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Objetivo: Analisar o perfil epidemiológico da população acometida por Acidente Vascular Encefálico (AVE) em Araçatuba - São Paulo (SP), estimar a importância dos indicadores de prevalência e incidência de AVE no município, correlacionando aos dados nacionais e estaduais e avaliar a mortalidade para AVE, segundo idade, sexo, escolaridade, cor/ raça e tempo de internação, além de correlacionar com os gastos anuais na terapêutica da doença. Métodos: Trata-se de um estudo epidemiológico descritivo, retrospectivo, e documental, com abordagem quantitativa dos casos registrados de AVE nos sistemas de internação hospitalares disponíveis no banco DATASUS, de pacientes do município de Araçatuba, localizado na região Noroeste do Estado de SP, entre 2008 a 2018. Resultados: Os resultados evidenciaram que o município de Araçatuba teve um decréscimo percentual de 10% (14 casos) no período avaliado, além disso 1.718 (74,17%) dos indivíduos acometidos por AVE eram da raça branca, 2.181 (94,17%) eram predominantemente da faixa etária acima dos 40 anos. Quanto aos atendimentos, 2.315 (99,95%) dos atendimentos por AVE são de caráter urgente, tempo médio de permanência teve um aumento de 2,4 (46,15%) dias de permanência e os custos de atendimentos no município representam 0,92% do gasto total do estado de SP. Conclusão: Nosso estudo observou que a incidência de AVE no município é influenciada por faixa etária acima dos 60 anos, baixo nível de escolaridade, raça branca e sexo masculino.

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Urinary fistula is a one of the most common complications after kidney transplantation. Conservative treatment with stent and Foley catheter drainage may be tried, however in some cases more invasive approach is needed. Caliceal fistula is a rare condition and the diagnosis may be missed. Here we present an interesting case of caliceal-cutaneous fistula diagnosed by computed tomography after living kidney transplantation. After failure of conservative management, the patient was successfully treated with partial nephrectomy.

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PURPOSE: The learning curve is a period in which the surgical procedure is performed with difficulty and slowness, leading to a higher risk of complications and reduced effectiveness due the surgeon's inexperience. We sought to analyze the residents' learning curve for open radical prostatectomy (RP) in a training program. MATERIALS AND METHODS: We conducted a prospective study from June 2006 to January 2008 in the academic environment of the University of Sao Paulo. Five residents operated on 184 patients during a four-month rotation in the urologic oncology division, mentored by the same physician assistants. We performed sequential analyses according to the number of surgeries, as follows: ≤ 10, 11 to 19, 20 to 28, and ≥ 29. RESULTS: The residents performed an average of 37 RP each. The average psa was 9.3 ng/mL and clinical stage T1c in 71% of the patients. The pathological stage was pT2 (73%), pT3 (23%), pT4 (4%), and 46% of the patients had a Gleason score 7 or higher. In all surgeries, the average operative time and estimated blood loss was 140 minutes and 488 mL. Overall, 7.2% of patients required blood transfusion, and 23% had positive surgical margins. CONCLUSION: During the initial RP learning curve, we found a significant reduction in the operative time; blood transfusion during the procedures and positive surgical margin rate were stable in our series.

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PURPOSE: The learning curve is a period in which the surgical procedure is performed with difficulty and slowness, leading to a higher risk of complications and reduced effectiveness due the surgeon's inexperience. We sought to analyze the residents' learning curve for open radical prostatectomy (RP) in a training program. MATERIALS AND METHODS: We conducted a prospective study from June 2006 to January 2008 in the academic environment of the University of São Paulo. Five residents operated on 184 patients during a four-month rotation in the urologic oncology division, mentored by the same physician assistants. We performed sequential analyses according to the number of surgeries, as follows: = 10, 11 to 19, 20 to 28, and = 29. RESULTS: The residents performed an average of 37 RP each. The average psa was 9.3 ng/mL and clinical stage T1c in 71 percent of the patients. The pathological stage was pT2 (73 percent), pT3 (23 percent), pT4 (4 percent), and 46 percent of the patients had a Gleason score 7 or higher. In all surgeries, the average operative time and estimated blood loss was 140 minutes and 488 mL. Overall, 7.2 percent of patients required blood transfusion, and 23 percent had positive surgical margins. CONCLUSION: During the initial RP learning curve, we found a significant reduction in the operative time; blood transfusion during the procedures and positive surgical margin rate were stable in our series.

