Repositório RCAAP

Introduction: Shortage of high quality donors led to an increasing need of compatible organs: grafts with multiple renal arteries (MRA) are one of the solutions, although being a potential risk factor that can impair outcomes. The aim of this study is to provide a view of our experience with multiple renal arteries grafts in renal transplantation and compare the outcome between multiple renal arteries and single renal artery (SRA) groups. Material and Methods: A retrospective study of 2989 kidney transplants was performed in our department between January 1980 and February 2017: demographic characteristics and outcomes were compared between recipients of grafts with multiple renal arteries (648; 21.7%) and single renal artery (2341; 78.3%). Statistical analysis was done using IBM SPSS Statistics 22: chi-square, independent sample t-test and Kaplan Meier tests were used with a p value of 0.05. Results: Grafts from cadaveric donors occurred in 95.8% of the single renal artery group and 97.4% of multiple renal arteries group. The recipients of multiple renal arteries group had a previous higher time on dialysis (50.3 ± 43.1 vs 46.30 ± 37.5 months, p:0.04), a longer operative time (2.43 ± 0.57 vs 2.28 ± 0.49 hours, p<0.001), a higher cold ischemia time (19h08 ± 6h05 vs 18h34 ± 6h17 hours, p:0.04) and more red blood cell transfusions (1.8 ± 0.8 vs 1.7 ± 0.8 packs, p:0.01) than the recipients of single renal artery kidney recipients. In the multiple renal arteries group, ex-vivo bench surgery techniques, in vivo sequential anastomosis and mixed techniques were used. The different options did not affect the outcomes. The rate of delayed graft function, surgical complications, length of hospital stay, acute and chronic rejections, graft loss, death were not statistically different. The follow-up was not statistically different: multiple renal arteries (8 ± 7.3 years) versus single renal artery (7.7 ± 6.6 years) group (p:0.1). The current state of the patient was not dependent on the number of arteries used. Conclusion: Multiple renal arteries grafts were not a problem in our unit: despite of having a longer operative time, higher cold ischemia time and higher blood transfusions rate, short and long-term outcomes were comparable between groups. At this level, literature results are not consensual: prospective studies are necessary.

Cavernosal abscess is an uncommon condition. It can be idiopathic or with an underlying cause. Surgical drainage and systemic antibiotics remain the first line of treatment regarding long-term sequelae. The authors report a rare case of a 51-year-old man with a bilateral cavernosal abscess with no underlying cause. The patient was treated with surgical drainage and systemic antibiotics. Culture of pus was positive for Staphylococcus aureus. There were no sequelae at six-month follow-up.

Introduction: Chronic kidney disease is a prevalent disorder, with a significant number of late stage patients, which only options are renal replacement therapy and transplantation. Kidney transplantation is associated with higher quality of life and lower mortality. The increasing gap between the demand for kidneys and its availability for transplantation has prompted the research and development of an alternative source to the conventional brain dead donors, the donors after cardiac death. The latter need preservation techniques in order to offer similar functional results. In the present article, we proposed to review the recent evidence about the role of extracorporeal membrane oxygenation as preservation technique in the harvesting of kidneys from donors after circulatory death. Material and Methods: A literature research was conducted in PubMed/MEDLINE, using the following expressions: “kidney transplantation”; “non-heart-beating donor”; “donation after cardiac death”; “extracorporeal membrane oxygenation”; “abdominal normothermic perfusion”. Based on the selected articles, it was performed a non-systematic review, summarizing the recent evidence about the role of extracorporeal membrane oxygenation as preservation technique in the harvesting of kidneys from donors after circulatory death. Results: The evidence suggests that extracorporeal membrane oxygenation is better than the other preservation techniques used in donors after cardiac death, as it has been associated to improved renal allograft outcomes. Regarding the conventional deceased donors, the brain dead, this technique allows similar results, particularly when compared with expanded criteria donors. Discussion: Organ preservation through extracorporeal membrane oxygenation in cardiac death donors has favorable functional results and, for this reason, may contribute to increase the pool of donors. The logistical challenges of the technique restrict its implementation. Conclusion: In the long-term, should be created conditions so that extracorporeal membrane oxygenation in donors after cardiac death may be widely implemented, increasing the number of kidneys obtained for transplantation.

