MARCOS FIGUEIREDO MELLO
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- Urethral duplication type influences on the complications rate and number of surgical procedures(2017) LOPES, Roberto Iglesias; GIRON, Amilcar Martins; MELLO, Marcos Figueiredo; BARBOSA NETO, Cristovao Machado; SANTOS, Joana dos; MOSCARDI, Paulo Renato Marcelo; SROUGI, Victor; DENES, Francisco Tibor; SROUGI, MiguelIntroduction: Urethral duplication is rare. Characterized by the presence of two urethral channels. This anomaly presents a great variety of clinical findings that depend on the type of duplication that often is associated with other anomalies. Material and Methods: We report thirteen boys with urethral duplication managed in our institution between 1988-02015. Clinical findings, associated anomalies, treatment of urethral duplication and our results are described. Patients were classified according to Effmann classification. Results: Mean patient's age was 38.3 +/- 34.7 months (3-0136 months). Mean follow-up was 7.7 +/- 3.4 years (3y8m-014y2m). Type II A2 was the most common pattern (8/13 patients, 61.5%), followed by type IA (3/13 patients, 23%) and IIA1 (2/13 patients, 15.3%). The most frequent clinical manifestations were urinary tract infections (UTI) observed in 11/13 patients (84.6%) and anal urinary leakage, found in 7/13 patients (53.8%). Associated anomalies were found in 9/13 patients (69.2%). Required surgeries were 3.53 +/- 2.84 procedures per patient. Considering groups: Type IIA2 4.25 +/- 3.28, type IIA1 4 +/- 1.41 and type IA 1.33 +/- 0.57 needed procedures per patient. Complications rate were 0% for type IA, 50% for type IIA1 and 75% for type IIA2. Conclusions: Patients with incomplete duplication (type I A or I B) can totally be asymptomatic, with no need of surgical correction. Type IIA2 is the most complex form of duplication to correct and multiple procedures might be required because of the very hypoplastic orthotopic dorsal urethral tissue. Surgical treatment should be individualized and parents should be advised on complications and need of multiple surgeries according to urethral duplication type.
- Single-stage Abdominoplasty Using Groin Flaps Without Osteotomies: Management of Exstrophy-epispadias Complex(2018) GIRON, Amilcar Martins; MELLO, Marcos Figueiredo; BERJEAUT, Ricardo Haidar; MACHADO, Marcos Giannetti; SILVA, Gabriel Carvalho dos Anjos; CEZARINO, Bruno Nicolino; OLIVEIRA, Lorena Marcalo; LOPES, Roberto Iglesias; DENES, Francisco TiborBACKGROUND The optimal treatment for children born with exstrophy-epispadia complex is still a matter of AND OBJECTIVE debate.(1,2,3) We demonstrate the Single-Stage Abdominoplasty using Groin Flap technique to close the abdominal wall of children with classic bladder exstrophy (CBE) without osteotomy neither radical soft tissue mobilization. Advantages over current techniques are less risk of penile tissue loss and avoidance of osteotomies. MATERIAL AND METHODS Abdominal wall repair consists in using the hypogastric skin, rectus, and obliquus externus abdom inalis muscle fascial flaps. These groin flaps are rotated medially resulting in a very strong abdominal wall support. Groin flaps are made of rectus anterior fascia rotated medially, flipped over, and sutured with Prolene sutures to close the defect. By rotating the fascial flaps medially, complete reinforcement of the abdominal wall to the level of the pubic bone is achieved. This permits abdominal closure maintenance without tension. RESULTS Groin flap was applied to 128 patients with CBE referenced from all over the country. Most of these patients returned to their home areas making difficult their follow up. However, we have 44 cases that have regular clinical visits. Mean follow-up was 10.3 4.5 years (2 years 8 months-16 years). Successful closure was achieved in 43 patients (97.7%) as a single procedure; one patient had a complete wound dehiscence and needed another reconstruction (2.2%). Four patients (9.1%) presented abdominal hernias that needed surgical management. When continence is evaluated, we present similar literature rates (60%).(4) CONCLUSION Abdominal reconstruction using Groin flaps has advantages over the traditional approaches to CBE. It reduces the surgical steps and facilitates the closure of the abdominal wall without the need of osteotomies and consequent immobilization during the postoperative period. It is feasible at any age and can be also very useful as a salvage technique even after previous failed procedures. Finally, it minimizes the number of surgeries. (C) 2018 Elsevier Inc.