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BACKGROUND: Sensitized patients (pts) may develop acute antibody-mediated rejection (AMR) due to preformed donor-specific antibodies, undetected by pre-transplant complement-dependent cytotoxicity (CDC) crossmatch (XM). We hypothesized that C4d staining in 1-h post-reperfusion biopsies (1-h Bx) could detect early complement activation in the renal allograft due to preformed donor-specific antibodies. METHODS: To test this hypothesis, renal transplants (n = 229) performed between June 2005 and December 2007 were entered into a prospective study of 1-h Bx and stained for C4d by immunofluorescence. Transplants were performed against a negative T-cell CDC-XM with the exception of three cases with a positive B-cell XM. RESULTS: All 229 1-h Bx stained negative for C4d. Fourteen pts (6%) developed AMR. None of the 14 protocol 1-h Bx stained positive for C4d in peritubular capillaries (PTC). However, all indication biopsies-that diagnosed AMR-performed at a median of 8 days after transplantation stained for C4d in PTC. CONCLUSIONS: These data show that C4d staining in 1-h Bx is, in general, not useful for the early detection of AMR when CDC-XM is negative.

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INTRODUCTION AND OBJECTIVES: Recurrent transplant pyelonephritis (RTP) secondary to vesico-ureteral reflux (VUR) to the transplant kidney (KTx) remains a significant cause of infectious complications with impact on patient and graft outcomes. Our objective was to verify the safety and efficacy of transurethral injection of Durasphere(®) to relieve RTP secondary to VUR after renal transplantation. PATIENTS AND METHODS: Between June 2004 and July 2008, eight patients with RTP (defined as two or more episodes of pyelonephritis after transplantation) and VUR to the KTx were treated with subureteral injections of Durasphere(®). The mean age at surgery was 38.8 ± 13.8 yr (23-65). The patients were followed regularly every six months. The mean interval between the KTx and the treatment was 76 ± 74.1 (10-238 months). The mean follow-up was 22.3 ± 16.1 months (8-57 months). RESULTS: Six patients (75%) were free of pyelonephritis during a mean period of follow-up of 23.2 ± 17.1 months (8-57 months). Two of them had no VUR and four cases presented with G II VUR (pre-operative G IV three cases and one case G III). In one case, symptomatic recurrent cystitis made a second treatment necessary. This patient remained free of infections for three yr after the first treatment and for 18 months after the second treatment. Of the remaining two patients, one had six episodes of RTP before treatment in a period of three yr and only two episodes after treatment in two yr of follow-up. The last case had a new episode of pyelonephritis five months after treatment. CONCLUSIONS: Transurethral injection therapy with Durasphere(®) is a safe and effective minimally invasive treatment option for KTx patients with recurrent RTP. A second treatment seems to be necessary in some cases.

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Objectives: The aim of this study was to compare the results of laparoscopic donor nephrectomy with open donor nephrectomy. Methods: A non-randomized prospective analysis was conducted of living donor kidney transplantations (118 open donor nephrectomies; 57 laparoscopic donor nephrectomies) between January 2005 and December 2007 in the Kidney Transplantation Unit of Hospital das Clínicas of Faculdade de Medicina of the Universidade de São Paulo. Results: Mean donor operative time, mean donor hospital stay, mean postoperative creatinine values, and rates of complications and graft survival were similar for both groups. A significant statistical difference in warm ischemia time was observed between the open donor nephrectomy and laparoscopic donor nephrectomy groups (p < 0.001). There was only one conversion in the laparoscopic donor nephrectomy group. Conclusions: Laparoscopic donor nephrectomy is a safe procedure for a donor nephrectomy, comparable to an open procedure with similar results despite a longer warm ischemia time.

Objetivos: O objetivo deste estudo foi comparar a nefrectomia radical laparoscópica e a nefrectomia subcostal do doador. Métodos: Foi realizado um estudo prospectivo e não randomizado dos pacientes submetidos entre Janeiro 2005 e Dezembro 2007 a nefrectomia para doação renal na Unidade de Transplante Renal do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (118 casos de nefrectomia subcostal do doador; 57 casos de nefrectomia radical laparoscópica). Resultados: Tempo cirúrgico, tempo de internação hospitalar do doador, creatinina sérica pós-transplante e taxas de complicação e da sobrevida do rim transplantado foram similares para ambos os grupos. Foi encontrada uma diferença estatisticamente significante no tempo de isquemia quente (p < 0,001). Houve somente uma conversão no grupo submetido a nefrectomia laparoscópica. Conclusões: A nefrectomia laparoscópica do doador é procedimento seguro para doação renal e com resultados similares à nefrectomia subcostal, apesar de maior tempo de isquemia quente.

