Rodrigo Romão - Academia.edu (original) (raw)

Papers by Rodrigo Romão

Research paper thumbnail of Laparoscopic Adrenalectomy in Children for Neuroblastoma

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2012

Background: Neuroblastoma is one of the most common solid tumors in the pediatric population and ... more Background: Neuroblastoma is one of the most common solid tumors in the pediatric population and the adrenal gland is the main abdominal site of this tumor. The laparoscopic approach has become the standard of care for most benign adrenal tumors in adults, but the role of laparoscopic adrenalectomy in children for malignant tumor is still a point of controversy. However, there is a growing experience with laparoscopic neuroblastoma resection of small lesions and the use of minimally invasive techniques for the initial management of infiltrative neuroblastoma in the last years. The aim of this study is to describe our initial experience with laparoscopic adrenalectomy for neuroblastoma in children, based on surgical outcomes. Methods: A retrospective review of 7 laparoscopic adrenalectomies performed in a single institution between October 2008 and October 2009. We focused our analysis on early surgical outcomes. Results: The mean tumoral size was 2.8 ± 0.9 cm, the average surgical time was 138.6 ± 65.5 minutes, and the mean hospital stay was 2.9 ± 1.6 days. One stage IV patient was submitted to conversion due to bleeding and needed blood transfusion. There were no late complications or deaths and the mean follow-up time was 18.8 ± 6.1 months. Conclusions: The laparoscopic approach for adrenal neuroblastoma resection is feasible in children with good outcomes, but should be reserved to patients with small, well-circumscribed adrenal lesions, without invasive or infiltrative disease.

Research paper thumbnail of Utility and cost-effectiveness of uroflowmetry in a busy pediatric urology practice

Canadian Urological Association Journal, 2014

Introduction: Uroflowmetry (UF) is frequently employed in daily pediatric urology practice for di... more Introduction: Uroflowmetry (UF) is frequently employed in daily pediatric urology practice for diagnostic and follow-up purposes. We assess the utility and cost-effectiveness of UF in the management of patients seen at a tertiary care centre.Methods: We retrospectively reviewed the charts of consecutive patients who had a UF between January 1, 2010 and March 31, 2010. We collected data on demographics, diagnosis, UF parameters and the impact of the UF on management. The impact on management was defined as indication for surgery, introduction of new medications and bladder retraining based on clinical and UF findings.Results: In total, 524 patients were included in the study. In 63 (12%) patients, UF was performed as part of the evaluation at the first clinic appointment. The most common diagnoses were voiding dysfunction (VD) 41%, hypospadias 26%, vesicoureteric reflux (VUR) 16%, monosymptomatic nocturnal enuresis (NE) 8%, posterior urethral valves 5% and meatal stenosis (MS) 4%. In...

Research paper thumbnail of 1021 Morphological Characteristics of Ureteropelvic Junction Obstruction (Upjo) from Infancy to Adulthood and Implications in Surgical Management

The Journal of Urology, 2012

Research paper thumbnail of 617 Erosion of Calcified Marcroplastique: A Late Complication Following Injection for Vesico-Ureteral Reflux

The Journal of Urology, 2012

Research paper thumbnail of V3-12 Laparoscopic Pediatric Pyeloplasty and Placement of an Externalized Pyelo-Ureteral Stent

The Journal of Urology, 2014

The meatus was coronal, subcoronal and distal penile in 6, 10 & 14 patients in group e 1 and 4, 1... more The meatus was coronal, subcoronal and distal penile in 6, 10 & 14 patients in group e 1 and 4, 11 & 15 patients in group-2 (p-value 0.786). There is no significant difference between both groups concerning operative time. Modified onlay island urethroplasty has significantly less complications and better cosmetic outcome, urinary stream and relatives satisfaction. CONCLUSIONS: Modified onlay island flap urethroplasty might offer a good alternative to Mathieu urethroplasty in patients with distal hypospadias and narrow urethral plates. Further studies including larger number of patients, longer follow up with objective evaluation of functional outcome should be encouraged to ensure these early results.

Research paper thumbnail of Comparative Analysis of Detorsion Alone Versus Detorsion and Tunica Albuginea Decompression (Fasciotomy) with Tunica Vaginalis Flap Coverage in the Surgical Management of Prolonged Testicular Ischemia

The Journal of Urology, 2012

Purpose: Recent data suggest that testicular torsion may include an element of the compartment sy... more Purpose: Recent data suggest that testicular torsion may include an element of the compartment syndrome that improves with decompression. In 2009 we instituted tunica albuginea incision with tunica vaginalis flap coverage as an alternative in cases in which the torsed testis continued to appear ischemic after detorsion. Materials and Methods: The medical records of 65 boys who underwent scrotal exploration for testicular torsion between 2000 and 2010 were reviewed. There were 6 patients excluded from study due to lack of followup. Of the remaining 59 patients 31 (52.5%) showed improvement in testicular appearance after detorsion and underwent orchiopexy, whereas 28 (47.5%) did not show evidence of recovery after detorsion. Of these patients 11 underwent tunica albuginea incision with tunica vaginalis flap coverage and 17 underwent orchiectomy. Demographic data, duration of symptoms and rate of testicular salvage were analyzed. Results: Mean patient age was 11.8 years (detorsion plus orchiopexy), 10.1 years (tunica albuginea incision plus tunica vaginalis flap coverage) and 10.1 years (detorsion plus orchiectomy). Average followup was greater than 6 months in all groups. Mean duration of torsion was 13.4 hours (detorsion plus orchiopexy), 31.2 hours (tunica albuginea incision plus tunica vaginalis flap coverage) and 67.5 hours (detorsion plus orchiectomy). Before tunica albuginea incision with tunica vaginalis flap coverage was offered, the rate of orchiectomy was 35.9% (14 of 39) vs 15% (3 of 20) after this technique was introduced (p Ͻ0.05). The rates of testicular salvage were 62.5% (detorsion plus orchiopexy), 54.6% (tunica albuginea incision plus tunica vaginalis flap coverage) and 0% (detorsion plus orchiectomy). Although the numbers are limited, it is likely that without tunica albuginea incision with tunica vaginalis flap coverage 6 of 11 testes would have been removed. Conclusions: This preliminary experience suggests that tunica albuginea incision with tunica vaginalis flap coverage is a promising option for the management of clinically marginal torsed testes, enhancing salvageability after prolonged ischemia. We recommend considering this maneuver before performing orchiectomy in selected cases of testicular torsion.

