Retroperitoneoscopic adrenalectomy in pheochromocytoma

Since the first laparoscopic adrenalectomy, the technique has evolved and it has become the standard of care for many adrenal diseases, including pheochromocytoma. Two laparoscopic accesses to the adrenal have been developed: transperitoneal and retroperitoneal. Retroperitoneoscopic adrenalectomy may be recommended for the treatment of pheochromocytoma with the same peri-operative outcomes of the transperitoneal approach because it allows direct access to the adrenal glands without increasing the operative risks. Although technically more demanding than the transperitoneal approach, retroperitoneoscopy can shorten the mean operative time, which is critical for cases with pheochromocytoma where minimizing the potential for intra-operative hemodynamic changes is essential. Blood loss and the convalescence time can be also shortened by this approach. There is no absolute indication for either the transperitoneal or retroperitoneal approach; however, the latter procedure may be the best option for patients who have undergone previous abdominal surgery and obese patients. Also, retroperitoneoscopic adrenalectomy is a good alternative for treating cases with inherited pheochromocytomas, such as multiple endocrine neoplasia type 2A, in which the pheochromocytoma is highly prevalent and frequently occurs bilaterally

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear understanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5,6,7 vast areas of the tropics remain understudied.8,9,10,11 In the American tropics, Amazonia stands out as the world's most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepresented in biodiversity databases.13,14,15 To worsen this situation, human-induced modifications16,17 may eliminate pieces of the Amazon's biodiversity puzzle before we can use them to understand how ecological communities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple organism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region's vulnerability to environmental change. 15%–18% of the most neglected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lost

Effect of tamsulosin and nifedipine on the clearance of fragments after extracorporeal shock waves lithotripsy in patients with kidney stones - a prospective, double-blind and randomized study