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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.

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OBJECTIVES: The aim of this study was to compare the results of laparoscopic donor nephrectomy with open donor nephrectomy. METHODS: A non-randomized prospective analysis was conducted of living donor kidney transplantations (118 open donor nephrectomies; 57 laparoscopic donor nephrectomies) between January 2005 and December 2007 in the Kidney Transplantation Unit of Hospital das Clínicas of Faculdade de Medicina of the Universidade de São Paulo. RESULTS: Mean donor operative time, mean donor hospital stay, mean postoperative creatinine values, and rates of complications and graft survival were similar for both groups. A significant statistical difference in warm ischemia time was observed between the open donor nephrectomy and laparoscopic donor nephrectomy groups (p < 0.001). There was only one conversion in the laparoscopic donor nephrectomy group. CONCLUSIONS: Laparoscopic donor nephrectomy is a safe procedure for a donor nephrectomy, comparable to an open procedure with similar results despite a longer warm ischemia time.

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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 percent), proteinuria occurred in one patient (0.85 percent), and a transitory increase of creatinine levels occurred in two patients (1.7 percent). 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.

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Introdução: A curva de aprendizado em cirurgia é um período de sedimentação de habilidades onde procedimentos são realizados com maior dificuldade e lentidão, maior risco de complicações intra-operatórias e menor eficácia clínico-funcional devido à inexperiência do cirurgião. Nós analisamos a curva de aprendizado inicial da prostatectomia radical retropúbica realizada por médicos residentes do Setor de Uro-Oncologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Método: estudo prospectivo, envolvendo 184 prostatectomias radicais retropúbicas, realizadas por cinco residentes consecutivamente, entre 02/06/2006 e 31/01/2008. Foram considerados: o tempo operatório, sangramento transoperatório, necessidade de transfusão sanguínea, taxa de margens cirúrgicas comprometidas, complicações intra-operatórias e avaliação funcional precoce. Resultados: cada residente realizou em média 37 cirurgias. O PSA mediano foi de 9,3 ng/mL e o estágio clínico T1c em 71% dos pacientes. O estágio patológico foi pT2 (73%), pT3 (23%), pT4 (4%); o escore de Gleason na peça cirúrgica foi de 54% (Gleason <7), 33% (Gleason 7) e 13% (Gleason >7). O tempo cirúrgico mediano foi de 140 minutos, o sangramento mediano de 488 mL e a necessidade de transfusão sanguínea de 7,2%. A taxa de margens cirúrgicas positivas de 23% foi constante nos 30 primeiros casos. A avaliação funcional precoce (até 6 meses de pós-operatório) mostrou 89% de continência, 57% de disfunção erétil e 7% de recidiva bioquímica. Conclusão: Durante a curva de aprendizado da prostatectomia radical, ocorre redução significativa do tempo operatório após 20 cirurgias e tendência de redução do sangramento e da necessidade de transfusão sanguínea após 29 cirurgias. As margens cirúrgicas permanecem estáveis em 23%.

Introduction: The learning curve is a period of skills improvement. Procedures are carried through with longer operating time, high risk of surgical complications and sub optimal functional outcomes. We have analyzed the residents' initial learning curve in open radical prostatectomy in our institution. Method: Between June of 2006 and January of 2008, 184 open radical prostatectomies have been performed in our service by five senior residents in Urology. We prospectively evaluated: operating time, blood loss, blood transfusion rate, positive surgical margins, intra-operative complications and early functional outcomes. Results: an average of 37 open radical prostatectomies was performed by each resident. Medium PSA was 9,3ng/mL; clinical stage T1c in 71% of the patients. The pathological stage was pT2 (73%), pT3 (23%), pT4 (4%) and Gleason score was 54% (Gleason <7), 33% (Gleason 7) and 13% (Gleason >7). The medium operating time was 140 minutes, medium blood loss of 488 mL and positive margins were found in 23% during the first 30 cases. Early functional outcomes (less than 6 months after surgery) revealed 89% of urinary continence, 43% of normal erectile function and 7% of biochemical recurrence. Conclusion: During the initial learning curve significant reduction in operating time occurs after first 20 procedures, blood loss and transfusion improves after 29 prostatectomies and positive margins remain stable during the first 30 patients (23%).