- One - staged reconstruction of bladder exstrophy in male patients: long - term follow-up outcomes(2017) GIRON, Amilcar Martins; MELLO, Marcos Figueiredo; CARVALHO, Paulo Afonso; MOSCARDI, Paulo Renato Marcelo; LOPES, Roberto Iglesias; SROUGI, MiguelIntroduction: The surgical correction of bladder exstrophy remains challenging. In our institution, the repair has evolved from a staged repair to one-stage reconstruction. The one-stage reconstruction includes; bladder closure, Cantwell-Ransley neourethroplasty and abdominoplasty using groin flaps, without the need of pelvic ostheotomies. Repair of urinary continence (UC) and vesicoureteral reflux (VUR) is done after development of the infant. Objective: To present our experience of our modified one-stage reconstruction of bladder exstrophy in male patients. Materials and Methods: Medical records of male patients submitted to one-stage reconstruction of bladder exstrophy were analyzed retrospectively. Fifteen exstrophy bladder patients with mean age 4.2 +/- 7 years were treated at our institution between 1999-2013. Results: Eleven patients were referred to us after previous surgery. Sixteen procedures were performed; one patient had complete wound dehiscence and needed another reconstruction (6.7%). Mean follow up was 10.3 +/- 4.5 years. No patient has had a loss of renal function. Postoperative complications: four patients (26.6%) presented small fistulas, one presented penile rotation. Eleven patients (73.3%) patients underwent bladder-neck surgery. Five (33.3%) required bladder augmentation. Three cases (20%) needed subsequent treatment of VUR. At the time of our review nine (60%) patients achieved UC, two (13.3 %) patient without additional procedure. A mean of 3 +/- 1.1 procedures (2-5) was accomplished per children. Conclusions: One-stage reconstruction minimizes the number of surgical procedures required to achieve UC and potentiates bladder-neck function. The advantages of using groin flaps over current techniques for complete repair are the small risk for penile tissue loss and the avoidance of ostheotomies.
- Evaluating TIMP-2 and IGFBP-7 as a predictive tool for kidney injury in ureteropelvic junction obstruction(2022) MELLO, Marcos Figueiredo; BESSA JUNIOR, Jose de; REIS, Sabrina T.; KONDO, Enzo Yagi; YU, Luis; DENES, Francisco Tibor; LOPES, Roberto IglesiasA major challenge in the management of ureteropelvic junction obstruction (UPJO) is the selection of patients who would benefit from surgical treatment. Tissue inhibitor metalloproteinase-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) indicate renal cell stress and are associated with cell cycle arrest. The [TIMP-2] [IGFBP7] ratio (Nephrocheck (R)) has been recently applied in patients in intensive care units patients to predict the development of acute kidney injury. In this study, we evaluated the performance of these biomarkers performance to distinguishing obstructive hydronephrosis (HN) from non-obstructive HN. Materials and Methods: Consecutive patients with UPJO were enrolled in this study. Urinary [TIMP-2] [IGFBP7] and clinical characteristics (hydronephrosis grade, differential renal function, and drainage half-time) were measured in the following groups: 26 children with obstructive HN at initial diagnosis (group IA) and after six months of dismembered pyeloplasty (group 1B); 22 children with non-obstructive HN (group 2), and 26 children without any urinary tract condition, as the control group (group 3). Results: Comparing the initial samples, [TIMP-2] [IGFBP7] had higher levels in the HN groups and lower levels in the control group; however, no difference was observed between the HN groups (obstructive vs. non-obstructive). After six months of followup, patients who underwent dismembered pyeloplasty showed stability in the urinary concentration of [TIMP-2] [IGFBP7]. All patients with [TIMP-2] [IGFBP7] higher than 1.0 (ng/mL)(2)/1000 had diffuse cortical atrophy on ultrasonography. Conclusions: We showed that urinary levels of urinary [TIMP-2] [IGFBP7] are higher in children with HN than controls. Nephrocheck (R) is not reliable in predicting the need for surgical intervention for pediatric patients with UPJO.