Introdução: A litotripsia extracorpórea por ondas de choque (LEOC) é o tratamento mais utilizado para cálculos renais de até 20 mm. O uso adjuvante de algumas drogas pode aumentar as taxas de sucesso do procedimento e diminuir a sua morbidade. Objetivos: Avaliar os efeitos da tansulosina e do nifedipino nas taxas de sucesso, nos episódios de dor e na velocidade de eliminação dos fragmentos após o tratamento de cálculos renais de 5 a 20 mm com uma única sessão de LEOC. Casuística e Métodos: Foram estudados prospectivamente 136 indivíduos portadores de cálculos renais entre 5 e 20 mm, submetidos à LEOC entre 2006 e 2009. Os pacientes foram divididos aleatoriamente em 3 grupos para receber diariamente tansulosina 0,4 mg, nifedipino retard 20mg ou placebo por até 30 dias da realização de LEOC. A analgesia foi feita com celecoxibe 200 mg. Os pacientes foram avaliados semanalmente por meio de radiografia de abdome. Foi definido como sucesso do tratamento a ausência de fragmentos maiores que 4 mm ao final de 30 dias. Os parâmetros avaliados foram: taxa de sucesso do tratamento, ocorrência de rua de cálculos, necessidade de analgésicos, intensidade de dor após a LEOC, tempo de eliminação de fragmentos, efeitos adversos da medicação e visitas ao Pronto Socorro. Resultados: Cento e onze pacientes completaram o estudo. Não houve diferenças demográficas entre os pacientes e nem em relação ao tamanho dos cálculos entre os grupos. As taxas de sucesso foram de 60,5% (23 de 38) no Grupo Tansulosina, 48,6% (17 de 35) no Grupo Nifedipino e 36,8% (14 de 38) no Grupo Placebo. (p=0,118) Entre os pacientes com cálculos de 10 a 20 mm, a taxa de sucesso foi significativamente maior nos Grupos Tansulosina (61,9%) e Nifedipino (60,0%) do que no Grupo Placebo (26,1%) (p=0,024), porém não foi significativa entre os cálculos de 5 a 9 mm (p=0,128). O Número Necessário para Tratar (NNT) da Tansulosina foi de 2,9 e o do Nifedipino foi de 3, considerando-se o uso para cálculos de 10 a 20 mm. Os pacientes que usaram nifedipino tiveram mais efeitos adversos do que os do Grupo Placebo (28,5 % x 2,6% respectivamente, p = 0,009), porém sem levar à interrupção do uso da drogas. Não houve diferença significativa entre os grupos Tansulosina x Nifedipino e Tansulosina x Placebo em relação aos efeitos adversos (p= 0,15 e p = 0,054, respectivamente). Não houve diferença entre os grupos com relação à intensidade da dor observada após o tratamento (p=0,28), ao número de comprimidos de Celecoxibe (p=0,39), ao tempo de eliminação dos fragmentos (p=0,6), à ocorrência de rua de cálculos (p=0,482) e ao número de vistas ao Pronto Socorro (p=0,175). Conclusões: O uso adjuvante de tansulosina ou de nifedipino após LEOC aumenta a taxa de sucesso para cálculos renais entre 10 e 20 mm, porém sem diminuir a intensidade da dor ou a necessidade de analgésicos após o tratamento, nem o tempo de eliminação dos fragmentosPurpose: We evaluated the effects of the adjuvant use of tamsulosin and nifedipine after extracorporeal shock wave lithotripsy (SWL) for 5-20 mm kidney stones. Materials and Methods: We conducted a randomized double-blind trial involving 136 patients with radiopaque kidney stones between 2006 and 2009. Patients were divided into three groups to receive daily treatments of 0.4 mg tamsulosin, 20 mg nifedipine retard or placebo for up to 30 days after one session of SWL. The parameters assessed were success rate, analgesic requirements, pain intensity, time to clearance, adverse effects and occurrence of Steinstrasse. Results: The success rate was 60.5% (23 of 38) in the Tamsulosin group, 48.6% (17 of 35) in the Nifedipine group and 36.8% (14 of 38) in the Placebo group (p=0.118). For stones ranging from 10 to 20 mm, the success rates were significantly higher in the Tamsulosin (61.9%) and Nifedipine groups (60.0%) when compared with the Placebo group (26.1%) (p=0.024), but not for the 5-9 mm stones (p=0.128). The Number Needed to Treat was 2.9 for tamsulosin and 3 for nifedipine. Adverse events were more frequent in the Nifedipine than the Placebo Group (28.5% vs. 2.6%, respectively, p=0.009). There was no difference among groups with regard to stone and demographic characteristics, pain intensity, time to clearance and Steinstrasse. Conclusions: Adjuvant use of tamsulosin or nifedipine after SWL significantly increased the success rates for 10 to 20 mm renal stones and could be recommended. Both drugs had similar beneficial effects and adverse event

Effect of tamsulosin and nifedipine on the clearance of fragments after extracorporeal shock waves lithotripsy in patients with kidney stones - a prospective, double-blind and randomized study