Research paper thumbnail of Nephron Sparing Surgery for Unilateral Wilms Tumor in Children with Predisposing Syndromes: Single Center Experience Over 10 Years

The Journal of Urology, 2012

Unilateral Wilms tumors associated with predisposing syndromes are treated with preoperative chem... more Unilateral Wilms tumors associated with predisposing syndromes are treated with preoperative chemotherapy followed by surgical resection. We describe our experience with nephron sparing surgery for Wilms tumor in this population at risk for metachronous lesions. We conducted a retrospective review of all children with a predisposing syndrome who underwent nephrectomy for malignancy during a 10-year period (2000 to 2010). Data collected included age, mode of detection, tumor size, treatment, pathology results, followup time and recurrence episodes. From 2000 to 2010, 13 of 75 (19%) patients treated for Wilms tumor were diagnosed with predisposing syndrome(s). Eight patients with unilateral tumors were treated and had a mean age at diagnosis of 27 months (range 7 months to 9 years). Beckwith-Wiedemann syndrome, isolated hemihyperplasia, WAGR (Wilms tumor, Aniridia, Genitourinary abnormalities, mental Retardation) syndrome and isolated 11p13 deletion were the underlying diagnoses in 3, 2, 2 and 1 patient, respectively. All but 2 patients were diagnosed by screening ultrasound and 5 underwent preoperative chemotherapy. Median tumor size at surgery was 2.5 cm (range 1 to 13). Nephron sparing surgery was performed in 6 of 8 patients. Pathological study showed favorable histology Wilms tumor and nephrogenic rests in 6 and 2 patients, respectively. After a mean followup of 36 months (range 6 to 72) no recurrences were documented and all children had normal creatinine levels. Nephron sparing surgery appears safe for patients with unilateral Wilms tumor associated with predisposing syndrome(s), allowing for the preservation of renal function and good oncologic outcomes for the available followup time. If more studies confirm our observation, current recommendations for the surgical treatment of Wilms tumor may need to reemphasize the value of attempting nephron sparing surgery in this patient population.

Research paper thumbnail of 550 Should Proximal Hypospadias with Bilaterally Descended Gonads Be Considered a Disorder of Sex Development (DSD)?

The Journal of Urology, 2011

Although the pathophysiology of recurrent UTI is multifactorial, its incidence in patients after ... more Although the pathophysiology of recurrent UTI is multifactorial, its incidence in patients after hypospadias repair is higher than normal population. This incidence may vary on surgical technique, for instance patients who underwent TIP repair may potentially have partial obstruction leading to elevated PVR and VUR. On the contrary patients experiencing recurrent UTI following a complicated TVIF repairs likely had increased urethral colonization secondary to urethral diverticulum or fistulas. Therefore, recurrent post-hypospadias surgery UTI should prompt a specific assessment for potentially functionally relevant post-surgical anatomic abnormality.

Research paper thumbnail of Early Postoperative Ultrasound After Open Pyeloplasty in Children with Prenatal Hydronephrosis Helps Identify Low Risk of Recurrent Obstruction

The Journal of Urology, 2012

Prediction of successful pyeloplasty can be challenging, particularly in asymptomatic children tr... more Prediction of successful pyeloplasty can be challenging, particularly in asymptomatic children treated for worsening prenatally diagnosed hydronephrosis. We evaluated early noninvasive objective predictors of success in this population. Materials and Methods: We reviewed patients who underwent pyeloplasty for asymptomatic, prenatally detected, worsening hydronephrosis treated between 2000 and 2010 with followup greater than 1 year. For all patients renal pelvis anteroposterior diameter in a mid transverse view and Society for Fetal Urology hydronephrosis grade were evaluated preoperatively and 3 to 4 months postoperatively. Aside from subjective evaluation based on change in hydronephrosis grade, we estimated the percentage of improvement in anteroposterior diameter (preoperative diameter Ϫ postoperative diameter/preoperative diameter). Repeat intervention after pyeloplasty arbitrarily defined failure. Patients were categorized into 3 groups, ie no failure on followup ultrasound (group 1), no failure with postoperative nuclear scan to document success (group 2) and failed pyeloplasty (group 3). ROC curves were plotted to correlate 4 variables with failure, namely preoperative anteroposterior diameter, postoperative anteroposterior diameter, percent improvement in anteroposterior diameter and subjective change in grade. Results: Of 229 patients 192 (84%) who met inclusion criteria had ultrasound at 3 to 4 months postoperatively available. Mean age at surgery was 19 months and mean Ϯ SD followup was 49.9 Ϯ 27.7 months. Percent improvement in anteroposterior diameter and postoperative anteroposterior diameter measure were the most reliable variables to predict failure (AUC 0.88 and 0.86, respectively, p Ͻ0.0001), whereas preoperative anteroposterior diameter and subjective changes in grade were not good predictors (AUC 0.52, p Ͼ0.05). A percent improvement in anteroposterior diameter of 38% or greater or postoperative anteroposterior diameter of 11.5 mm or less was associated with success, with sensitivity of 100% and specificity of 61% and 55%, respectively. Conclusions: Percent improvement in anteroposterior diameter and postoperative pelvic anteroposterior diameter measure can provide objective guidance as to which patients need closer monitoring during followup, and can help select children at low risk for repeat intervention after pyeloplasty.

Research paper thumbnail of Glans amputation during routine neonatal circumcision: Mechanism of injury and strategy for prevention

Journal of Pediatric Urology, 2013

Objective: Glans injury during circumcision is an uncommon yet potentially devastating complicati... more Objective: Glans injury during circumcision is an uncommon yet potentially devastating complication. Its mechanism remains poorly understood. Herein we critically evaluate a case series and, based on common characteristics, hypothesize the mechanism of injury as well as means to prevent it. Methods: Retrospective review of circumcision-related glans amputation cases referred for evaluation and management, focusing on detection of common history and presentation patterns in order to evaluate possible underlying mechanisms. Results: A neonatal elective circumcision was conducted using a Mogen clamp and an oblique injury to the ventro-lateral aspect of the glans was noted in 6 cases referred over a 5-year period, suggesting a similar trauma pattern. The urethra was consistently involved. The amputated segments were reattached as free composite grafts in 2/6 cases. Three patients underwent delayed glansplasty months after the trauma in an attempt to restore natural symmetry and cosmesis. In one case a buccal mucosa graft was employed to rebuild the ventral coronal sulcus. Conclusions: Trauma pattern suggests that the ventral glans is at high risk for injury by traction on incompletely released ventral preputial adhesions with subsequent glans entrapment.

Research paper thumbnail of Laparoscopic ureteral ligation (clipping): a novel, simple procedure for pediatric urinary incontinence due to ectopic ureters associated with non-functioning upper pole renal moieties

Journal of Pediatric Urology, 2014

Research paper thumbnail of Malignant tumor of the trachea in children: diagnostic pitfalls and surgical management

Journal of Pediatric Surgery, 2009

Primary tracheal malignant neoplasms are very rare. Histologically, squamous cell and adenoid cys... more Primary tracheal malignant neoplasms are very rare. Histologically, squamous cell and adenoid cystic carcinomas are the most common types of malignant primary tracheal tumors when all age groups are studied. In the past 5 years, we treated 2 children with tracheal mucoepidermoid carcinoma. Herein we report both cases and review the literature on the subject with particular emphasis on diagnosis and surgical management.

