiasis in the pediatric age group with minimally invasive methodology represents an attractive alternative. This study presents results of extracorporeal shockwave lithotripsy, a minimally invasive methodology, for the treatment of urolithiasis in children. Methods: in the period between September 1991 and September 2000, 87 children were submitted to extracorporeal shockwave lithotripsy; as six of them presented with two calculi 93 urinary calculi were treated over that period. The Dornier-Philips lithotriptor was used in the procedures. Results: pelvic, superior and medium caliceal calculi were fragmented and eliminated in 87.7% and 77.8% of cases, respectively. Inferior caliceal stones were eliminated in 64.7% of cases. Only one of the three patients with staghorn calculi became stone-free after therapy (33.3%). All patients with ureteral calculi were stone-free after therapy. Bladder stones were fragmented and eliminated in 60% of cases. Conclusions: extracorporeal shockwave lithotripsy is a safe and effective treatment for pelvic, caliceal, ureteral and bladder urolithiasis in children. Staghorn calculi have not shown satisfactory results when treated by this method. Extracorporeal shockwave lithotripsy results were influenced in our experience by the position and size of the treated calculi.