RESUMO
INTRODUCTION: Upper tract urothelial carcinoma (UTUC) accounts for 5-10% of all urothelial tumors (1). Radical nephroureterectomy (RNU) remains the standard treatment for high, and low-grade UTUC (2). Although the open approach has been considered the gold standard, robotic techniques have shown comparable oncological outcomes with potential advantages in terms of peri-operative morbidity (3). MATERIALS AND METHODS: We present a novel "Keyhole" technique for management of distal ureter and bladder cuff during robotic RNU. This technique allows the surgeon to directly visualize the ureteric orifices, delineate resection borders, and maintain oncologic principles of en-bloc excision without necessitating secondary cystotomy incision or concomitant endoscopic procedure. Descriptive demographic characteristics, surgical, pathological, and oncological outcomes were analyzed. Complications were reported using the Clavien-Dindo classification system. RESULTS: Between 2015 and 2020, ten patients underwent robotic RNU with bladder cuff excision using the Keyhole technique (single-dock, single-position). Median age was 75 years. Eight patients underwent surgery for right-sided tumors. Median operative time, estimated blood loss, and length of hospital stay were 287 min, 100 mL, and 3 days, respectively. No intraoperative complications occurred, and one grade II complication occurred during the 90-day postoperative period. All patients had high-grade UTUC, being 90% pure urothelial. Bladder recurrences occurred in 30% of patients with an overall median follow-up of 11.2 months. CONCLUSIONS: Keyhole technique for the management of distal ureter and bladder cuff during RNU represents a feasible approach with minimal 90-day complications and low bladder recurrence rate at centers of experience.
Assuntos
Carcinoma de Células de Transição , Procedimentos Cirúrgicos Robóticos , Ureter , Neoplasias Ureterais , Neoplasias da Bexiga Urinária , Idoso , Carcinoma de Células de Transição/patologia , Carcinoma de Células de Transição/cirurgia , Humanos , Nefrectomia/métodos , Nefroureterectomia/métodos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodos , Ureter/patologia , Ureter/cirurgia , Neoplasias Ureterais/patologia , Neoplasias Ureterais/cirurgia , Bexiga Urinária/patologia , Bexiga Urinária/cirurgia , Neoplasias da Bexiga Urinária/cirurgiaRESUMO
Chronic constipation is a common diagnosis with a high prevalence in the elderly. Constipation affects the quality of life of sick individuals, bringing several clinical complications.
Assuntos
Constipação Intestinal/complicações , Insuficiência Renal/etiologia , Idoso de 80 Anos ou mais , Doença Crônica , Constipação Intestinal/induzido quimicamente , Constipação Intestinal/diagnóstico por imagem , Feminino , Humanos , Laxantes/efeitos adversos , Insuficiência Renal/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Ureter/diagnóstico por imagem , Ureter/patologiaRESUMO
OBJECTIVES: We examined the effects of tadalafil, one of the phosphodiesterase type 5 (PDE5) inhibitors, in a rat model of with partial and complete unilateral ureteral obstruction (UUO). METHODS: The rats were divided into 5 groups: sham (n=6), partial unilateral ureteral obstruction (PUUO, n=6), PUUO with tadalafil treatment (PUUO+T; Cialis, 10 mg/72 h, intragastric; Lilly, Indianapolis, Indiana, USA), complete unilateral ureteral obstruction (CUUO, n=6), and CUUO with tadalafil treatment (CUUO+T). RESULTS: Fifteen days after the UUO, the ureter presented changes in the layers of urothelium and significant infiltration of inflammatory cells in the PUUO and CUUO groups. Compared with the sham, PUUO and CUUO groups had severe increased inflammatory cell infiltration. The urothelial epithelium exhibited cell degeneration and loss because of the swollen, atrophic, and denuded epithelial cells in the PUUO and CUUO groups. In the PUUO+T and CUUO+T groups, the urothelium revealed less epithelial cell degeneration and loss.The expressions of α-smooth muscle actin (α-SMA) and transforming growth factor-ß (TGF-ß) exhibited up-regulation in the PUUO and CUUO groups. The expression of TGF-ß decreased positively correlated with that of α-SMA in the tadalafil therapy groups, PUUO+T and CUUO+T. CONCLUSION: The phosphodiesterase type 5 inhibitor's tadalafil reduced expressions of α-SMA and TGF-ß in the obstructed ureters, measured by biochemical examinations. In addition, tadalafil decreased urothelium degeneration due to the decreased epithelial cell loss and inflammatory cell infiltration. Our results show that tadalafil prevents or slows down the onset of ureter inflammation and urothelial degeneration in rats with UUO.