- Urinary extracellular matrix proteins as predictors of the severity of ureteropelvic junction obstruction in children(2021) MELLO, Marcos Figueiredo; REIS, Sabrina Thalita dos; KONDO, Enzo Yagi; BESSA JUNIOR, Jose de; DENES, Francisco Tibor; LOPES, Roberto IglesiasIntroduction Ureteropelvic junction obstruction (UPJO) particu-larly represents a challenge in regard to manage-ment, as not all hydronephrosis (HN) represent a kidney-damaging state. Urinary biomarkers have been proposed as noninvasive tools. Extracellular matrix (ECM) proteins are associated with tissue fibrosis in the setting of UPJO and is poorly explored. Objective To investigate whether urinary ECM proteins are useful to discriminate the severity of urinary obstruction on unilateral UPJO. Study design Children with unilateral UPJO were prospective enrolled. Urinary (u) matrix metalloproteinases (MMP-1,-2,-9 and TIMP-1,-2) as well as clinical characteristics were measured in the following groups: 26 children with obstructive HN at initial diagnosis and after six months of dismembered pyeloplasty; 22 children with non-obstructive HN at diagnosis and after six months of observation; 26 children without any urinary tract condition, as the control group. Results were assessed statistically using for homogenous groups, a one-way analysis of variances (ANOVA) and for nonparametric groups, Mann-Whitney test or Kruskal-Wallis test was per -formed. ROC curves were performed. Results Baseline samples demonstrated a higher concentra-tion of uMMP-1/Cr, uMMP-2/Cr, u-TIMP-1/Cr and u-TIMP-2/Cr in obstructive HN group; uMMP-9/Cr levels were higher in non-obstructive HN group and all studied biomarkers had lower concentrations for the control group. On follow-up, for the obstructive HN group, urinary concentration of uTIMP-1/Cr and uTIMP-2/Cr decreased, and uMMP-1/Cr, uMMP-2/Cr and uMMP-9/Cr increased when comparing preop-erative to postoperative values. In the non-obstructive HN group, all proteins analyzed were stable after six months of observation. ROC curves analysis showed a promising diagnostic profile for the detection of obstructive HN for uTIMP-1/Cr (area under the curve-AUC-; of 0.692), uTIMP-2/Cr (AUC of 0.678) and for uMMP-2/Cr (AUC of 0.655). Discussion The severity of kidney obstruction could correlate with the urinary ECM proteins concentration in this study. This is concordant with prior studies demon-strating that a disruption of the balance of accu-mulation/degradation of the ECM proteins occur on obstructive uropathy. Limitations of our study include the older age of our patients and that these markers had no influence at all on the surgical decision. Conclusion We demonstrate that obstructive HN have signifi-cantly higher uMMP-2, uTIMP-1 and uTIMP-2 con-centrations. Particularly, uTIMP-2 levels were correlated to severity of obstruction and therefore, it might be a useful urinary biomarker to correctly allocate children with HN between surgical man-agement vs follow-up. After pyeloplasty, uTIMP-1 and uTIMP-2 presented a progressive decrease postoperatively, which is also highly desirable for urinary markers.
