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Introduction: Adrenal carcinomas are rare and are associated with a very poor prognosis. The incidence is estimated to be 1 in 1.7 million which represents 0.02% of all cancers and 0.2% of all cancer mortality. The 5-year survival rate is 38%. The purpose of this paper is to present a single-institution experience in excising right-sided giant adrenal carcinomas, discussing the difficulties and the usage of special surgical devices to facilitate the procedure. Patients and Methods: During June 2001 to June 2003, 18 patients with right-sided adrenal tumors were treated at the State University of Campinas Hospital – UNICAMP. 4 out of the 18 patients presented lesions >15 cm, representing the study group. The mean age was 37 (range 26–65) years, 3 patients were younger than 35 years, and 2 patients were men. A right-sided extended subcostal incision was the surgical access in 1 patient (case 1) and a right-sided thoracoabdominal incision in the other 3 patients. Results: Adrenal cortical carcinoma was the histological diagnosis according to the Weiss criteria; no positive surgical margin was detected, even in those patients with invasion of the hepatic capsule. The median follow-up period was 15 (range 6–30) months. Conclusions: A subcostal extended incision can accomplish broad exposure, if articulated costal retractors are available (used in liver transplantation), otherwise a thoracoabdominal incision is the best option. The most important feature of surgery is to accomplish an efficient hemostasis of the liver parenchyma. Suture and stitches are not suitable for minor vascular structures, and electrocauterization sometimes promotes hepatic lesions and does not provide bleeding control. Thus, the need for special hemostatic means is real, and they should be avaiable in these situations.

We compared laparoscopy assisted and open ileocystoplasty in an experimental model in pigs. We evaluated intraoperative aspects, postoperative recovery, peritoneal adhesions and functional results.The study included 30 male pigs divided into 4 groups, including 10 with laparoscopy assisted ileocystoplasty, 10 with open surgery, 5 with sham laparoscopy and 5 with sham open surgery. Variables studied were total operative time, ileovesical anastomosis time, postoperative urodynamic findings (bladder capacity and compliance), daily and weekly weight gain, and intraperitoneal adhesions (incidence, type and score).Mean operative time in the laparoscopic and open groups was 179.4 and 69.6 minutes, respectively, which was significantly different (p0.05). Mean ileovesical anastomosis time was also significantly different for laparoscopic vs open surgery (74.8 vs 31.8 minutes, p0.05). Significant differences were observed in mean weekly weight gain during the first 4 weeks after surgery. Postoperatively bladder capacity and compliance differences among the groups were not significantly different (p0.05). The overall incidence of intraperitoneal adhesions was not significantly different in all groups (p0.05). However, in the open vs laparoscopy, sham laparoscopy and sham open surgery groups adhesion complexity was greater and mean score was higher (4.2 vs 2.8, 2.0 and 2.0, respectively), which was statistically significantly different (p0.05).Laparoscopy assisted ileocystoplasty requires more operative time than open surgery. However, postoperative recovery is more rapid and intraperitoneal adhesions are less complex in pigs with laparoscopy assisted ileocystoplasty vs conventional surgery. Functional results are comparable for open and laparoscopy assisted ileocystoplasty.

OBJECTIVE: The purpose of this series is to report our experience in managing ureteral trauma, focusing on the importance of early diagnosis, correct treatment, and the impact of associated injuries on the management and morbid-mortality. MATERIALS AND METHODS: From January 1994 to December 2002, 1487 laparotomies for abdominal trauma were performed and 20 patients with ureteral lesions were identified, all of them secondary to penetrating injury. Medical charts were analyzed as well as information about trauma mechanisms, diagnostic routine, treatment and outcome. RESULTS: All patients were men. Mean age was 27 years. The mechanisms of injury were gunshot wounds in 18 cases (90%) and stab wounds in two (10%). All penetrating abdominal injuries had primary indication of laparotomy, and neither excretory urography nor computed tomography were used in any case before surgery. The diagnosis of ureteric injury was made intra-operatively in 17 cases (85%). Two ureteral injuries (10%) were initially missed. All patients had associated injuries. The treatment was dictated by the location, extension and time necessary to identify the injury. The overall incidence of complications was 55%. The presence of shock on admission, delayed diagnosis, Abdominal Trauma Index > 25, Injury Severity Score > 25 and colon injuries were associated to a high complication rate, however, there was no statistically significant difference. There were no mortalities in this group. CONCLUSIONS: A high index of suspicion is required for diagnosis of ureteral injuries. A thorough exploration of all retroperitoneal hematoma after penetrating trauma should be an accurate method of diagnosis; even though it failed in 10% of our cases.

Bladder dysfunction may lead to urinary incontinence and progressive kidney deterioration. When clinical treatment fails, bladder augmentation is the operation of choice in most cases. The purpose of this study was the standardization of the technique of videolaparoscopic ileocystoplasty in a porcine model and demonstration of a tutor-supervised learning curve.The study was conducted on 15 Large-White male pigs (20-25 kg) that underwent ileocystoplasty with 15 cm of distal ileum shaped into a using extracorporeal technique and laparoscopic ileovesical anastomosis. Operative time, ileovesical anastomosis time, intraoperative complications, and extravasation after anastomosis were evaluated. To assess the learning curve, the animals were divided into three groups of five: group I (operated on in collaboration with a tutor), group II (treated under the supervision of tutor), and group III (without the tutor's collaboration or supervision).Total surgical time and ileovesical anastomosis time revealed significant differences (P0.05) between groups I and III (70% reduction) as well as between groups II and III (64% reduction).Laparoscopic ileocystoplasty in pigs is feasible without special laparoscopic material. Ten initial procedures with a tutor's help were important for technique acquisition and mastery. A sharp increase in efficiency occurs between the tenth and fifteenth procedures. These procedures should be executed at least ten times in the presence of the tutor to enable the surgeon to overcome the learning curve.

OBJECTIVE To describe a technical modification that facilitates nephron-sparing surgery (NSS) for renal tumours, without clamping the renal pedicle or promoting renal surface hypothermia. PATIENTS AND METHODS Seventeen patients with renal tumours had NSS using the selective renal-parenchymal clamping technique. In 11 patients the tumour was polar and in six it was central. The mean (range) size of the tumours was 3.6 (2-6) cm. The technique was performed using one or two large Satinsky vascular clamps. Time was not limited as there was no clamping of the renal pedicle, or renal hypothermia. RESULTS The mean (range) operative duration was 190 (120-300) min. Only one patient needed a blood transfusion. There were no complications in 13 patients after NSS. The mean (range) hospital stay was 5 (3-12) days. The pathological examination detected malignant tumours in 13 patients, and a microscopic examination showed adequate surgical margins in all. The mean (range) follow-up was 24.5 (4-60) months. No patients required haemodialysis immediately after surgery or later. CONCLUSIONS Selective renal parenchymal clamping is a simple and efficient technical manoeuvre that facilitates NSS without dissection or clamping of the renal pedicle. Time is not limited as the ischaemia is limited to the tissue surrounding the tumour. The operative duration and blood loss are acceptable and the complications similar to those with the conventional technique. The size and position of the tumour could be limiting factors to this technique.