Introduction: Obesity is an increasingly common disease in patients with end-stage chronic kidney disease candidates for renal transplantation. It is an important factor that should be addressed in the period before renal transplantation. The aim of this study is to evaluate the impact of pretransplantation body mass index (BMI) in graft and recipient outcomes. Material and Methods: An observational retrospective analysis of 913 kidney transplantations was performed between September 2010 and May 2017. Recipients were categorized in groups: obesity (group 1), overweight (group 2) and normal BMI (group 3). A preoperative protocol was used: recipient and donor characteristics, perioperative data, graft and patient survival were evaluated. The software used was IBM SPSS Statistics 23: p value of < 0.05 was considered statiscally significant. Results: Overweight was observed in 36.2% and obesity in 12.3%. In groups 1 and 2, there was a higher prevalence of type II diabetes mellitus compared with group 3 (17.9%, 16.4%, 6.6%, respectively, p < 0.001). Recipient creatinine serum levels at first and third months were also statistically different. Both groups 1 and 2 showed higher surgery duration and postoperative length of stay. It was noticed a lower immediate diuresis rate in group 1 (63.2%) and in group 2 (80.4%), p < 0.0001. Perioperative complications were more prevalent in groups 1 and 2, especially lymphocele formation (21.4% and 7.7%, respectively, versus 3.6%) and wound dehiscence (21.4% and 5.8%, respectively, versus 1.2%), p < 0.05. No statistically differences were seen in graft and patient survival. Conclusion: Pretransplantation weight is important in renal transplantation: worse renal function in the first and third months, longer surgery duration and postoperative length of stay, higher delayed graft function rate and a higher prevalence of lymphocele formation and wound dehiscence were noticed in both non-normal weight groups. However, obese and overweight groups showed similar survival and long-term outcome comparing with normal BMI recipients.

Introduction: Our objective was to evaluate success and complication rates of different techniques of transvaginal correction for apical prolapse using native tissues. Material and Methods: Retrospective study of 41 transvaginal apical prolapse repair using native tissues, performed by the Urogynecology Department of a tertiary hospital, from January 2013 to June 2018. Results: In our sample, mean age was 66 years; all women were multiparous and 95.1% were postmenopausal. Regarding past surgical history 47.5% had a previous hysterectomy and 17.5% an anterior, 10.0% a posterior and 7.5% an apical prolapse repair. On clinical examination, in addition to apical prolapse, 24.4% presented prolapse of the anterior compartment, 4.9% of the posterior compartment and 53.7% of both. Surgical apical prolapse correction was performed with transvaginal uterosacral ligament suspension in 22.0% of cases, sacrospinous ligament fixation in 68.3% and iliococcygeus fixation in 9.8%. At the same surgical session, 39.0% underwent vaginal hysterectomy (with anterior and posterior colporrhaphy in 7/16, anterior repair in 4/16 and posterior repair in 3/16 cases), 7.3% had anterior compartment repair, 2.4% posterior compartment repair and in 36.6% both compartments were repaired. During the perioperative period there were no reported complications. Therapeutic success was observed in 82.9%. Clinical apical prolapse recurrence occurred in 17.1% and 4.9% had recurrence of other types of prolapse. It was reported a case of urge incontinence and two cases of fistulas. In 34.1%, these complications occurred in the first 6 months after surgery. There was no statistically significant difference concerning either the success or the occurrence of complications between the three different techniques of apical prolapse repair. Conclusions: The use of native tissues to correct apical prolapse was an effective and safe method with low morbidity. In this study all of the techniques of apical repair were equally effective suggesting that surgeon’s experience must be considered when deciding which procedure to perform.

Introduction: Although the risk of urethral trauma while treating bladder stones is worrisome, evidence about the best treatment approach is scarce. The aim of this study is to compare the safety and efficacy of transurethral cystolithotomy and percutaneous suprapubic cystolithotomy in adults´ bladder lithiasis treatment. Methods: We retrospectively evaluated 120 patients (January 2012 to December 2017) who were surgically treated for bladder lithiasis with percutaneous suprapubic cystolithotomy (n= 20) and transurethral cystolithotomy (n= 100). Age, gender, calculi size, surgery duration, hospital stay, post-operative infections, haematuria, pain and urethral strictures were evaluated. Previous diagnosis of benign prostate hyperplasia and urethral strictures were also considered. Results: Both groups were homogeneous according to the pre-operative variables evaluated, including calculi dimensions and simultaneous diagnosis. Median surgery time in percutaneous suprapubic cystolithotomy and transurethral cystolithotomy were 65 and 58 minutes, respectively (p= 0.043). Pain and haematuria were similar in both groups. Median hospital stay was 2.0 days in both groups. Median follow-up time was 13 months. In the transurethral cystolithotomy, three patients (3%) developed urethral stricture while none of the patients treated with PSC developed urethral strictures during the follow-up (p= 0.435). Discussion: Percutaneous suprapubic cystolithotomy theoretically offers an advantage over transurethral cystolithotomy in terms of urethral trauma, although we did not observe a significant difference. However, it deserves to be considered, especially in patients with known urethral strictures that may hinder transurethral access. Further prospective studies with more patients may however confirm these theoretical advantages.

