ABSTRACT A major challenge in the management of ureteropelvic junction obstruction (UPJO) is the selection of patients who would benefit from surgical treatment. Tissue inhibitor metalloproteinase-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) indicate renal cell stress and are associated with cell cycle arrest. The [TIMP-2] [IGFBP7] ratio (Nephrocheck®) has been recently applied in patients in intensive care units patients to predict the development of acute kidney injury. In this study, we evaluated the performance of these biomarkers performance to distinguishing obstructive hydronephrosis (HN) from non-obstructive HN. Materials and Methods: Consecutive patients with UPJO were enrolled in this study. Urinary [TIMP-2] [IGFBP7] and clinical characteristics (hydronephrosis grade, differential renal function, and drainage half-time) were measured in the following groups: 26 children with obstructive HN at initial diagnosis (group 1A) and after six months of dismembered pyeloplasty (group 1B); 22 children with non-obstructive HN (group 2), and 26 children without any urinary tract condition, as the control group (group 3). Results: Comparing the initial samples, [TIMP-2] [IGFBP7] had higher levels in the HN groups and lower levels in the control group; however, no difference was observed between the HN groups (obstructive vs. non-obstructive). After six months of follow-up, patients who underwent dismembered pyeloplasty showed stability in the urinary concentration of [TIMP-2] [IGFBP7]. All patients with [TIMP-2] [IGFBP7] higher than 1.0 (ng/mL)2/1000 had diffuse cortical atrophy on ultrasonography. Conclusions: We showed that urinary levels of urinary [TIMP-2] [IGFBP7] are higher in children with HN than controls. Nephrocheck® is not reliable in predicting the need for surgical intervention for pediatric patients with UPJO.

Resumo A ultrassonografia com contraste de microbolhas é um método ainda pouco utilizado no Brasil, mas que tem grandes vantagens, ainda mais na faixa pediátrica, como ausência de radiação e dispensa de sedação/anestesia. O contraste de microbolhas tem se mostrado bastante seguro e com raríssimas reações adversas graves. Apresentaremos nesta revisão a técnica para o uso desse contraste na ultrassonografia, bem como as principais aplicações na faixa pediátrica, como avaliação das lesões hepáticas focais, do trauma abdominal, do enxerto hepático e renal nos transplantes, das alças intestinais e da pesquisa de refluxo vesicoureteral. É importante que radiologistas que exerçam funções em centros pediátricos conheçam essa ferramenta promissora.

Abstract Although contrast-enhanced ultrasound has been shown to provide considerable benefits, particularly in pediatric patients, it is still used relatively rarely in Brazil. It has proven to be a safe technique, and adverse effects are rare. In this review, we address the technique and main applications of contrast-enhanced ultrasound in the pediatric population, including the evaluation of focal liver lesions, abdominal trauma, kidney grafts, liver grafts, bowel loops, and vesicoureteral reflux. It is important for pediatric radiologists to be acquainted with this promising tool, understanding its applications and limitations.

ABSTRACT Introduction: Symptomatic duplex kidneys usually present with recurrent urinary tract infection due to ureteral obstruction (megaureter, ureterocele or ectopic ureter) and/or vesicoureteral reflux. Upper-pole nephrectomy is a widely accepted procedure to correct symptomatic duplex systems with poor functioning moieties, also known as upper or proximal approach. The distal ureteral stump syndrome (DUSS) can be a late complication of this approach. There is no consensus upon the length of ureteral dissection and the better approach to symptomatic disease in duplex systems, so we aim to identify if extended ureteral dissection can prevent DUSS in top-down approach. Materials and Methods: Forty-four consecutive patients with symptomatic duplex system were retrospectively classified into two groups: those with limited ureteral excision after heminephrectomy (HN) (group-1) and those with extended ureterectomy after HN (group-2). Patients were followed-up for at least 36 months regarding outcomes of distal ureteral stump. Results: Overall complication was 20%. A total of 8 patients required unplanned further surgery in Group-1 (30%) whereas only 1 patient required unplanned surgery in group 2 (6%) (p=0.07). Subgroup analysis showed that Group-1 presented more DUSS requiring surgery during follow-up than group-2 (p=0.04). Factors possibly affecting complications incidence (such as ureterocele or ectopic ureter) did not differ between groups (p=0.72 and p=0.78). Conclusion: Upper pole nephrectomy should be performed with extended distal ureteral dissection to prevent ureteral stump complications.