Research paper thumbnail of Surgical treatment of hepatic tumors in children: lessons learned from liver transplantation

Journal of Pediatric Surgery, 2009

Hepatectomy remains a complex operation even in experienced hands. The objective of the present s... more Hepatectomy remains a complex operation even in experienced hands. The objective of the present study was to describe our experience in liver resections, in the light of liver transplantation, emphasizing the indications for surgery, surgical techniques, complications, and results. The medical records of 53 children who underwent liver resection for primary or metastatic hepatic tumors were reviewed. Ultrasonography, computed tomographic (CT) scan, and needle biopsy were the initial methods used to diagnose malignant tumors. After neoadjuvant chemotherapy, tumor resectability was evaluated by another CT scan. Surgery was performed by surgeons competent in liver transplantation. As in liver living donor operation, vascular anomalies were investigated. The main arterial anomalies found were the right hepatic artery emerging from the superior mesenteric artery and left hepatic artery from left gastric artery. Hilar structures were dissected very close to liver parenchyma. The hepatic artery and portal vein were dissected and ligated near their entrance to the liver parenchyma to avoid damaging the hilar vessels of the other lobe. During dissection of the suprahepatic veins, the venous infusion was decreased to reduce central venous pressure and potential bleeding from hepatic veins and the vena cava. Fifty-three children with hepatic tumors underwent surgical treatment, 47 patients underwent liver resections, and in 6 cases, liver transplantation was performed because the tumor was considered unresectable. There were 31 cases of hepatoblastoma, with a 9.6% mortality rate. Ten children presented with other malignant tumors-3 undifferentiated sarcomas, 2 hepatocellular carcinomas, 2 fibrolamellar hepatocellular carcinomas, a rhabdomyosarcoma, an immature ovarian teratoma, and a single neuroblastoma. These cases had a 50% mortality rate. Six children had benign tumors-4 mesenchymal hamartoma, 1 focal nodular hyperplasia, and a mucinous cystadenoma. All of these children had a favorable outcome. Hepatic resections included 22 right lobectomies, 9 right trisegmentectomies, 8 left lobectomies, 5 left trisegmentectomies, 2 left segmentectomies, and 1 case of monosegment (segment IV) resection. The overall mortality rate was 14.9%, and all deaths were related to recurrence of malignant disease. The mortality rate of hepatoblastoma patients was less than other malignant tumors (P = .04). The resection of hepatic tumors in children requires expertise in pediatric surgical practice, and many lessons learned from liver transplantation can be applied to hepatectomies. The present series showed no mortality directly related to the surgery and a low complication rate.

Research paper thumbnail of Preserving bowel length with a transluminal stent in neonates with multiple intestinal anastomoses: a case series and review of the literature

Journal of Pediatric Surgery, 2011

Background/purpose: In neonatal surgery, preserving small bowel length is important to avoid shor... more Background/purpose: In neonatal surgery, preserving small bowel length is important to avoid short bowel syndrome. Our aim was to assess the outcomes of intraluminal stenting of neonatal multiple intestinal anastomoses. Methods: We conducted a retrospective review of 9 patients (5, single institution; 4, published literature) who received multiple anastomoses stented by a silicon tube. Demographics, surgical anatomy and complications, nutritional outcomes, and follow-up were reviewed. Results: Diagnosis was multiple intestinal atresias in 8 patients and necrotizing enterocolitis in 1. A silicon catheter entered either the mucous fistula (5 patients received a jejunostomy/mucous fistula) or a proximal opening on the dilated bowel and was threaded through viable segments of the bowel. The bowel ends were approximated. Stent was externalized in 7 patients. Final mean small bowel length was 63.9 cm. All complications (3 patients, leak/stricture) required surgery. Mean time to stent removal, feeds initiation, and parenteral nutrition (PN) discontinuation was 31.2 days, 17.3 days, and 159 days, respectively. Only 1 patient remains on PN (mean follow-up, 25.4 months). Conclusions: Multiple intestinal anastomoses stenting is an excellent technique to avoid short bowel syndrome in the setting of multiple viable segments of gut, such as type IV intestinal atresia or necrotizing enterocolitis. Both our experience and the published literature show no mortality and PN-free survival.

Research paper thumbnail of Transanal endorectal pull-through in children with Hirschsprung's disease—technical refinements and comparison of results with the Duhamel procedure

Journal of Pediatric Surgery, 2009

Transanal endorectal pull-through (TEPT) has drastically changed the treatment of Hirschsprung&am... more Transanal endorectal pull-through (TEPT) has drastically changed the treatment of Hirschsprung's disease (HD). A short follow-up of children submitted to TEPT reveals results that are similar to the classic transabdominal pull-through procedures. However, few reports compare the late results of TEPT with transabdominal pull-through procedures with respect to complication rates and the fecal continence. The aims of the present work are to describe some technical refinements that we introduced in the procedure and to compare the short and long-term outcome of TEPT with the outcomes of a group of patients with HD who previously underwent the Duhamel procedure. Thirty-five patients who underwent TEPT were prospectively studied and compared to a group of 29 patients who were treated with colostomy followed by a classical Duhamel pull-through. The main modifications introduced in the TEPT group were no preoperative colon preparation, operation conducted under general anesthesia in addition to regional sacral anesthesia, use of only one purse-string suture in the rectal mucosa before transanal submucosal dissection, and no use of retractors and electrocautery during the submucosal dissection. The most frequent early complications of TEPT group were perineal dermatitis (22.8%) and anastomotic strictures (8.6%). The comparison with patients who underwent Duhamel procedure revealed no difference in the incidence of preoperative enterocolitis, the patients of the TEPT group were younger at the time of diagnosis and of surgery, they had shorter operating times, and they began oral feeding more quickly after the operation. The incidence of wound infection was lower in the TEPT group. Moreover, the TEPT and Duhamel groups showed no difference in the incidences of mortality, postoperative partial continence, and total incontinence. Although the incidences of complete continence and postoperative enterocolitis were not different, a tendency to the increased incidence in the TEPT group was observed. This study further supports the technical advantages, the simplicity, and the decreased incidence of complications of a primary TEPT procedure when compared to a classical form of pull-through. Some technical refinements are described, and no preoperative colon preparation was necessary for the patients studied here. The results show that the long-term outcomes of the modified TEPT procedure are generally better than those obtained with classical approaches.

Research paper thumbnail of Laparoscopic extended cardiomyotomy in children: an effective procedure for the treatment of esophageal achalasia

Journal of Pediatric Surgery, 2010

Achalasia of the esophagus is characterized by aperistalsis and incomplete relaxation of the lowe... more Achalasia of the esophagus is characterized by aperistalsis and incomplete relaxation of the lower esophageal sphincter in response to swallowing. The objective of the present study is to present the experience of a modified Heller myotomy via a laparoscopic approach for the treatment of children who had this condition. A retrospective review of medical records of all patients who underwent this procedure from 2000 to 2009 was performed. The procedure consisted of an extended esophagomyotomy beginning on the lower part of the lower esophageal sphincter and continuing 5 to 6 cm above on the lower third of the esophagus, and then extended 3 to 4 cm below to the stomach, associated with an anterior 180-degree hemi-fundoplication according to Dor's technique. Fifteen patients were included in the study. There were 8 female and 7 male patients. Mean operating time was 190 minutes with no intraoperative complications and 1 conversion to open surgery because of difficulty in dissecting an inflamed distal esophagus. In a mean follow-up period of 32.3 months, 2 patients had recurrence of mild dysphagia that disappeared spontaneously, and 1 required a single botulinum toxin injection with complete resolution of symptoms. We conclude that the laparoscopic extended Heller myotomy with Dor fundoplication is a safe and effective method for the treatment for achalasia in the pediatric population even in advanced cases.