Introdução: A litotripsia extracorpórea por ondas de choque (LEOC) é o tratamento mais utilizado para cálculos renais de até 20 mm. O uso adjuvante de algumas drogas pode aumentar as taxas de sucesso do procedimento e diminuir a sua morbidade. Objetivos: Avaliar os efeitos da tansulosina e do nifedipino nas taxas de sucesso, nos episódios de dor e na velocidade de eliminação dos fragmentos após o tratamento de cálculos renais de 5 a 20 mm com uma única sessão de LEOC. Casuística e Métodos: Foram estudados prospectivamente 136 indivíduos portadores de cálculos renais entre 5 e 20 mm, submetidos à LEOC entre 2006 e 2009. Os pacientes foram divididos aleatoriamente em 3 grupos para receber diariamente tansulosina 0,4 mg, nifedipino retard 20mg ou placebo por até 30 dias da realização de LEOC. A analgesia foi feita com celecoxibe 200 mg. Os pacientes foram avaliados semanalmente por meio de radiografia de abdome. Foi definido como sucesso do tratamento a ausência de fragmentos maiores que 4 mm ao final de 30 dias. Os parâmetros avaliados foram: taxa de sucesso do tratamento, ocorrência de rua de cálculos, necessidade de analgésicos, intensidade de dor após a LEOC, tempo de eliminação de fragmentos, efeitos adversos da medicação e visitas ao Pronto Socorro. Resultados: Cento e onze pacientes completaram o estudo. Não houve diferenças demográficas entre os pacientes e nem em relação ao tamanho dos cálculos entre os grupos. As taxas de sucesso foram de 60,5% (23 de 38) no Grupo Tansulosina, 48,6% (17 de 35) no Grupo Nifedipino e 36,8% (14 de 38) no Grupo Placebo. (p=0,118) Entre os pacientes com cálculos de 10 a 20 mm, a taxa de sucesso foi significativamente maior nos Grupos Tansulosina (61,9%) e Nifedipino (60,0%) do que no Grupo Placebo (26,1%) (p=0,024), porém não foi significativa entre os cálculos de 5 a 9 mm (p=0,128). O Número Necessário para Tratar (NNT) da Tansulosina foi de 2,9 e o do Nifedipino foi de 3, considerando-se o uso para cálculos de 10 a 20 mm. Os pacientes que usaram nifedipino tiveram mais efeitos adversos do que os do Grupo Placebo (28,5 % x 2,6% respectivamente, p = 0,009), porém sem levar à interrupção do uso da drogas. Não houve diferença significativa entre os grupos Tansulosina x Nifedipino e Tansulosina x Placebo em relação aos efeitos adversos (p= 0,15 e p = 0,054, respectivamente). Não houve diferença entre os grupos com relação à intensidade da dor observada após o tratamento (p=0,28), ao número de comprimidos de Celecoxibe (p=0,39), ao tempo de eliminação dos fragmentos (p=0,6), à ocorrência de rua de cálculos (p=0,482) e ao número de vistas ao Pronto Socorro (p=0,175). Conclusões: O uso adjuvante de tansulosina ou de nifedipino após LEOC aumenta a taxa de sucesso para cálculos renais entre 10 e 20 mm, porém sem diminuir a intensidade da dor ou a necessidade de analgésicos após o tratamento, nem o tempo de eliminação dos fragmentosPurpose: We evaluated the effects of the adjuvant use of tamsulosin and nifedipine after extracorporeal shock wave lithotripsy (SWL) for 5-20 mm kidney stones. Materials and Methods: We conducted a randomized double-blind trial involving 136 patients with radiopaque kidney stones between 2006 and 2009. Patients were divided into three groups to receive daily treatments of 0.4 mg tamsulosin, 20 mg nifedipine retard or placebo for up to 30 days after one session of SWL. The parameters assessed were success rate, analgesic requirements, pain intensity, time to clearance, adverse effects and occurrence of Steinstrasse. Results: The success rate was 60.5% (23 of 38) in the Tamsulosin group, 48.6% (17 of 35) in the Nifedipine group and 36.8% (14 of 38) in the Placebo group (p=0.118). For stones ranging from 10 to 20 mm, the success rates were significantly higher in the Tamsulosin (61.9%) and Nifedipine groups (60.0%) when compared with the Placebo group (26.1%) (p=0.024), but not for the 5-9 mm stones (p=0.128). The Number Needed to Treat was 2.9 for tamsulosin and 3 for nifedipine. Adverse events were more frequent in the Nifedipine than the Placebo Group (28.5% vs. 2.6%, respectively, p=0.009). There was no difference among groups with regard to stone and demographic characteristics, pain intensity, time to clearance and Steinstrasse. Conclusions: Adjuvant use of tamsulosin or nifedipine after SWL significantly increased the success rates for 10 to 20 mm renal stones and could be recommended. Both drugs had similar beneficial effects and adverse event