ABSTRACT Purpose: To describe our experience in the management of retained encrusted ureteral stents using a single session combined endourological approach. Materials and Methods: Patients with retained encrusted ureteral stents who had been submitted to a single session combined endourological approach from June 2010 to June 2018 were prospectively evaluated. Patients were divided according to the Forgotten-Encrusted-Calcified (FECal) classification. The stone burden, surgical intervention, number of interventions until stone free status, operation time, hospital stay, complications, stone analysis, and stone-free rate were compared between groups. ANOVA was used to compare numerical variables, and the Mann-Whitney or Chi-square test to compare categorical variables between groups. Results: We evaluated 50 patients with a mean follow-up of 2.9±1.4 years (mean±SD). The groups were comparable in terms of age, sex, laterality, BMI, comorbidities, ASA, reason for stent passage, and indwelling time. The stone burden was higher for grades IV and V (p=0.027). Percutaneous nephrolithotomy was the most common procedure (p=0.004) for grades IV and V. The number of procedures until the patients were stone-free was 1.92±1.40, and the hospital stay (4.2±2.5 days), complications (22%), and stone analysis (66% calcium oxalate) were similar between groups. The stone-free rate was lower in grades III to V (60%, 54.5%, and 50%). Conclusions: The endoscopic combined approach in the supine position is a safe and feasible technique that allows removal of retained and encrusted stents in a single procedure. The FECal classification seems to be useful for surgical planning.

ABSTRACT Objective To assess the feasibility and outcomes of laparoscopic pyeloplasty in children with complex ureteropelvic junction obstruction (UPJO) and compare to children with iso-lated UPJO without associated urinary tract abnormalities. Material and Methods Medical records of 82 consecutive children submitted to transperi-toneal laparoscopic pyeloplasty in a 12-year period were reviewed. Eleven cases were con-sidered complex, consisting of atypical anatomy including horseshoe kidneys in 6 patients, pelvic kidneys in 3 patients, and a duplex collecting system in 2 patients. Patients were di-vided into 2 groups: normal anatomy (group 1) and complex cases (group 2). Demographics, perioperative data, outcomes and complications were recorded and analyzed. Results Mean age was 8.9 years (0.5-17.9) for group 1 and 5.9 years (0.5-17.2) for group 2, p=0.08. The median operative time was 200 minutes (180-230) for group 1 and 203 minutes (120-300) for group 2, p=0.15. Major complications (Clavien ≥3) were 4 (5.6%) in group 1 and 1 (6.3%) in group 2, p=0.52. No deaths or early postoperative complications such as: urinoma or urinary leakage or bleeding, occurred. The success rate for radiologic improvement and flank pain improvement was comparable between the two groups. Re-garding hydronephrosis, significant improvement was present in 62 patients (93.4%) of group 1 and 10 cases (90.9%) of group 2, p=0.99. The median hospital stay was 4 days (IQR 3-4) for group 1 and 4.8 days (IQR 3-6) for group 2, p=0.27. Conclusions Transperitoneal laparoscopic pyeloplasty is feasible and effective for the management of UPJO associated with renal or urinary tract anomalies.

ABSTRACT Introduction: Urethral duplication is rare. Characterized by the presence of two urethral channels. This anomaly presents a great variety of clinical findings that depend on the type of duplication that often is associated with other anomalies. Material and Methods: We report thirteen boys with urethral duplication managed in our institution between 1988-2015. Clinical findings, associated anomalies, treatment of urethral duplication and our results are described. Patients were classified according to Effmann classification. Results: Mean patient's age was 38.3±34.7 months (3-136 months). Mean follow-up was 7.7±3.4 years (3y8m-14y2m). Type II A2 was the most common pattern (8/13 patients, 61.5%), followed by type IA (3/13 patients, 23%) and IIA1 (2/13 patients, 15.3%). The most frequent clinical manifestations were urinary tract infections (UTI) observed in 11/13 patients (84.6%) and anal urinary leakage, found in 7/13 patients (53.8%). Associated anomalies were found in 9/13 patients (69.2%). Required surgeries were 3.53±2.84 procedures per patient. Considering groups: Type IIA2 4.25±3.28, type IIA1 4±1.41 and type IA 1.33±0.57 needed procedures per patient. Complications rate were 0% for type IA, 50% for type IIA1 and 75% for type IIA2. Conclusions: Patients with incomplete duplication (type I A or I B) can totally be asymptomatic, with no need of surgical correction. Type IIA2 is the most complex form of duplication to correct and multiple procedures might be required because of the very hypoplastic orthotopic dorsal urethral tissue. Surgical treatment should be individualized and parents should be advised on complications and need of multiple surgeries according to urethral duplication type.