Research paper thumbnail of Comparison Between Laparoscopic and Open Radical Nephroureterectomy in a Contemporary Group of Patients: Are Recurrence and Disease-Specific Survival Associated with Surgical Technique?

European Urology, 2010

Background: Open radical nephroureterectomy (ORN) is the current standard of care for upper tract... more Background: Open radical nephroureterectomy (ORN) is the current standard of care for upper tract urothelial carcinoma (UTUC), but laparoscopic radical nephroureterectomy (LRN) is emerging as a minimally invasive alternative. Questions remain regarding the oncologic safety of LRN and its relative equivalence to ORN. Objective: Our aim was to compare recurrence-free and disease-specific survival between ORN and LRN. Design, setting, and participants: We retrospectively analyzed data from 324 consecutive patients treated with radical nephroureterectomy (RN) between 1995 and 2008 at a major cancer center. Patients with previous invasive bladder cancer or contralateral UTUC were excluded. Descriptive data are provided for 112 patients who underwent ORN from 1995 to 2001 (pre-LRN era). Comparative analyses were restricted to patients who underwent ORN (n = 109) or LRN (n = 53) from 2002 to 2008. Median follow-up for patients without disease recurrence was 23 mo. Intervention: All patients underwent RN. Measurements: Recurrence was categorized as bladder-only recurrence or any recurrence (bladder, contralateral kidney, operative site, regional lymph nodes, or distant metastasis). Recurrence-free probabilities were estimated using Kaplan-Meier methods. A multivariable Cox model was used to evaluate the association between surgical approach and disease recurrence. The probability of disease-specific death was estimated using the cumulative incidence function. Results and limitations: Clinical and pathologic characteristics were similar for all patients. The recurrence-free probabilities were similar between ORN and LRN (2-yr estimates: 38% and 42%, respectively; p = 0.9 by log-rank test). On multivariable analysis, the surgical approach was not significantly associated with disease recurrence (hazard ratio [HR]: 0.88 for LRN vs ORN; 95% confidence interval [CI], 0.57-1.38; p = 0.6). There was no significant difference in bladder-only recurrence (HR: 0.78 for LRN vs ORN; 95% CI, 0.46-1.34; p = 0.4) or disease-specific mortality (p = 0.9). This study is limited by its retrospective nature. Conclusions: Based on the results of this retrospective study, no evidence indicates that oncologic control is compromised for patients treated with LRN in comparison with ORN.

Research paper thumbnail of Gastroesophageal reflux disease in children: efficacy of Nissen fundoplication in treating digestive and respiratory symptoms. Experience of a single center

Diseases of the Esophagus, 2008

Fundoplication has been commonly performed in neurologically impaired and normal children with co... more Fundoplication has been commonly performed in neurologically impaired and normal children with complicated gastroesophageal reflux disease. The relationship between gastroesophageal reflux disease and respiratory diseases is still unclear. We aimed to compare results of open and laparoscopic procedures, as well as the impact of fundoplication over digestive and respiratory symptoms. From January 2000 to June 2007, 151 children underwent Nissen fundoplication. Data were prospectively collected regarding age at surgery, presence of neurologic handicap, symptoms related to reflux (digestive or respiratory, including recurrent lung infections and reactive airways disease), surgical approach, concomitant procedures, complications, and results. Mean age was 6 years and 9 months. Eighty-two children (54.3%) had neurological handicaps. The surgical approach was laparoscopy in 118 cases and laparotomy in 33. Dysphagia occurred in 23 patients submitted to laparoscopic and none to open procedure (P = 0.01). A total of 86.6% of patients with digestive symptoms had complete resolution or significant improvement of the problems after the surgery. A total of 62.2% of children with recurrent lung infections showed any reduction in the frequency of pneumonias. Only 45.2% of patients with reactive airway disease had any relief from bronchospasm episodes after fundoplication. The comparisons demonstrated that Nissen fundoplication was more effective for the resolution of digestive symptoms than to respiratory manifestations (P = 0.04). Open or laparoscopic fundoplication are safe procedures with acceptable complication indices and the results of the surgery are better for digestive than for respiratory symptoms.

Research paper thumbnail of Percutaneous Central Venous Catheterization in a Pediatric Intensive Care Unit

Critical Care Medicine, 1990

We prospectively determined the complications of percutaneous central venous catheterizations per... more We prospectively determined the complications of percutaneous central venous catheterizations performed by medical house officers In 302 patients. We also analyzed the factors affectlng the success and complication rates of such invasive procedures. The central vein was successfully catheterized In 363 (77%) of 470 attempts. The Internal jugular and subclavian vein approaches were significantly more successful (86K) than the external jugular vein approach (61 %, P c 0.001 by x*). The success rate improved significantly when catheterization was attempted under elective circumstances(P c 0.003) and also after the vein was Initially located with a smallgauge needle (P c 0.001). Our results suggest that efforts should be abandoned after the third unsuccessful pass with a largegauge needle in the same site. Complications of catheter insertion included bleeding (ten patients), hematoma (15 patients), inadvertent arterial punctures (14 patients), iatrogenic pleural effusions (four patients), and pneumothoraces (eight patients). No compllcatlons appeared to have a major adverse effect on a patient's clinical course. The inexperienced operator (fewer than 25 prior catheterizations) has a success rate equal to that of the more experienced operator (more than 25 priorcatheterizations), but he may be more likely to produce a complication. Medlcal house officers can perform percutaneous central venous catheterizations with a high rate of success and at low risk to the patient.

Research paper thumbnail of Carcinoma folicular de tireóide: estudo retrospectivo

Revista do Colégio Brasileiro de Cirurgiões, 2001

OBJETIVOS: Abordar o diagnóstico, tratamento e evolução do carcinoma folicular da tireóide. MÉTOD... more OBJETIVOS: Abordar o diagnóstico, tratamento e evolução do carcinoma folicular da tireóide. MÉTODOS: Análise retrospectiva dos dados de 38 pacientes submetidos à tireoidectomia por carcinoma folicular puro, num período de 10 anos no HC-FMUSP. O tempo médio de seguimento foi de três anos e três meses. Nove pacientes eram do sexo masculino (23,7%) e 29 do sexo feminino (76,3%), com idades entre 19 e 87 anos (média=49,5). RESULTADOS: Em 17 (58,6%) dos doentes, observou-se nódulo único à ultra-sonografia, e 23 (79,3%) tinham nódulos frios à cintilografia. Sintomatologia esteve presente em 33 pacientes (86,8%). A punção aspirativa por agulha fina (PAAF), realizada em 27 pacientes, revelou padrão folicular em 24 (88,9%), carcinoma papilífero em 2 (7,4%) e bócio em 1 (3,7%). Tireoidectomia total foi o tratamento final em 34 pacientes e esvaziamento cervical foi realizado em três casos. Apenas 5 (13,1%) obtiveram confirmação diagnóstica ao exame de congelação intra-operatória. Houve 2 (5,2%...