The skin-to-calyx distance measured by renal ct scan and ultrasound

PurposeWe developed a stereotactic device to guide the puncture for percutaneous nephrolithotripsy, which uses the distance from the target calyx to its perpendicular point on skin (SCD) to calculate the needle´s entry angle. This study seeks to validate the use of measurements obtained by ultrasound (US) and computerized tomography (CT) for needle´s entry angle calculation and to study factors that may interfere in this procedure.Materials and MethodsHeight, weight, abdominal circumference, CT of the urinary tract in dorsal decubitus (DD) and ventral decubitus (VD), and US of the kidneys in VD were obtained from thirty-five renal calculi patients. SCD obtained were compared and correlated with body-mass index (BMI).ResultsBMI was 28.66 ± 4.6 Kg/m2. SCD on CT in DD was 8.40 ± 2.06cm, in VD was 8.32 ± 1.95cm, in US was 6.74 ± 1.68cm. SCD measured by US and CT were statistically different (p < 0.001), whereas between CT in DD and VD were not. SCD of the lower calyx presented moderate correlation with BMI.ConclusionSCD obtained by CT in ventral and dorsal decubitus may be used for calculation of the needle´s entry angle. SCD obtained by US cannot be used. A rule for the correlation between BMI and the SCD could not be determined

Percutaneous Nephrolithotomy in Obese Patients: Comparison Between the Prone and Total Supine Position

Background: Percutaneous nephrolithotomy (PCNL) can be performed in the prone or in the supine position. Comparisons between the two techniques in obese patients are rare in the current literature. Methods: The records of obese patients (body mass index &gt;30) who underwent PCNL in the prone or complete supine positions were reviewed. All patients had a noncontrast CT before and after the procedure. Stones were graded according to the Guy stone score and complications according to the Clavien grading. The stone-free rates, operative time, surgical complications, and hospital stay were analyzed. Results: A total of 56 PCNL were performed in 42 patients. Twenty-four PCNL were performed in the prone and 32 in the total supine position. Stone-free rate on the first postoperative day was 50% in the prone and 46.9% in the supine position (P = 1.0). Final stone-free rates were 83.3% and 78.1%, respectively (P = 0.74). Mean operative time was 164.6 minutes in the prone and 120.3 minutes in the supine position (P = 0.0017), and hospital stay was 4.38 and 2.68 days (P = 0.014), respectively. The transfusion rate was 20.8% in the prone and zero in the supine position patients (P = 0.01). Excluding Guy IV stones, transfusion rate was 8.3% in the prone position (P = 0.1). Significant surgical complications rate was 12.5% in the prone and 3.1% in the supine position (P = 0.302). Conclusion: PCNL performed in the prone or in the complete supine position in obese patients presents similar outcomes. The supine decubitus position has the advantages of a significantly shorter operative time and hospital stay

Management of Chronic Unilateral Hematuria by Ureterorenoscopy

Background and Purpose: Chronic unilateral hematuria is characterized by intermittent or continuous gross hematuria that cannot be diagnosed using standard radiology and hematology methods. In the past, it was managed with partial or total nephrectomy. In the age of minimally invasive procedures, however, endoscopy has enabled more accurate diagnosis and management. We analyzed our experience with transurethral ureterorenoscopy using a flexible ureteroscope to determine the feasibility and success of endoscopic management of renal hematuria. Patients and Methods: We reviewed the records of 13 patients who presented with chronic unilateral hematuria, in whom radiologic and laboratory tests failed to reveal the source of bleeding. In the cases in which the lesion was identified, after complete inspection of the collecting systems, the bleeding site was treated ureteroscopically with a holmium: yttrium-aluminum-garnet ( YAG) laser. Results: Follow-up ranged from 4 to 60 months ( mean 26 mos). During the follow-up of the 13 patients, 11 remained symptom-free, with only one session of flexible ureterorenoscopy necessary. Relapse occurred in two patients after 4 months and 6 months, respectively; during a second session of flexible ureteroscopy, the bleeding site was successfully identified and cauterized with a holmium: YAG laser. No surgical complications occurred. Conclusions: Conservative treatment of patients with chronic unilateral hematuria should always be considered. Laser ureteroscopic treatment is an excellent method and should be considered as the first option for the management of chronic unilateral hematuria