Estado atual do transplante renal no Brasil e sua inserção no contexto mundial

Comparado aos demais países do mundo, o Brasil ocupa o segundo lugar em número de transplantes renais por ano. Considerando, entretanto, suas dimensões continentais, quando se analisa o número de transplantes por milhão de população, ocupa apenas o trigésimo terceiro lugar. Muitos fatores contribuem para este fato. A legislação que regulamenta doação de órgãos e transplantes no Brasil é bastante recente e foi criada com quase 10 anos de atraso quando comparado com outros países que ocupam primeiras posições na lista de efetividade de sistemas de captação. Uma enorme heterogeneidade na distribuição regional de centros de transplantes com cerca de 25% dos estados brasileiros com atividade mínima ou nula em termos destes procedimentos é também motivo de preocupação. Observa-se uma baixa efetividade dos mecanismos de procura de órgãos com índices de notificação de potenciais doadores falecidos muito baixos na maior parte do país. O pouco conhecimento da população sobre o conceito e segurança do diagnóstico de morte encefálica e do processo de doação, fazem com que, apesar do uso de critérios bastante rigorosos para este diagnóstico, a principal causa da não conversão de doador potencial para doador efetivo, seja a recusa familiar. Em termos de sobrevida do enxerto e do paciente, os índices brasileiros são comparáveis a centros norte americanos e europeus. A taxa de sobrevida de cinco anos do enxerto é de 86% para doador vivo e 73% para falecido. A sobrevida de cinco anos é de 94% para receptores de rins de doador vivo e de 86% para doador falecido. Enquanto países europeus e os Estados Unidos procuram por estratégias alternativas para aumentar o número de transplantes renais como o uso de doadores em parada cardíaca ou a realização de transplantes ABO incompatíveis, o Brasil parece ter muito a progredir simplesmente investindo em estratégias para tornar o atual modelo mais eficiente.Brazil is the second country in the word in terms of absolute number of renal transplants per year. However, considering its continental dimensions and total population, it occupies only the 33th place in terms of number of procedures per million of habitants. Many factors contribute for this fact. Brazilian legislation regarding organ transplantation is recent and was created with an average delay of 10 years compared to countries in the top of the efficiency list. Also, an enormous heterogeneity in distribution of renal transplant centers among Brazilian states also is a point of concern and in almost 25% of them there is none or only a few number of these procedures. In addition, a low rate of potential deceased donors notification aggravate this situation. Another point is that there is poor understanding of the population in regards to the brain death concept and deceased donation process lead to a low rate of conversion from a potential to an effective donor. In spite of using very rigid criteria to diagnosis of brain death, the major cause of this failure is family deny. In terms of patient and graft survival, Brazilian numbers are similar of United States and European centers. Five years graft survival rate is 86% for live donation and 73% for deceased. Five years recipient survival is 94% for live and 86% for deceased donors. While European countries and United States are looking for alternative strategies to increase number of renal transplantations as non heart beat and ABO incompatible donation, Brazil seams to have a lot to progress simply investing on strategies to make the actual model more efficient

Current management issues of immediate postoperative care in pediatric kidney transplantation

The number of pediatric kidney transplants has been increasing in many centers worldwide, as the procedure provides long-lasting and favorable outcomes; however, few papers have addressed the immediate postoperative care of this unique population. Herein, we describe the management of these patients in the early postoperative phase. After the surgical procedure, children should ideally be managed in a pediatric intensive care unit, and special attention should be given to fluid balance, electrolyte disturbances and blood pressure control. Antibiotic and antiviral prophylaxes are usually performed and are based on the recipient and donor characteristics. Thrombotic prophylaxis is recommended for children at high risk for thrombosis, although consensus on the optimum therapy is lacking. Image exams are essential for good graft control, and Doppler ultrasound must be routinely performed on the first operative day and promptly repeated if there is any suspicion of kidney dysfunction. Abdominal drains can be helpful for surveillance in patients with increased risk of surgical complications, such as urinary fistula or bleeding, but are not routinely required. The immunosuppressive regimen starts before or at the time of kidney transplantation and is usually based on induction with monoclonal or polyclonal antibodies, depending on the immunological risk, and maintenance with a calcineurin inhibitor (tacrolimus or ciclosporin), an anti-proliferative agent (mycophenolate or azathioprine) and steroids

The transrectal ultrasound/MRI fusion biopsy for prostate cancer diagnosis after previous negative biopsy: a case report