ABSTRACT Introduction Horseshoe kidney occurs in 1 per 400-800 live births and are more frequently observed in males (M:F 2:1). Ureteropelvic junction obstruction (UPJO) is commonly associated with horseshoe kidneys. The variable blood supply, presence of the isthmus and high insertion of the ureter contribute to this problem. Case report An asymptomatic 6 year-old boy presented with antenatal hydronephrosis. Ultrasonography and CT scan demonstrated left UPJO associated with a horseshoe kidney. DMSA showed 33% of function on the left side. DTPA showed a flat curve and lack of washout. A left dismembered laparoscopic pyeloplasty was performed after identification of crossing vessels and abnormal implantation of the ureter. After one year, the child is asymptomatic. DTPA demonstrated a good washout curve. Results Our cohort consisted of six patients, five males and one female, with a mean age of 6 years (range 6m-17 years) and a mean follow-up of 3 years. Ureteropelvic junction obstruction was more common on the left side. Symptoms appeared only in 34% of the cases. Mean operative time was 198 minutes (range 120-270 minutes). Crossing vessels were common (observed in 50% patients). High implantation of ureter was seen in 67% patients and intrinsic obstruction in 83%. Surgical difficulties were found in two cases. Hospital stay was 4.3 days (3 to 6 days), with only one patient having a mild complication (pyelonephritis). All cases had clinical and radiologic improvement. Conclusion Laparoscopic pyeloplasty is safe and feasible in children with UPJO in horseshoe kidneys, with good results and minimal morbidity.

ABSTRACT Introduction The surgical correction of bladder exstrophy remains challenging. In our institution, the repair has evolved from a staged repair to one-stage reconstruction. The one-stage reconstruction includes; bladder closure, Cantwell-Ransley neourethroplasty and abdominoplasty using groin flaps, without the need of pelvic ostheotomies. Repair of urinary continence (UC) and vesicoureteral reflux (VUR) is done after development of the infant. Objective To present our experience of our modified one-stage reconstruction of bladder exstrophy in male patients. Materials and Methods Medical records of male patients submitted to one-stage reconstruction of bladder exstrophy were analyzed retrospectively. Fifteen exstrophy bladder patients with mean age 4.2±7 years were treated at our institution between 1999-2013. Results 2 5 Conclusions One-stage reconstruction minimizes the number of surgical procedures required to achieve UC and potentiates bladder-neck function. The advantages of using groin flaps over current techniques for complete repair are the small risk for penile tissue loss and the avoidance of ostheotomies.

ABSTRACT Introduction: Nephrolitiasis, once considered an adult disease, has become increasingly prevalent in children, with an increase from 6% to 10 % annually in past 25 years. Kidney stones in pediatric population can result from metabolic diseases in up to 50% of children affected. Other factors associated with litiasis are infection, dietary factors, and anatomic malformations of urinary tract. Standard treatment procedures for pediatric population are similar to adult population. Extracorporeal shock wave lithotripsy (ESWL), ureterorenoscopy (URS), percutaneous nepfrolithotomy (PCNL), as well as laparoscopic and retroperitoneoscopic approaches can be indicated in selected cases. The advantages of laparoscopic or retroperitoneoscopic approaches are shorter mean operation time, no trauma of renal parenchyma, lower bleeding risk, and higher stone-free rates, especially in pelvic calculi with extrarenal pelvis, where the stone is removed intact. Patient and Methods: A 10 year-old girl presented with right abdominal flank pain, macroscopic hematuria, with previous history of urinary infections‥ Further investigation showed an 1,5 centimeter calculi in right kidney pelvis. A previous ureterorenoscopy was tried with no success, and a double J catheter was placed. After discussing options, a retroperitoneoscopic pielolithotomy was performed. Results: The procedure occurred with no complications, and the calculi was completely removed. The foley catheter was removed in first postoperative day and she was discharged 2 days after surgery. Double J stent was removed after 2 weeks. Conclusions: Retroperitoneoscopic pielolithotomy is a feasible and safe procedure in children, with same outcomes of the procedure for adult population.