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Não é infreqüente ouvir que, em transplante renal, inovações de impacto no âmbito cirúrgico já não são mais prováveis. No entanto, soluções de alto impacto econômico ainda surgem com freqüência e muitas delas têm surgido no Brasil, contribuindo significativamente para a mudança de conduta cirúrgica em transplante renal a nível mundial. A técnica cirúrgica do transplante renal propriamente dita está bem estabelecida há anos, sendo muito parecida entre os diversos serviços de transplante. Já no que se refere ao tratamento cirúrgico das complicações do transplante e dos pacientes com doenças associadas à insuficiência renal crônica dialítica (IRCD), observamos considerável controvérsia e variação nas condutas. Este estudo pretende oferecer um panorama sobre as técnicas cirúrgicas utilizadas no transplante renal, as complicações decorrentes deste procedimento e os resultados obtidos pelo Serviço de Transplante Renal do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo...

Is not rare to hear that, on kidney transplantation, improvements on surgical aspects are not probable anymore. Although, solutions with high economical impact arises frequently and, many of them, in Brazil, contributing, significantly, for changes on surgical conduct on kidney transplantation worldwide. The surgical techniques for kidney transplantation are well established and do not change between the groups of transplants. Although, the surgical treatment of complicated outcomes and of patients with diseases related to chronic renal failure is still controversial. This study aims to offer a general overview about the surgical techniques of kidney transplantation, complications inherent to this procedure and the results obtained by the Kidney Transplantation Team of Clinic Hospital of São Paulo University Medical School.

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INTRODUCTION: Treatment of the cryptorchid testicle is justified due to the increased risk of infertility and malignancy as well as the risk of testicular trauma and psychological stigma on patients and their parents. Approximately 20% of cryptorchid testicles are nonpalpable. In these cases, the videolaparoscopic technique is a useful alternative method for diagnosis and treatment. MATERIALS AND METHODS: We present data concerning 90 patients submitted to diagnostic laparoscopy for impalpable testicles. Forty-six patients (51.1%) had intra-abdominal gonads. In 25 testicles of 19 patients, we performed a two stage laparoscopic Fowler-Stephens orchiopexy. The other 27 patients underwent primary laparoscopic orchiopexy, in a total of 29 testicles. RESULTS: We obtained an overall 88% success rate with the 2 stage Fowler-Stephens approach and only 33% rate success using one stage Fowler-Stephens surgery with primary vascular ligature. There was no intraoperative complication in our group of patients. In the laparoscopic procedures, the cosmetic aspect is remarkably more favorable as compared to open surgeries. Hospital stay and convalescence were brief. CONCLUSIONS: In pediatric age group, the laparoscopic approach is safe and feasible. Furthermore, the laparoscopic orchiopexy presents excellent results in terms of diagnosis and therapy of the impalpable testis, which is why this technique has been routinely incorporated in our Department.

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INTRODUCTION: Treatment of the cryptorchid testicle is justified due to the increased risk of infertility and malignancy as well as the risk of testicular trauma and psychological stigma on patients and their parents. Approximately 20 percent of cryptorchid testicles are nonpalpable. In these cases, the videolaparoscopic technique is a useful alternative method for diagnosis and treatment. MATERIALS AND METHODS: We present data concerning 90 patients submitted to diagnostic laparoscopy for impalpable testicles. Forty-six patients (51.1 percent) had intra-abdominal gonads. In 25 testicles of 19 patients, we performed a two stage laparoscopic Fowler-Stephens orchiopexy. The other 27 patients underwent primary laparoscopic orchiopexy, in a total of 29 testicles. RESULTS: We obtained an overall 88 percent success rate with the 2 stage Fowler-Stephens approach and only 33 percent rate success using one stage Fowler-Stephens surgery with primary vascular ligature. There was no intraoperative complication in our group of patients. In the laparoscopic procedures, the cosmetic aspect is remarkably more favorable as compared to open surgeries. Hospital stay and convalescence were brief. CONCLUSIONS: In pediatric age group, the laparoscopic approach is safe and feasible. Furthermore, the laparoscopic orchiopexy presents excellent results in terms of diagnosis and therapy of the impalpable testis, which is why this technique has been routinely incorporated in our Department.

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