Introdução: A adoção da biópsia de próstata guiada por fusão de imagens de ressonância magnética (RM) multiparamétrica está se tornando um método importante no diagnóstico do câncer de próstata, especialmente para aqueles com suspeita de lesão localizada na região anterior, que normalmente não é amostrada na biópsia randomizada. Métodos: Aqui relatamos um caso de homem com PSA persistentemente elevado e com uma biópsia randomizada anterior negativa. O PSA atual era de 8,1 ng / dL e a ressonância magnética multiparamétrica mostrou uma lesão suspeita PIRADS-4 de 2 cm localizada na região anterior da zona de transição direita na altura da base e terço médio da glândula. Foi realizada uma biópsia transretal guiada por fusão de imagens de ressonância multiparamétrica (TRUS / mpMRI) e o exame anatomopatológico mostrou a presença de adenocarcinoma escore de Gleason 3 + 4 (ISUP II) apenas nos fragmentos amostrados na área suspeita da mpMRI. Revisamos o papel da mpMRI no diagnóstico do câncer de próstata na rebiópsia.Introduction: The adoption of multiparametric MRI (mpMRI) guided fusion biopsy is becoming an important tool to improve the diagnostic yield in those suspected of having prostate cancer, especially for patients with suspicious lesion located at the anterior region that is uncommonly sampled at randomized biopsy. Methods: Herein we report a case of a man with persistent elevated PSA and a previous negative randomized prostate biopsy. His PSA was 8.1 ng/dL and a multiparametric MRI showed a 2cm suspicious PIRADS-4 lesion located at the anterior region of the right transition zone at base and mid gland. A transrectal ultrasound/MRI (TRUS/mpMRI) fusion biopsy was performed and its pathologic report showed a Gleason 3+4 (ISUP II) that was present only in the fragments that sampled the suspected area at MRI. We review the role of mpMRI in the diagnosis of prostate cancer at rebiopsy

Prognostic factors affecting outcomes in multivisceral en bloc resection for colorectal cancer

OBJECTIVES: This study sought to determine the clinical and pathological factors associated with perioperative morbidity, mortality and oncological outcomes after multivisceral en bloc resection in patients with colorectal cancer. METHODS: Between January 2009 and February 2014, 105 patients with primary colorectal cancer selected for multivisceral resection were identified from a prospective database. Clinical and pathological factors, perioperative morbidity and mortality and outcomes were obtained from medical records. Estimated local recurrence and overall survival were compared using the log-rank method, and Cox regression analysis was used to determine the independence of the studied parameters. ClinicalTrials.gov: NCT02859155. RESULTS: The median age of the patients was 60 (range 23-86) years, 66.7% were female, 80% of tumors were located in the rectum, 11.4% had stage-IV disease, and 54.3% received neoadjuvant chemoradiotherapy. The organs most frequently resected were ovaries and annexes (37%). Additionally, 30.5% of patients received abdominoperineal resection. Invasion of other organs was confirmed histologically in 53.5% of patients, and R0 resection was obtained in 72% of patients. The overall morbidity rate of patients in this study was 37.1%. Ureter resection and intraoperative blood transfusion were independently associated with an increased number of complications. The 30-day postoperative mortality rate was 1.9%. After 27 (range 5-57) months of follow-up, the mortality and local recurrence rates were 23% and 15%, respectively. Positive margins were associated with a higher recurrence rate. Positive margins, lymph node involvement, stage III/IV disease, and stage IV disease alone were associated with lower overall survival rates. On multivariate analysis, the only factor associated with reduced survival was lymph node involvement. CONCLUSIONS: Multivisceral en bloc resection for primary colorectal cancer can be performed with acceptable rates of morbidity and mortality and may lead to favorable oncological outcomes

Detecting and grading prostate cancer in radical prostatectomy specimens through deep learning techniques

OBJECTIVES: This study aims to evaluate the ability of deep learning algorithms to detect and grade prostate cancer (PCa) in radical prostatectomy specimens. METHODS: We selected 12 whole-slide images of radical prostatectomy specimens. These images were divided into patches, and then, analyzed and annotated. The annotated areas were categorized as follows: stroma, normal glands, and Gleason patterns 3, 4, and 5. Two analyses were performed: i) a categorical image classification method that labels each image as benign or as Gleason 3, Gleason 4, or Gleason 5, and ii) a scanning method in which distinct areas representative of benign and different Gleason patterns are delineated and labeled separately by a pathologist. The Inception v3 Convolutional Neural Network architecture was used in categorical model training, and a Mask Region-based Convolutional Neural Network was used to train the scanning method. After training, we selected three new whole-slide images that were not used during the training to evaluate the model as our test dataset. The analysis results of the images using deep learning algorithms were compared with those obtained by the pathologists. RESULTS: In the categorical classification method, the trained model obtained a validation accuracy of 94.1% during training; however, the concordance with our expert uropathologists in the test dataset was only 44%. With the image-scanning method, our model demonstrated a validation accuracy of 91.2%. When the test images were used, the concordance between the deep learning method and uropathologists was 89%. CONCLUSION: Deep learning algorithms have a high potential for use in the diagnosis and grading of PCa. Scanning methods are likely to be superior to simple classification methods