Research paper thumbnail of Laparoscopic Adrenalectomy in Children for Neuroblastoma

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2012

Background: Neuroblastoma is one of the most common solid tumors in the pediatric population and ... more Background: Neuroblastoma is one of the most common solid tumors in the pediatric population and the adrenal gland is the main abdominal site of this tumor. The laparoscopic approach has become the standard of care for most benign adrenal tumors in adults, but the role of laparoscopic adrenalectomy in children for malignant tumor is still a point of controversy. However, there is a growing experience with laparoscopic neuroblastoma resection of small lesions and the use of minimally invasive techniques for the initial management of infiltrative neuroblastoma in the last years. The aim of this study is to describe our initial experience with laparoscopic adrenalectomy for neuroblastoma in children, based on surgical outcomes. Methods: A retrospective review of 7 laparoscopic adrenalectomies performed in a single institution between October 2008 and October 2009. We focused our analysis on early surgical outcomes. Results: The mean tumoral size was 2.8 ± 0.9 cm, the average surgical time was 138.6 ± 65.5 minutes, and the mean hospital stay was 2.9 ± 1.6 days. One stage IV patient was submitted to conversion due to bleeding and needed blood transfusion. There were no late complications or deaths and the mean follow-up time was 18.8 ± 6.1 months. Conclusions: The laparoscopic approach for adrenal neuroblastoma resection is feasible in children with good outcomes, but should be reserved to patients with small, well-circumscribed adrenal lesions, without invasive or infiltrative disease.

Research paper thumbnail of Utility and cost-effectiveness of uroflowmetry in a busy pediatric urology practice

Canadian Urological Association Journal, 2014

Introduction: Uroflowmetry (UF) is frequently employed in daily pediatric urology practice for di... more Introduction: Uroflowmetry (UF) is frequently employed in daily pediatric urology practice for diagnostic and follow-up purposes. We assess the utility and cost-effectiveness of UF in the management of patients seen at a tertiary care centre.Methods: We retrospectively reviewed the charts of consecutive patients who had a UF between January 1, 2010 and March 31, 2010. We collected data on demographics, diagnosis, UF parameters and the impact of the UF on management. The impact on management was defined as indication for surgery, introduction of new medications and bladder retraining based on clinical and UF findings.Results: In total, 524 patients were included in the study. In 63 (12%) patients, UF was performed as part of the evaluation at the first clinic appointment. The most common diagnoses were voiding dysfunction (VD) 41%, hypospadias 26%, vesicoureteric reflux (VUR) 16%, monosymptomatic nocturnal enuresis (NE) 8%, posterior urethral valves 5% and meatal stenosis (MS) 4%. In...

Research paper thumbnail of 1021 Morphological Characteristics of Ureteropelvic Junction Obstruction (Upjo) from Infancy to Adulthood and Implications in Surgical Management

The Journal of Urology, 2012

Research paper thumbnail of 617 Erosion of Calcified Marcroplastique: A Late Complication Following Injection for Vesico-Ureteral Reflux

The Journal of Urology, 2012

Research paper thumbnail of V3-12 Laparoscopic Pediatric Pyeloplasty and Placement of an Externalized Pyelo-Ureteral Stent

The Journal of Urology, 2014

The meatus was coronal, subcoronal and distal penile in 6, 10 & 14 patients in group e 1 and 4, 1... more The meatus was coronal, subcoronal and distal penile in 6, 10 & 14 patients in group e 1 and 4, 11 & 15 patients in group-2 (p-value 0.786). There is no significant difference between both groups concerning operative time. Modified onlay island urethroplasty has significantly less complications and better cosmetic outcome, urinary stream and relatives satisfaction. CONCLUSIONS: Modified onlay island flap urethroplasty might offer a good alternative to Mathieu urethroplasty in patients with distal hypospadias and narrow urethral plates. Further studies including larger number of patients, longer follow up with objective evaluation of functional outcome should be encouraged to ensure these early results.

Research paper thumbnail of Comparative Analysis of Detorsion Alone Versus Detorsion and Tunica Albuginea Decompression (Fasciotomy) with Tunica Vaginalis Flap Coverage in the Surgical Management of Prolonged Testicular Ischemia

The Journal of Urology, 2012

Purpose: Recent data suggest that testicular torsion may include an element of the compartment sy... more Purpose: Recent data suggest that testicular torsion may include an element of the compartment syndrome that improves with decompression. In 2009 we instituted tunica albuginea incision with tunica vaginalis flap coverage as an alternative in cases in which the torsed testis continued to appear ischemic after detorsion. Materials and Methods: The medical records of 65 boys who underwent scrotal exploration for testicular torsion between 2000 and 2010 were reviewed. There were 6 patients excluded from study due to lack of followup. Of the remaining 59 patients 31 (52.5%) showed improvement in testicular appearance after detorsion and underwent orchiopexy, whereas 28 (47.5%) did not show evidence of recovery after detorsion. Of these patients 11 underwent tunica albuginea incision with tunica vaginalis flap coverage and 17 underwent orchiectomy. Demographic data, duration of symptoms and rate of testicular salvage were analyzed. Results: Mean patient age was 11.8 years (detorsion plus orchiopexy), 10.1 years (tunica albuginea incision plus tunica vaginalis flap coverage) and 10.1 years (detorsion plus orchiectomy). Average followup was greater than 6 months in all groups. Mean duration of torsion was 13.4 hours (detorsion plus orchiopexy), 31.2 hours (tunica albuginea incision plus tunica vaginalis flap coverage) and 67.5 hours (detorsion plus orchiectomy). Before tunica albuginea incision with tunica vaginalis flap coverage was offered, the rate of orchiectomy was 35.9% (14 of 39) vs 15% (3 of 20) after this technique was introduced (p Ͻ0.05). The rates of testicular salvage were 62.5% (detorsion plus orchiopexy), 54.6% (tunica albuginea incision plus tunica vaginalis flap coverage) and 0% (detorsion plus orchiectomy). Although the numbers are limited, it is likely that without tunica albuginea incision with tunica vaginalis flap coverage 6 of 11 testes would have been removed. Conclusions: This preliminary experience suggests that tunica albuginea incision with tunica vaginalis flap coverage is a promising option for the management of clinically marginal torsed testes, enhancing salvageability after prolonged ischemia. We recommend considering this maneuver before performing orchiectomy in selected cases of testicular torsion.