Assuntos
Inibidores da Fosfodiesterase 5/farmacologia , Tadalafila/farmacologia , Obstrução Ureteral/tratamento farmacológico , Obstrução Ureteral/patologia , Actinas/análise , Animais , Ensaio de Imunoadsorção Enzimática , Inflamação/patologia , Inflamação/prevenção & controle , Masculino , Ratos Sprague-Dawley , Valores de Referência , Reprodutibilidade dos Testes , Fator de Crescimento Transformador beta/análise , Regulação para Cima , Ureter/efeitos dos fármacos , Ureter/patologiaRESUMO
SUMMARY OBJECTIVES: We examined the effects of tadalafil, one of the phosphodiesterase type 5 (PDE5) inhibitors, in a rat model of with partial and complete unilateral ureteral obstruction (UUO). METHODS: The rats were divided into 5 groups: sham (n=6), partial unilateral ureteral obstruction (PUUO, n=6), PUUO with tadalafil treatment (PUUO+T; Cialis, 10 mg/72 h, intragastric; Lilly, Indianapolis, Indiana, USA), complete unilateral ureteral obstruction (CUUO, n=6), and CUUO with tadalafil treatment (CUUO+T). RESULTS: Fifteen days after the UUO, the ureter presented changes in the layers of urothelium and significant infiltration of inflammatory cells in the PUUO and CUUO groups. Compared with the sham, PUUO and CUUO groups had severe increased inflammatory cell infiltration. The urothelial epithelium exhibited cell degeneration and loss because of the swollen, atrophic, and denuded epithelial cells in the PUUO and CUUO groups. In the PUUO+T and CUUO+T groups, the urothelium revealed less epithelial cell degeneration and loss. The expressions of α-smooth muscle actin (α-SMA) and transforming growth factor-β (TGF-β) exhibited up-regulation in the PUUO and CUUO groups. The expression of TGF-β decreased positively correlated with that of α-SMA in the tadalafil therapy groups, PUUO+T and CUUO+T. CONCLUSION: The phosphodiesterase type 5 inhibitor's tadalafil reduced expressions of α-SMA and TGF-β in the obstructed ureters, measured by biochemical examinations. In addition, tadalafil decreased urothelium degeneration due to the decreased epithelial cell loss and inflammatory cell infiltration. Our results show that tadalafil prevents or slows down the onset of ureter inflammation and urothelial degeneration in rats with UUO.
RESUMO OBJETIVOS: Examinamos os efeitos do tadalafil em um dos inibidores da fosfodiesterase tipo 5 (PDE5) em um modelo de rato com obstrução ureteral unilateral parcial e completa (UUO). MÉTODOS: Os ratos foram divididos em cinco grupos: sham (n = 6), obstrução ureteral unilateral parcial (PUUO, n = 6), PUUO com tadalafil (PUUO T; Cialis, 10 mg/72 h, intragástrica; Lilly, Indianapolis, Indiana, EUA), completa obstrução ureteral unilateral (CUUO, n = 6) e CUUO com tratamento com tadalafil (CUUO T). RESULTADOS: Quinze dias após a UUO, o ureter apresentou alterações nas camadas de urotélio e infiltração significativa de células inflamatórias nos grupos PUUO e CUUO. Em comparação com os grupos sham, PUUO e CUUO, houve um aumento grave da infiltração de células inflamatórias. O epitélio urotelial exibiu degeneração e perda celular devido às células epiteliais inchadas, atróficas e desnudas nos grupos PUUO e CUUO. Nos grupos PUUO T e CUUO T, o urotélio revelou menor degeneração e perda de células epiteliais. Nós mostramos que a expressão da actina do músculo liso-α (α-SMA) e do fator de crescimento transformador-β (TGF-β) foram exibidas como sub-regulação nos grupos PUUO e CUUO. A expressão do TGF-β foi diminuída positivamente correlacionada com a da α-SMA nos grupos de terapia com tadalafil, PUUO T e CUUO T. CONCLUSÃO: O tadalafil do inibidor da fosfodiesterase tipo 5 reduziu as expressões α-SMA e TGF-β nos ureteres obstruídos, medidos por exames bioquímicos. Além disso, o tadalafil diminuiu a degeneração do urotélio devido à diminuição da perda de células epiteliais e da infiltração de células inflamatórias. Nossos resultados mostram que o tadalafil previne ou retarda o início da inflamação do ureter e degeneração urotelial em ratos com UUO.