Parathyroidectomy after kidney transplantation: short- and long-term impact on renal function

INTRODUCTION: Kidney transplantation corrects endocrine imbalances. Nevertheless, these early favorable events are not always followed by rapid normalization of parathyroid hormone secretion. A possible deleterious effect of parathyroidectomy on kidney transplant function has been reported. This study aimed to compare acute and longterm renal changes after total parathyroidectomy with those occurring after general surgery. MATERIALS AND METHODS: This was a retrospective case-controlled study. Nineteen patients with persistent hyperparathyroidism underwent parathyroidectomy due to hypercalcemia. The control group included 19 patients undergoing various general and urological operations. RESULTS: In the parathyroidectomy group, a significant increase in serum creatinine from 1.58 to 2.29 mg/dl (P < 0.05) was noted within the first 5 days after parathyroidectomy. In the control group, a statistically insignificant increase in serum creatinine from 1.49 to 1.65 mg/dl occurred over the same time period. The long-term mean serum creatinine level was not statistically different from baseline either in the parathyroidectomy group (final follow-up creatinine = 1.91 mg/dL) or in the non-parathyroidectomy group (final follow-up creatinine = 1.72 mg/dL). CONCLUSION: Although renal function deteriorates in the acute period following parathyroidectomy, long-term stabilization occurs, with renal function similar to both preoperative function and to a control group of kidney-transplanted patients who underwent other general surgical operations by the final follow up

Comparação dos imuno-ensaios de fluorescência polarizada (TDx) e enzimático competitivo (EMIT 2000 ) na dosagem da concentração de ciclosporina A no sangue total

Evaluation of Cyclosporin A (CyA) blood concentration is imperative in solid organ transplantation in order to achieve maximal immunosuppression with the least side effects. We compared the results of whole blood concentrations of CyA in 50 blood samples simultaneously evaluated by the fluorescent polarization immune assay (TDx) and the enzymatic competitive immune assay (EMIT 2000). There was a strong correlation between both kits for any range of CyA blood concentration (R=0.99, pA avaliação da concentração sanguínea de ciclosporina A (CyA) é necessária em transplantes de órgãos sólidos para obter-se máxima imunosupressão e mínimos efeitos colaterais. Nós comparamos os resultados da concentração de CyA em 50 amostras sanguíneas analisadas pelos métodos dos imuno-ensaios de fluorescência polarizada (TDx) e enzimático competitivo (EMIT 2000). Houve uma forte correlação entre ambos métodos para qualquer faixa de concentração de CyA (R=0.99,

Single-use versus reusable flexible ureteroscopes: a comprehensive cost-analysis decision model