- Reoperative Laparoscopic Ureteropelvic Junction Obstruction Repair in Children: Safety and Efficacy of the Technique(2017) MOSCARDI, Paulo Renato Marcelo; BARBOSA, Joao Arthur Brunhara Alves; ANDRADE, Hiury Silva; MELLO, Marcos Figueiredo; CEZARINO, Bruno Nicolino; OLIVEIRA, Lorena Marcalo; SROUGI, Miguel; DENES, Francisco Tibor; LOPES, Roberto IglesiasPurpose: Failure after pyeloplasty for ureteropelvic junction obstruction in children may occur in up to 10% of cases. Therapeutic options include Double-J (R) stent placement, endoscopic treatment and reoperation. Laparoscopic and robotic reoperative modalities seem safe and efficacious, although pediatric series are limited in the literature. We report the largest known series of reoperative laparoscopic ureteropelvic junction obstruction repair in children and compare this approach to primary laparoscopic pyeloplasty. Materials and Methods: We reviewed all children undergoing laparoscopic pyeloplasty at a single institution from 2004 to 2015. Reoperative laparoscopic ureteropelvic junction obstruction repair was compared to primary pyeloplasty. Groups were analyzed regarding demographics, operative time, complications, length of hospital stay and success, defined by improvement of symptoms, ultrasound and renogram. Results: We identified 11 cases of reoperation (8 redo pyeloplasties and 3 ureterocalycostomies) and 71 primary pyeloplasties. Groups were not different in age, gender or weight. Median followup was 37 months. Median time between primary pyeloplasty and reoperation was 34 months. Median operative time was 205 minutes for the reoperative group and 200 for primary pyeloplasty (p = 0.98). Length of stay was longer in the reoperative group (p = 0.049), although no major complications were recorded in this group. All reoperative cases and 96% of primary pyeloplasty cases remained asymptomatic following surgery (p = 0.99). Postoperative improvement was similar for both groups on ultrasound (90% for reoperation vs 92% for primary pyeloplasty, p = 0.99) and renogram (80% vs 88%, p = 0.6). Conclusions: Laparoscopy seems to be safe and effective for management of failed pyeloplasty in children. Based on our data, reoperation is as safe and effective as primary pyeloplasty.
- Transperitoneal laparoscopic pyeloplasty in children: does upper urinary tract anomalies affect surgical outcomes?(2018) BRUNHARA, Joao Arthur; MOSCARDI, Paulo Renato Marcelo; MELLO, Marcos Figueiredo; ANDRADE, Hiury Silva; CARVALHO, Paulo Afonso de; CEZARINO, Bruno Nicolino; DENES, Francisco Tibor; LOPES, Roberto IglesiasObjective: To assess the feasibility and outcomes of laparoscopic pyeloplasty in children with complex ureteropelvic junction obstruction (UPJO) and compare to children with iso-lated UPJO without associated urinary tract abnormalities. Material and Methods: Medical records of 82 consecutive children submitted to trans-peritoneal laparoscopic pyeloplasty in a 12-year period were reviewed. Eleven cases were con-sidered complex, consisting of atypical anatomy including horseshoe kidneys in 6 patients, pelvic kidneys in 3 patients, and a duplex collecting system in 2 patients. Patients were di-vided into 2 groups: normal anatomy (group 1) and complex cases (group 2). Demographics, perioperative data, outcomes and complications were recorded and analyzed. Results: Mean age was 8.9 years (0.5-17.9) for group 1 and 5.9 years (0.5-17.2) for group 2, p=0.08. The median operative time was 200 minutes (180-230) for group 1 and 203 minutes (120-300) for group 2, p=0.15. Major complications (Clavien =3) were 4 (5.6%) in group 1 and 1 (6.3%) in group 2, p=0.52. No deaths or early postoperative complications such as: urinoma or urinary leakage or bleeding, occurred. The success rate for radiologic improvement and flank pain improvement was comparable between the two groups. Re-garding hydronephrosis, significant improvement was present in 62 patients (93.4%) of group 1 and 10 cases (90.9%) of group 2, p=0.99. The median hospital stay was 4 days (IQR 3-4) for group 1 and 4.8 days (IQR 3-6) for group 2, p=0.27. Conclusions: Transperitoneal laparoscopic pyeloplasty is feasible and effective for the management of UPJO associated with renal or urinary tract anomalies.