Assuntos
Animais , Masculino , Obstrução Ureteral/patologia , Obstrução Ureteral/tratamento farmacológico , Inibidores da Fosfodiesterase 5/farmacologia , Tadalafila/farmacologia , Valores de Referência , Ureter/efeitos dos fármacos , Ureter/patologia , Ensaio de Imunoadsorção Enzimática , Regulação para Cima , Reprodutibilidade dos Testes , Fator de Crescimento Transformador beta/análise , Actinas/análise , Ratos Sprague-Dawley , Inflamação/patologia , Inflamação/prevenção & controleRESUMO
SUMMARY Chronic constipation is a common diagnosis with a high prevalence in the elderly. Constipation affects the quality of life of sick individuals, bringing several clinical complications.
RESUMO A obstipação crônica é um diagnóstico com alta prevalência comum em idosos. A constipação afeta a qualidade de vida das pessoas doentes, carregando muitas complicações clínicas.
Assuntos
Humanos , Feminino , Idoso de 80 Anos ou mais , Constipação Intestinal/complicações , Insuficiência Renal/etiologia , Ureter/patologia , Ureter/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Doença Crônica , Constipação Intestinal/induzido quimicamente , Constipação Intestinal/diagnóstico por imagem , Insuficiência Renal/diagnóstico por imagem , Laxantes/efeitos adversosRESUMO
PURPOSE: To evaluate the clinical stenosis or precursor histological changes that ureteral access sheaths commonly used in ureteroscopic surgeries may cause in the long term in ureter. METHODS: In this study, the animals were divided into 9 groups and according to their groups, ureters of the rabbits were endoscopically fitted with 2F and 3F ureter catheters. The catheters were left in place and withdrawn after a specified period of time. All the ureters were excised and evaluated macroscopically, microscopically and histologically. Ureter diameters were measured and FGF-2 (+) labeled fibroblasts were counted in connective tissue as stenosis precursors. RESULTS: Macroscopically or microscopically, no stenosis was found in any group. The ureter diameter of the group that were catheterized for the longest time with the catheter that had the widest diameter was significantly lower than the group with the shorter duration and the catheter with the narrower diameter and the control group. When the groups were compared in terms of their FGF values, there was a significant difference in FGF-2 counts at all three ureter levels (p <0.05). CONCLUSION: The use of ureteral access sheath may lead to histological changes, as its diameter and duration increase.
Assuntos
Ureter/cirurgia , Ureteroscopia/instrumentação , Cateterismo Urinário/instrumentação , Doenças Urológicas/cirurgia , Animais , Modelos Animais de Doenças , Masculino , Coelhos , Estatísticas não Paramétricas , Ureter/patologiaRESUMO
Abstract Purpose: To evaluate the clinical stenosis or precursor histological changes that ureteral access sheaths commonly used in ureteroscopic surgeries may cause in the long term in ureter. Methods: In this study, the animals were divided into 9 groups and according to their groups, ureters of the rabbits were endoscopically fitted with 2F and 3F ureter catheters. The catheters were left in place and withdrawn after a specified period of time. All the ureters were excised and evaluated macroscopically, microscopically and histologically. Ureter diameters were measured and FGF-2 (+) labeled fibroblasts were counted in connective tissue as stenosis precursors. Results: Macroscopically or microscopically, no stenosis was found in any group. The ureter diameter of the group that were catheterized for the longest time with the catheter that had the widest diameter was significantly lower than the group with the shorter duration and the catheter with the narrower diameter and the control group. When the groups were compared in terms of their FGF values, there was a significant difference in FGF-2 counts at all three ureter levels (p <0.05). Conclusion: The use of ureteral access sheath may lead to histological changes, as its diameter and duration increase.
Assuntos
Animais , Masculino , Ratos , Ureter/cirurgia , Doenças Urológicas/cirurgia , Cateterismo Urinário/instrumentação , Ureteroscopia/instrumentação , Ureter/patologia , Estatísticas não Paramétricas , Modelos Animais de DoençasRESUMO
ABSTRACT Purpose: Bladder cancer (BC) may involve the ureteral orifice, and the resection of the orifice has oncological and functional consequences such as development of upper tract urothelial carcinoma (UTUC), vesicoureteral reflux or ureteral stenosis. The aim of this study was to investigate the oncological and functional outcomes of the ureteral orifice resection in BC patients and determine the predictive factors for UTUC development. Materials and Methods: A total of 1359 patients diagnosed with BC, between 1992 and 2012, were reviewed retrospectively. Patients were grouped with respect to orifice resection and compared for development of UTUC, survival and functional outcomes. Kaplan-Meier method was used to compare survival outcomes. Logistic regression analysis was performed to determine predictors of UTUC development. Results: Ureteral orifice involvement was detected in 138 (10.2%) patients. The rate of synchronous (10.1% vs. 0.7%, p=0.0001) and metachronous (5.3% vs. 0.9%, p=0.0001) UTUC development was found to be higher in patients with ureteral orifice involvement. Orifice involvement and tumor stage were found to be associated with development of UTUC in the regression analysis. Overall (p=0.963) and cancer specific survival rates (p=0.629) were found to be similar. Hydronephrosis was also significantly higher in patients with orifice involved BC, due to the orifice obstruction caused by the tumor (33.3% vs. 13.9%, p<0.05). Conclusions: BC with ureteral orifice involvement has significantly increased the risk of having synchronous or metachronous UTUC. However, orifice involvement was not found to be associated with survival outcomes. Development of stricture due to resection is a very rare complication.