Purpose: The significant improvements in flexible ureterorenoscopes have made flexible ureteroscopy the main treatment modality to target upper urinary pathologies. The purpose of this study was to critically evaluate all literature concerning the cost-effectiveness of flexible ureteroscopy comparing single-use with reusable scopes. Methods: A systematic online literature review was performed in PubMed, Embase and Google Scholar databases. Two separate urologists (GSM and FCT) performed the online search and reviewed all papers considered suitable and relevant for this analysis. Because of the paucity of high quality publications, not only prospective assessments but also case control and case series studies were included in the final analysis. All factors potentially affecting surgical costs or clinical outcomes were considered in the analysis. Results: 741 studies with the previously elected terms were found. Of those, 18 were duplicated and 77 were not related to urology procedures and were excluded. Of the remaining 646 studies, 59 published between 2000 and 2018 were considered of relevance to the pre-defined queries and were selected for further analysis. Stone free and complication rates were similar between single-use and reusable scopes. In special, urinary tract infection rate following flexible ureteroscopy is not inferior if a single-use device is used instead of a reusable scope. Operative time was in average 20% shorter if a digital scope was used, single-use or not. There is a suggestion that the learning curve is shorter with single-use devices but this is not consistent in the literature. Surgeon expertise impacts the longevity of the flexible scope. Reusable digital scopes seem to last longer than optic ones, though scope longevity is very variable worldwide. New scopes usually last three to four times more than refurbished ones and single-use ureterorenoscopes have good resilience throughout long cases. Both sterilization method and cleaning process impact scope longevity, the best results being achieved with Cidex and a dedicated nurse to take care of the sterilization process. The main factors that negatively impact device longevity regarding patient and disease are lower pole pathologies, large stone burden and non-use of a ureteral access sheath. Conclusions: The cost-effectiveness of a flexible ureteroscopy program is dependent of several aspects that must be considered when deciding whether to choose between a single-use and a reusable ureterorenoscope. Disposable devices are already a reality and will progressively become the standard as manufacturing price falls significantly.Objetivo: As melhorias significativas nos ureterorrenoscópios flexíveis tornaram a ureteroscopia flexível a principal modalidade de tratamento para as patologias de trato urinário superior. O objetivo deste estudo foi avaliar criticamente toda a literatura sobre a custo-efetividade da ureteroscopia flexível comparando aparelhos de uso único com reutilizáveis. Métodos: Uma revisão sistemática da literatura online foi realizada nas bases de dados PubMed, Embase e Google Scholar. Dois urologistas distintos (GSM e FCT) realizaram a pesquisa online e revisaram todos os trabalhos considerados adequados e relevantes para esta análise. Devido à escassez de publicações de alta qualidade, não apenas as avaliações prospectivas, mas também os estudos de casos e séries de casos foram incluídos na análise final. Todos os fatores que potencialmente afetam os custos cirúrgicos ou os desfechos clínicos foram considerados na análise. Resultados: foram encontrados 741 estudos com os termos previamente eleitos. Destes, 18 eram duplicados e 77 não tinham relação com procedimentos de urologia e foram excluídos. Dos restantes 646 estudos, 59 publicados entre 2000 e 2018 foram considerados relevantes para as consultas pré-definidas e foram selecionados para análise posterior. As taxas de complicações e livres de cálculo foram semelhantes entre os escopos de uso único e reutilizáveis. Em especial, a taxa de infecção do trato urinário após ureteroscopia flexível não é inferior se um dispositivo de uso único for usado em vez de um reutilizável. O tempo cirúrgico foi em média 20% menor se um ureteroscópio digital foi usado, seja de uso único ou não. Há uma sugestão de que a curva de aprendizado é mais curta com dispositivos de uso único, mas isso não é consistente na literatura. A experiência do cirurgião afeta a longevidade do aparelho flexível. Os aparelhos digitais reutilizáveis parecem durar mais que os ópticos, embora a longevidade seja muito variável em todo o mundo. Os novos ureteroscópios costumam durar de três a quatro vezes mais do que os recondicionados e os ureterorrenoscópios de uso único apresentam boa resiliência em casos longos. Tanto o método de esterilização como o processo de limpeza impactam a longevidade do aparelho, sendo os melhores resultados alcançados com o Cidex e uma enfermeira dedicada para cuidar do processo de esterilização. Os principais fatores que impactam negativamente a longevidade do dispositivo em relação ao paciente e à doença são patologias do polo inferior, grande volume de cálculo e não uso de uma bainha de acesso ureteral. Conclusões: A relação custo-efetividade de um programa de ureteroscopia flexível é dependente de vários aspectos que devem ser considerados ao se decidir se deve escolher entre ureterorrenoscópio de uso único e reutilizável. Os dispositivos descartáveis já são uma realidade e se tornarão progressivamente o padrão a partir do momento que o preço de fabricação cair significativamente

Comparative and Prospective Analysis of Three Different Approaches for Live-Donor Nephrectomy

PURPOSE: Living donor nephrectomy is usually performed by a retroperitoneal flank incision. Due to the significant morbidity and long recovery time for a flank incision, anterior extra peritoneal sub-costal and transperitoneal video-laparoscopic methods have been described for donor nephrectomy. We prospectively compare the long-term results of donors as well as functional recipients submitted to these three approaches. MATERIALS AND METHODS: A total of 107 live donor renal transplantations were prospectively evaluated from May 2001 to January 2004. Donors were compared with regard to operative and warm ischemia time, postoperative pain, analgesic requirements, and complications. Recipients were compared with regard to graft function, acute cellular rejection, surgical complications, and graft and recipient survival. RESULTS: The mean operative and warm ischemia times were longer in the video-laparoscopic group (p<0.001), whereas patients of the flank incision group presented more postoperative pain (p=0.035), required more analgesics (p<0.001), had longer hospital stays (p<0.001), and suffered more pain on the 90th day after surgery (p=0.006). In the sub-costal and flank incision groups, there was a larger number of paraesthesias and abdominal wall asymmetries (p<0.001). Recipient groups were demographically comparable and presented similar acute tubular necrosis incidence and delayed graft function. The incidence of acute cellular rejection was higher in the video-laparoscopic and flank incision groups (p=0.013). There was no difference in serum creatinine levels, surgical complications, or recipient or graft survival between groups. CONCLUSIONS: The video-laparoscopic and sub-costal approaches proved to be safe, and to provide donor advantages relative to the flank incision approach. Among recipients, the complication rate, graft survival, and recipient survival were similar in all groups