Research paper thumbnail of Nephron Sparing Surgery for Unilateral Wilms Tumor in Children with Predisposing Syndromes: Single Center Experience Over 10 Years

The Journal of Urology, 2012

Unilateral Wilms tumors associated with predisposing syndromes are treated with preoperative chem... more Unilateral Wilms tumors associated with predisposing syndromes are treated with preoperative chemotherapy followed by surgical resection. We describe our experience with nephron sparing surgery for Wilms tumor in this population at risk for metachronous lesions. We conducted a retrospective review of all children with a predisposing syndrome who underwent nephrectomy for malignancy during a 10-year period (2000 to 2010). Data collected included age, mode of detection, tumor size, treatment, pathology results, followup time and recurrence episodes. From 2000 to 2010, 13 of 75 (19%) patients treated for Wilms tumor were diagnosed with predisposing syndrome(s). Eight patients with unilateral tumors were treated and had a mean age at diagnosis of 27 months (range 7 months to 9 years). Beckwith-Wiedemann syndrome, isolated hemihyperplasia, WAGR (Wilms tumor, Aniridia, Genitourinary abnormalities, mental Retardation) syndrome and isolated 11p13 deletion were the underlying diagnoses in 3, 2, 2 and 1 patient, respectively. All but 2 patients were diagnosed by screening ultrasound and 5 underwent preoperative chemotherapy. Median tumor size at surgery was 2.5 cm (range 1 to 13). Nephron sparing surgery was performed in 6 of 8 patients. Pathological study showed favorable histology Wilms tumor and nephrogenic rests in 6 and 2 patients, respectively. After a mean followup of 36 months (range 6 to 72) no recurrences were documented and all children had normal creatinine levels. Nephron sparing surgery appears safe for patients with unilateral Wilms tumor associated with predisposing syndrome(s), allowing for the preservation of renal function and good oncologic outcomes for the available followup time. If more studies confirm our observation, current recommendations for the surgical treatment of Wilms tumor may need to reemphasize the value of attempting nephron sparing surgery in this patient population.

Research paper thumbnail of 550 Should Proximal Hypospadias with Bilaterally Descended Gonads Be Considered a Disorder of Sex Development (DSD)?

The Journal of Urology, 2011

Although the pathophysiology of recurrent UTI is multifactorial, its incidence in patients after ... more Although the pathophysiology of recurrent UTI is multifactorial, its incidence in patients after hypospadias repair is higher than normal population. This incidence may vary on surgical technique, for instance patients who underwent TIP repair may potentially have partial obstruction leading to elevated PVR and VUR. On the contrary patients experiencing recurrent UTI following a complicated TVIF repairs likely had increased urethral colonization secondary to urethral diverticulum or fistulas. Therefore, recurrent post-hypospadias surgery UTI should prompt a specific assessment for potentially functionally relevant post-surgical anatomic abnormality.

Research paper thumbnail of Early Postoperative Ultrasound After Open Pyeloplasty in Children with Prenatal Hydronephrosis Helps Identify Low Risk of Recurrent Obstruction

The Journal of Urology, 2012

Prediction of successful pyeloplasty can be challenging, particularly in asymptomatic children tr... more Prediction of successful pyeloplasty can be challenging, particularly in asymptomatic children treated for worsening prenatally diagnosed hydronephrosis. We evaluated early noninvasive objective predictors of success in this population. Materials and Methods: We reviewed patients who underwent pyeloplasty for asymptomatic, prenatally detected, worsening hydronephrosis treated between 2000 and 2010 with followup greater than 1 year. For all patients renal pelvis anteroposterior diameter in a mid transverse view and Society for Fetal Urology hydronephrosis grade were evaluated preoperatively and 3 to 4 months postoperatively. Aside from subjective evaluation based on change in hydronephrosis grade, we estimated the percentage of improvement in anteroposterior diameter (preoperative diameter Ϫ postoperative diameter/preoperative diameter). Repeat intervention after pyeloplasty arbitrarily defined failure. Patients were categorized into 3 groups, ie no failure on followup ultrasound (group 1), no failure with postoperative nuclear scan to document success (group 2) and failed pyeloplasty (group 3). ROC curves were plotted to correlate 4 variables with failure, namely preoperative anteroposterior diameter, postoperative anteroposterior diameter, percent improvement in anteroposterior diameter and subjective change in grade. Results: Of 229 patients 192 (84%) who met inclusion criteria had ultrasound at 3 to 4 months postoperatively available. Mean age at surgery was 19 months and mean Ϯ SD followup was 49.9 Ϯ 27.7 months. Percent improvement in anteroposterior diameter and postoperative anteroposterior diameter measure were the most reliable variables to predict failure (AUC 0.88 and 0.86, respectively, p Ͻ0.0001), whereas preoperative anteroposterior diameter and subjective changes in grade were not good predictors (AUC 0.52, p Ͼ0.05). A percent improvement in anteroposterior diameter of 38% or greater or postoperative anteroposterior diameter of 11.5 mm or less was associated with success, with sensitivity of 100% and specificity of 61% and 55%, respectively. Conclusions: Percent improvement in anteroposterior diameter and postoperative pelvic anteroposterior diameter measure can provide objective guidance as to which patients need closer monitoring during followup, and can help select children at low risk for repeat intervention after pyeloplasty.

Research paper thumbnail of Glans amputation during routine neonatal circumcision: Mechanism of injury and strategy for prevention

Journal of Pediatric Urology, 2013

Objective: Glans injury during circumcision is an uncommon yet potentially devastating complicati... more Objective: Glans injury during circumcision is an uncommon yet potentially devastating complication. Its mechanism remains poorly understood. Herein we critically evaluate a case series and, based on common characteristics, hypothesize the mechanism of injury as well as means to prevent it. Methods: Retrospective review of circumcision-related glans amputation cases referred for evaluation and management, focusing on detection of common history and presentation patterns in order to evaluate possible underlying mechanisms. Results: A neonatal elective circumcision was conducted using a Mogen clamp and an oblique injury to the ventro-lateral aspect of the glans was noted in 6 cases referred over a 5-year period, suggesting a similar trauma pattern. The urethra was consistently involved. The amputated segments were reattached as free composite grafts in 2/6 cases. Three patients underwent delayed glansplasty months after the trauma in an attempt to restore natural symmetry and cosmesis. In one case a buccal mucosa graft was employed to rebuild the ventral coronal sulcus. Conclusions: Trauma pattern suggests that the ventral glans is at high risk for injury by traction on incompletely released ventral preputial adhesions with subsequent glans entrapment.

Research paper thumbnail of Laparoscopic ureteral ligation (clipping): a novel, simple procedure for pediatric urinary incontinence due to ectopic ureters associated with non-functioning upper pole renal moieties

Journal of Pediatric Urology, 2014

Research paper thumbnail of Malignant tumor of the trachea in children: diagnostic pitfalls and surgical management

Journal of Pediatric Surgery, 2009

Primary tracheal malignant neoplasms are very rare. Histologically, squamous cell and adenoid cys... more Primary tracheal malignant neoplasms are very rare. Histologically, squamous cell and adenoid cystic carcinomas are the most common types of malignant primary tracheal tumors when all age groups are studied. In the past 5 years, we treated 2 children with tracheal mucoepidermoid carcinoma. Herein we report both cases and review the literature on the subject with particular emphasis on diagnosis and surgical management.