Assuntos
Humanos , Masculino , Feminino , Idoso , Ureter/patologia , Neoplasias da Bexiga Urinária/patologia , Estudos Retrospectivos , Resultado do Tratamento , Estimativa de Kaplan-Meier , Pessoa de Meia-Idade , Invasividade Neoplásica , Estadiamento de NeoplasiasRESUMO
PURPOSE: Bladder cancer (BC) may involve the ureteral orifice, and the resection of the orifice has oncological and functional consequences such as development of upper tract urothelial carcinoma (UTUC), vesicoureteral reflux or ureteral stenosis. The aim of this study was to investigate the oncological and functional outcomes of the ureteral orifice resection in BC patients and determine the predictive factors for UTUC development. MATERIALS AND METHODS: A total of 1359 patients diagnosed with BC, between 1992 and 2012, were reviewed retrospectively. Patients were grouped with respect to orifice resection and compared for development of UTUC, survival and functional outcomes. Kaplan-Meier method was used to compare survival outcomes. Logistic regression analysis was performed to determine predictors of UTUC development. RESULTS: Ureteral orifice involvement was detected in 138 (10.2%) patients. The rate of synchronous (10.1% vs. 0.7%, p=0.0001) and metachronous (5.3% vs. 0.9%, p=0.0001) UTUC development was found to be higher in patients with ureteral orifice involvement. Orifice involvement and tumor stage were found to be associated with development of UTUC in the regression analysis. Overall (p=0.963) and cancer specific survival rates (p=0.629) were found to be similar. Hydronephrosis was also significantly higher in patients with orifice involved BC, due to the orifice obstruction caused by the tumor (33.3% vs. 13.9%, p<0.05). CONCLUSIONS: BC with ureteral orifice involvement has significantly increased the risk of having synchronous or metachronous UTUC. However, orifice involvement was not found to be associated with survival outcomes. Development of stricture due to resection is a very rare complication.
Assuntos
Ureter/patologia , Neoplasias da Bexiga Urinária/patologia , Idoso , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Estadiamento de Neoplasias , Estudos Retrospectivos , Resultado do TratamentoRESUMO
ABSTRACT Purpose: To determine the effect of diagnostic ureteroscopy on intravesical recurrence in patients with upper tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU). Materials and Methods: We conducted a retrospective analysis of 664 patients who were treated with RNU for UTUC from June 2000 to December 2011, excluding those who had concomitant/prior bladder tumors. Of the 664 patients, 81 underwent diagnostic ureteroscopy (URS). We analyzed the impact of diagnostic ureteroscopy on intravesical recurrence (IVR) using the Kaplan-Meier method. Univariate and multivariate analyses were used to determine the independent risk factors. Results: The median follow-up time was 48 months (interquartile range (IQR): 31-77 months). Patients who underwent ureteroscopy were more likely to have a small (p<0.01), early-staged (p=0.019), multifocality (p=0.035) and ureteral tumor (p<0.001). IVR occurred in 223 patients during follow-up within a median of 17 months (IQR: 7-33). Patients without preoperative ureteroscopy have a statistically significant better 2-year (79.3%±0.02 versus 71.4%±0.02, p<0.001) and 5-year intravesical recurrence-free survival rates (64.9%±0.05 versus 44.3%±0.06, p<0.001) than patients who underwent ureteroscopy. In multivariate analysis, the diagnostic ureteroscopy (p=0.006), multiple tumors (p=0.001), tumor size <3cm (p=0.008), low-grade (p=0.022) and pN0 stage tumor (p=0.045) were independent predictors of IVR. Conclusions: Diagnostic ureteroscopy is independently associated with intravesical recurrence after radical nephroureterectomy.