Os tumores de uretra são muito raros e bastante agressivos. Acometem mais frequentemente homens (2:1) e são mais comuns na raça branca (85% dos casos). Os sarcomas de tecidos moles são um grupo heterogêneo de tumores que surgem a partir da mesoderme embrionária e representam 1% de todos os casos de doença maligna urinária, raramente acometendo a uretra primariamente. Relamos aqui um caso extremamente raro de sarcoma uretral masculino com somente dois semelhantes publicados na literatura.

Urethral tumors are rare and aggressive. They usually affect men (2:1) and occur more commonly in white (85% of cases). Soft tissue sarcomas are a heterogeneous group of tumors that arise from embryonic mesoderm. It represents 1% of all cases of urinary tract malignancies and rarely primary affect the ureter. We report a case of male urethral sarcoma. To date, only two similar cases have been published in literature.

Contexto A amostragem de tecido de massas renais é tradicionalmente realizada através da abordagem percutânea ou pelo método laparoscópico. A utilidade do ultrassom endoscópico para biópsia de lesões renais ainda não está clara e poucos casos foram relatados na literatura. Objetivos Avaliar a factibilidade e os resultados da biópsia de tumores renais guiada por ultrassom endoscópico. Métodos Trata-se de uma série retrospectiva de casos de biópsias ecoguiadas de massa renal após avaliação com tomografia computadorizada ou ressonância magnética. Resultados Dez procedimentos foram realizados em nove pacientes do sexo masculino (idade média de 54,7 anos), no rim direito (n = 4), esquerdo (n = 4) e bilateralmente (n = 1). Massas renais (diâmetro médio 55 mm; variando de 13 a 160 mm) localizadas no pólo superior (n = 3), inferior (n = 2) e na região mesorenal (n = 3). Em dois casos, a massa envolvida mais de uma região renal. A ressecção cirúrgica confirmou carcinoma de células renais em seis pacientes nos quais a biópsia ecoguiada pré-operatória demonstrava carcinoma de células renais. Não foram relatadas complicações. Conclusões A biópsia de massas renais guiadas por ultrassom endoscópico é um procedimento seguro e viável, com bons resultados e mínima morbidade.

Context Tissue sampling of renal masses is traditionally performed via the percutaneous approach or laparoscopicaly. The utility of endoscopic ultrasound to biopsy renal lesions it remains unclear and few cases have been reported. Objectives To evaluate the feasibility and outcome of endoscopic ultrasound fine needle aspiration of renal tumors. Methods Consecutive subjects undergoing attempted endoscopic ultrasound fine needle aspiration of a kidney mass after evaluation with computerized tomography or magnetic resonance. Results Ten procedures were performed in nine male patients (median age 54.7 years) on the right (n = 4) and left kidney (n = 4) and bilaterally (n = 1). Kidney masses (median diameter 55 mm ; range 13-160 mm) were located in the upper pole (n = 3), the lower pole (n = 2) and the mesorenal region (n = 3). In two cases, the mass involved more than one kidney region. Surgical resection confirmed renal cell carcinoma in six patients in whom pre-operative endoscopic ultrasound fine needle aspiration demonstrated renal cell carcinoma. No complications were reported. Conclusions Endoscopic ultrasound fine needle aspiration appears as a safe and feasible procedure with good results and minimal morbidity.