Research paper thumbnail of Surgical treatment of hepatic tumors in children: lessons learned from liver transplantation

Journal of Pediatric Surgery, 2009

Hepatectomy remains a complex operation even in experienced hands. The objective of the present s... more Hepatectomy remains a complex operation even in experienced hands. The objective of the present study was to describe our experience in liver resections, in the light of liver transplantation, emphasizing the indications for surgery, surgical techniques, complications, and results. The medical records of 53 children who underwent liver resection for primary or metastatic hepatic tumors were reviewed. Ultrasonography, computed tomographic (CT) scan, and needle biopsy were the initial methods used to diagnose malignant tumors. After neoadjuvant chemotherapy, tumor resectability was evaluated by another CT scan. Surgery was performed by surgeons competent in liver transplantation. As in liver living donor operation, vascular anomalies were investigated. The main arterial anomalies found were the right hepatic artery emerging from the superior mesenteric artery and left hepatic artery from left gastric artery. Hilar structures were dissected very close to liver parenchyma. The hepatic artery and portal vein were dissected and ligated near their entrance to the liver parenchyma to avoid damaging the hilar vessels of the other lobe. During dissection of the suprahepatic veins, the venous infusion was decreased to reduce central venous pressure and potential bleeding from hepatic veins and the vena cava. Fifty-three children with hepatic tumors underwent surgical treatment, 47 patients underwent liver resections, and in 6 cases, liver transplantation was performed because the tumor was considered unresectable. There were 31 cases of hepatoblastoma, with a 9.6% mortality rate. Ten children presented with other malignant tumors-3 undifferentiated sarcomas, 2 hepatocellular carcinomas, 2 fibrolamellar hepatocellular carcinomas, a rhabdomyosarcoma, an immature ovarian teratoma, and a single neuroblastoma. These cases had a 50% mortality rate. Six children had benign tumors-4 mesenchymal hamartoma, 1 focal nodular hyperplasia, and a mucinous cystadenoma. All of these children had a favorable outcome. Hepatic resections included 22 right lobectomies, 9 right trisegmentectomies, 8 left lobectomies, 5 left trisegmentectomies, 2 left segmentectomies, and 1 case of monosegment (segment IV) resection. The overall mortality rate was 14.9%, and all deaths were related to recurrence of malignant disease. The mortality rate of hepatoblastoma patients was less than other malignant tumors (P = .04). The resection of hepatic tumors in children requires expertise in pediatric surgical practice, and many lessons learned from liver transplantation can be applied to hepatectomies. The present series showed no mortality directly related to the surgery and a low complication rate.

Research paper thumbnail of Preserving bowel length with a transluminal stent in neonates with multiple intestinal anastomoses: a case series and review of the literature

Journal of Pediatric Surgery, 2011

Background/purpose: In neonatal surgery, preserving small bowel length is important to avoid shor... more Background/purpose: In neonatal surgery, preserving small bowel length is important to avoid short bowel syndrome. Our aim was to assess the outcomes of intraluminal stenting of neonatal multiple intestinal anastomoses. Methods: We conducted a retrospective review of 9 patients (5, single institution; 4, published literature) who received multiple anastomoses stented by a silicon tube. Demographics, surgical anatomy and complications, nutritional outcomes, and follow-up were reviewed. Results: Diagnosis was multiple intestinal atresias in 8 patients and necrotizing enterocolitis in 1. A silicon catheter entered either the mucous fistula (5 patients received a jejunostomy/mucous fistula) or a proximal opening on the dilated bowel and was threaded through viable segments of the bowel. The bowel ends were approximated. Stent was externalized in 7 patients. Final mean small bowel length was 63.9 cm. All complications (3 patients, leak/stricture) required surgery. Mean time to stent removal, feeds initiation, and parenteral nutrition (PN) discontinuation was 31.2 days, 17.3 days, and 159 days, respectively. Only 1 patient remains on PN (mean follow-up, 25.4 months). Conclusions: Multiple intestinal anastomoses stenting is an excellent technique to avoid short bowel syndrome in the setting of multiple viable segments of gut, such as type IV intestinal atresia or necrotizing enterocolitis. Both our experience and the published literature show no mortality and PN-free survival.

Research paper thumbnail of Transanal endorectal pull-through in children with Hirschsprung's disease—technical refinements and comparison of results with the Duhamel procedure

Journal of Pediatric Surgery, 2009

Transanal endorectal pull-through (TEPT) has drastically changed the treatment of Hirschsprung&am... more Transanal endorectal pull-through (TEPT) has drastically changed the treatment of Hirschsprung's disease (HD). A short follow-up of children submitted to TEPT reveals results that are similar to the classic transabdominal pull-through procedures. However, few reports compare the late results of TEPT with transabdominal pull-through procedures with respect to complication rates and the fecal continence. The aims of the present work are to describe some technical refinements that we introduced in the procedure and to compare the short and long-term outcome of TEPT with the outcomes of a group of patients with HD who previously underwent the Duhamel procedure. Thirty-five patients who underwent TEPT were prospectively studied and compared to a group of 29 patients who were treated with colostomy followed by a classical Duhamel pull-through. The main modifications introduced in the TEPT group were no preoperative colon preparation, operation conducted under general anesthesia in addition to regional sacral anesthesia, use of only one purse-string suture in the rectal mucosa before transanal submucosal dissection, and no use of retractors and electrocautery during the submucosal dissection. The most frequent early complications of TEPT group were perineal dermatitis (22.8%) and anastomotic strictures (8.6%). The comparison with patients who underwent Duhamel procedure revealed no difference in the incidence of preoperative enterocolitis, the patients of the TEPT group were younger at the time of diagnosis and of surgery, they had shorter operating times, and they began oral feeding more quickly after the operation. The incidence of wound infection was lower in the TEPT group. Moreover, the TEPT and Duhamel groups showed no difference in the incidences of mortality, postoperative partial continence, and total incontinence. Although the incidences of complete continence and postoperative enterocolitis were not different, a tendency to the increased incidence in the TEPT group was observed. This study further supports the technical advantages, the simplicity, and the decreased incidence of complications of a primary TEPT procedure when compared to a classical form of pull-through. Some technical refinements are described, and no preoperative colon preparation was necessary for the patients studied here. The results show that the long-term outcomes of the modified TEPT procedure are generally better than those obtained with classical approaches.

Research paper thumbnail of Laparoscopic extended cardiomyotomy in children: an effective procedure for the treatment of esophageal achalasia

Journal of Pediatric Surgery, 2010

Achalasia of the esophagus is characterized by aperistalsis and incomplete relaxation of the lowe... more Achalasia of the esophagus is characterized by aperistalsis and incomplete relaxation of the lower esophageal sphincter in response to swallowing. The objective of the present study is to present the experience of a modified Heller myotomy via a laparoscopic approach for the treatment of children who had this condition. A retrospective review of medical records of all patients who underwent this procedure from 2000 to 2009 was performed. The procedure consisted of an extended esophagomyotomy beginning on the lower part of the lower esophageal sphincter and continuing 5 to 6 cm above on the lower third of the esophagus, and then extended 3 to 4 cm below to the stomach, associated with an anterior 180-degree hemi-fundoplication according to Dor's technique. Fifteen patients were included in the study. There were 8 female and 7 male patients. Mean operating time was 190 minutes with no intraoperative complications and 1 conversion to open surgery because of difficulty in dissecting an inflamed distal esophagus. In a mean follow-up period of 32.3 months, 2 patients had recurrence of mild dysphagia that disappeared spontaneously, and 1 required a single botulinum toxin injection with complete resolution of symptoms. We conclude that the laparoscopic extended Heller myotomy with Dor fundoplication is a safe and effective method for the treatment for achalasia in the pediatric population even in advanced cases.