Paciente de 23 anos, masculino, com antecedente de transplante de medula óssea por leucemia mieloide aguda. Há 5 anos, apresentou volumosa massa em região inguinal direita. No exame físico, foi constatada criptorquidia à direita. Os marcadores tumorais alfa-fetoproteína e beta-HCG encontravam-se dentro da normalidade, e a desidrogenase láctica estava aumentada. A tomografia computadorizada de abdomen e pelve revelou massa testicular direita com contiguidade pelo canal inguinal, até o retroperitônio ipsilateral, associada a hidronefrose direita. Devido ao alto risco de neoplasia germinativa em testículo criptorquídico, o paciente foi submetido à orquiectomia radical direita, cujo anatomopatológico revelou recidiva de leucemia mieloide aguda em testículo. Foi encaminhado para oncologia para terapia adjuvante. Nossa revisão não revelou nenhum caso semelhante na literatura.

A 23-year-old male with a history of bone marrow transplant for acute myeloid leukemia. He presented a large mass in the right inguinal region 5 years ago. Upon physical examination, right-sided cryptorchidism was observed. The tumor markers alpha-fetoprotein and beta-HCG were within normalcy range and lactate dehydrogenase was raised. Computed tomography of the abdomen and pelvis revealed right testicular mass in contiguity with the inguinal canal to the ipsilateral retroperitoneum, associated with right hydronephrosis. Due to the risk of germ-cell tumor in undescended testicle, the patient underwent radical right orchiectomy. The pathological examination showed recurrence of acute myeloid leukemia in the testis. He was referred to oncology for adjuvant therapy. Our literature review found no similar cases described.

CONTEXTOO tamanho peniano é uma grande preocupação para homens em diversas culturas. Apesar da grande variedade de possíveis métodos para o aumento peniano, nenhum ganhou aceitação unânime por especialistas no assunto. Mas na era dos procedimentos minimamente invasivos, a terapia de injeção para aumento peniano tem se tornado mais popular. Aqui relatamos um caso de injeção de metacrilato no pênis que evoluiu com deformidade peniana e disfunção sexual. Este trabalho também revisa a investigação e gerenciamento desta afecção.RELATO DE CASOUm homem de 36 anos procurou atendimento médico com queixa de deformidade peniana e disfunção sexual após injeção de metacrilato. Remoção cirúrgica foi realizada como tratamento. Após dois meses, satisfatórios resultados cosmético e funcional foram alcançados.CONCLUSÃOTrabalhos científicos mais bem estruturados para avaliar as taxas de complicação e resultados de todos os procedimentos para aumento peniano são necessários.

CONTEXTPenis size is a great concern for men in many cultures. Despite the great variety of methods for penile augmentation, none has gained unanimous acceptance among experts in the field. However, in this era of minimally invasive procedure, injection therapy for penile augmentation has become more popular. Here we report a case of methacrylate injection in the penis that evolved with penile deformity and sexual dysfunction. This work also reviews the investigation and management of this pathological condition.CASE REPORTA 36-year-old male sought medical care with a complaint of penile deformity and sexual dysfunction after methacrylate injection. The treatment administered was surgical removal. Satisfactory cosmetic and functional results were reached after two months.CONCLUSIONSThere is a need for better structured scientific research to evaluate the outcomes and complication rates from all penile augmentation procedures.

Um homem de 36 anos, depois de ser submetido a exames para avaliação de infertilidade masculina, foi diagnosticado com infertilidade masculina primária, criptorquidia bilateral, azoospermia não obstrutiva e fusão esplenogonadal descontínua. Carcinoma in situ estava presente no testículo esquerdo, que tinha localização intra-abdominal e estava associado à fusão esplenogonadal. Esse é o quarto caso de fusão esplenogonadal associada a câncer testicular, segundo nossa avaliação. Deve-se sempre ter em mente a possibilidade dessa associação em testículos criptorquídicos à esquerda.

A 36 year-old man after tests for assessing male infertility was diagnosed with primary infertility, bilateral cryptorchidism, non-obstructive azoospermia and discontinuous splenogonadal fusion. Carcinoma in situ was found in his left testicle, which was intra-abdominal and associated with splenogonadal fusion. To our knowledge, this is the fourth case of splenogonadal fusion associated with testicular cancer reported. One should always bear in mind the possibility of this association for the left cryptorchid testicle.

Subcapsular and perinephric hematomas are relatively common after shock-wave lithotripsy, but high-grade kidney injuries are extremely rare. We present the first case of a high-grade kidney injury after shock-wave lithotripsy managed conservatively. A 57-year-old white female patient with left 1.5cm superior ureteral calculi was submitted to shock-wave lithotripsy.