Research paper thumbnail of Comparison Between Laparoscopic and Open Radical Nephroureterectomy in a Contemporary Group of Patients: Are Recurrence and Disease-Specific Survival Associated with Surgical Technique?

European Urology, 2010

Background: Open radical nephroureterectomy (ORN) is the current standard of care for upper tract... more Background: Open radical nephroureterectomy (ORN) is the current standard of care for upper tract urothelial carcinoma (UTUC), but laparoscopic radical nephroureterectomy (LRN) is emerging as a minimally invasive alternative. Questions remain regarding the oncologic safety of LRN and its relative equivalence to ORN. Objective: Our aim was to compare recurrence-free and disease-specific survival between ORN and LRN. Design, setting, and participants: We retrospectively analyzed data from 324 consecutive patients treated with radical nephroureterectomy (RN) between 1995 and 2008 at a major cancer center. Patients with previous invasive bladder cancer or contralateral UTUC were excluded. Descriptive data are provided for 112 patients who underwent ORN from 1995 to 2001 (pre-LRN era). Comparative analyses were restricted to patients who underwent ORN (n = 109) or LRN (n = 53) from 2002 to 2008. Median follow-up for patients without disease recurrence was 23 mo. Intervention: All patients underwent RN. Measurements: Recurrence was categorized as bladder-only recurrence or any recurrence (bladder, contralateral kidney, operative site, regional lymph nodes, or distant metastasis). Recurrence-free probabilities were estimated using Kaplan-Meier methods. A multivariable Cox model was used to evaluate the association between surgical approach and disease recurrence. The probability of disease-specific death was estimated using the cumulative incidence function. Results and limitations: Clinical and pathologic characteristics were similar for all patients. The recurrence-free probabilities were similar between ORN and LRN (2-yr estimates: 38% and 42%, respectively; p = 0.9 by log-rank test). On multivariable analysis, the surgical approach was not significantly associated with disease recurrence (hazard ratio [HR]: 0.88 for LRN vs ORN; 95% confidence interval [CI], 0.57-1.38; p = 0.6). There was no significant difference in bladder-only recurrence (HR: 0.78 for LRN vs ORN; 95% CI, 0.46-1.34; p = 0.4) or disease-specific mortality (p = 0.9). This study is limited by its retrospective nature. Conclusions: Based on the results of this retrospective study, no evidence indicates that oncologic control is compromised for patients treated with LRN in comparison with ORN.

Research paper thumbnail of Gastroesophageal reflux disease in children: efficacy of Nissen fundoplication in treating digestive and respiratory symptoms. Experience of a single center

Diseases of the Esophagus, 2008

Fundoplication has been commonly performed in neurologically impaired and normal children with co... more Fundoplication has been commonly performed in neurologically impaired and normal children with complicated gastroesophageal reflux disease. The relationship between gastroesophageal reflux disease and respiratory diseases is still unclear. We aimed to compare results of open and laparoscopic procedures, as well as the impact of fundoplication over digestive and respiratory symptoms. From January 2000 to June 2007, 151 children underwent Nissen fundoplication. Data were prospectively collected regarding age at surgery, presence of neurologic handicap, symptoms related to reflux (digestive or respiratory, including recurrent lung infections and reactive airways disease), surgical approach, concomitant procedures, complications, and results. Mean age was 6 years and 9 months. Eighty-two children (54.3%) had neurological handicaps. The surgical approach was laparoscopy in 118 cases and laparotomy in 33. Dysphagia occurred in 23 patients submitted to laparoscopic and none to open procedure (P = 0.01). A total of 86.6% of patients with digestive symptoms had complete resolution or significant improvement of the problems after the surgery. A total of 62.2% of children with recurrent lung infections showed any reduction in the frequency of pneumonias. Only 45.2% of patients with reactive airway disease had any relief from bronchospasm episodes after fundoplication. The comparisons demonstrated that Nissen fundoplication was more effective for the resolution of digestive symptoms than to respiratory manifestations (P = 0.04). Open or laparoscopic fundoplication are safe procedures with acceptable complication indices and the results of the surgery are better for digestive than for respiratory symptoms.

Research paper thumbnail of Percutaneous Central Venous Catheterization in a Pediatric Intensive Care Unit

Critical Care Medicine, 1990

We prospectively determined the complications of percutaneous central venous catheterizations per... more We prospectively determined the complications of percutaneous central venous catheterizations performed by medical house officers In 302 patients. We also analyzed the factors affectlng the success and complication rates of such invasive procedures. The central vein was successfully catheterized In 363 (77%) of 470 attempts. The Internal jugular and subclavian vein approaches were significantly more successful (86K) than the external jugular vein approach (61 %, P c 0.001 by x*). The success rate improved significantly when catheterization was attempted under elective circumstances(P c 0.003) and also after the vein was Initially located with a smallgauge needle (P c 0.001). Our results suggest that efforts should be abandoned after the third unsuccessful pass with a largegauge needle in the same site. Complications of catheter insertion included bleeding (ten patients), hematoma (15 patients), inadvertent arterial punctures (14 patients), iatrogenic pleural effusions (four patients), and pneumothoraces (eight patients). No compllcatlons appeared to have a major adverse effect on a patient's clinical course. The inexperienced operator (fewer than 25 prior catheterizations) has a success rate equal to that of the more experienced operator (more than 25 priorcatheterizations), but he may be more likely to produce a complication. Medlcal house officers can perform percutaneous central venous catheterizations with a high rate of success and at low risk to the patient.

Research paper thumbnail of Carcinoma folicular de tireóide: estudo retrospectivo

Revista do Colégio Brasileiro de Cirurgiões, 2001

OBJETIVOS: Abordar o diagnóstico, tratamento e evolução do carcinoma folicular da tireóide. MÉTOD... more OBJETIVOS: Abordar o diagnóstico, tratamento e evolução do carcinoma folicular da tireóide. MÉTODOS: Análise retrospectiva dos dados de 38 pacientes submetidos à tireoidectomia por carcinoma folicular puro, num período de 10 anos no HC-FMUSP. O tempo médio de seguimento foi de três anos e três meses. Nove pacientes eram do sexo masculino (23,7%) e 29 do sexo feminino (76,3%), com idades entre 19 e 87 anos (média=49,5). RESULTADOS: Em 17 (58,6%) dos doentes, observou-se nódulo único à ultra-sonografia, e 23 (79,3%) tinham nódulos frios à cintilografia. Sintomatologia esteve presente em 33 pacientes (86,8%). A punção aspirativa por agulha fina (PAAF), realizada em 27 pacientes, revelou padrão folicular em 24 (88,9%), carcinoma papilífero em 2 (7,4%) e bócio em 1 (3,7%). Tireoidectomia total foi o tratamento final em 34 pacientes e esvaziamento cervical foi realizado em três casos. Apenas 5 (13,1%) obtiveram confirmação diagnóstica ao exame de congelação intra-operatória. Houve 2 (5,2%...