Devido à grande proximidade dos SPN com a órbita, SNC e outras estruturas, o cirurgião deve estar bem familiarizado com a anatomia nasossinusal. Foi efectuado um estudo retrospectivo de 150 TC-SPN realizadas no nosso centro, durante 2015. 75 exames preencheram os critérios de inclusão. Foi realizada análise de variáveis demográficas e anatómicas. A idade média foi 48 anos. Observámos agenésia do seio frontal em 6% dos lados avaliados e hipoplasia em 15%, defeito da lâmina papirácea (LP) em 11%, deiscência da artéria etmoidal anterior em 29%, célula Onodi em 16%, exposição do nervo óptico em 28% e exposição da artéria carótida interna em 19%, entre outras variáveis avaliadas. A altura média da lamela lateral foi maior no sexo masculino. O sexo feminino correlacionou-se com hipoplasia do seio maxilar e LP medializada. Uma avaliação cuidada da TC-SPN é essencial para alcançar melhores resultados cirúrgicos e menores taxas de complicação.

  O transplante pancreático representa uma alternativa cirúrgica para o tratamento de casos selecionados de doentes diabéticos, com o objetivo de evitar as complicações sistémicas da doença. A abordagem mais frequente é o transplante pancreático-renal simultâneo, em que o pâncreas é geralmente posicionado intra-peritonealmente na região pélvica direita. Vários métodos de imagem são usados para a avaliação do enxerto parenquimatoso, a anatomia vascular e a drenagem entérica. A compreensão do procedimento cirúrgico, das técnicas utilizadas e da anatomia pós-procedimento é fundamental à medida que o número destes casos aumenta. O radiologista deve também conhecer as possíveis complicações associadas e a sua aparência imagiológica, com a finalidade de preservar a máxima função do enxerto.

O baço errante é refere-se a um estado de hipermobilidade do baço, anormalmente localizado na parte inferior do abdômen ou na pelve, responsável por 0,2% das esplenectomias, acometendo crianças abaixo dos 10 anos e mulheres em idade fértil. O diagnóstico é essencialmente radiológico. Os achados da tomografia computadorizada e da ressonância magnética são a ausência do órgão no local anatômico e a presença de massa com atenuação/sinal de partes moles no andar inferior do abdome. O tratamento de escolha para o baço errante, quando assintomático, é a esplenopexia e, em casos de urgência, esplenectomia. Os autores descrevem um caso desta doença cujo diagnóstico foi realizado pela ressonância e o tratamento foi realizado de forma conservadora e com sucesso.

A cisticercose é causada pela tênia do porco, a Taenia solium, sendo o sistema nervoso central o local mais acometido, seguido pelo olho, músculo estriado, tecido subcutâneo, e raramente, outros tecidos. A maioria dos casos de cisticercose com acometimento muscular está associada com o envolvimento do sistema nervoso central – envolvimento muscular isolado é raro, além de frequentemente assintomático. Existem três manifestações clínicas diferentes de cisticercose muscular: mialgia miopática; tipo nodular ou massa; tipo pseudohipertrófico – neste ocorre a formação de cistos multiloculares no grupo muscular que, normalmente, estão orientados na direção da fibra muscular. A radiografia pode demonstrar múltiplas calcificações nos músculos ou tecido subcutâneo caso os cistos estejam calcificados. Na ultrassonografia, a cisticercose geralmente aparece como um cisto com escólex ecogênico excêntrico, mas pode apresentar variações. O tratamento da cisticercose depende do local acometido, sendo o albendazol e praziquantel as medicações mais utilizadas. Cisticercose muscular isolada ou subcutânea não requer tratamento específico a menos que seja dolorosa, podendo exigir a excisão. O seguimento com ultrassonografia é realizado após três semanas de medicação anti-helmíntica para avaliar para a resolução da lesão.  

Neck masses are common findings in pediatric patients, and are benign in the majority of cases. In addition to the more common tumors (lymphoma, rhabdomyosarcoma), rare tumors are also encountered in the pediatric head and neck. The imaging and clinical findings usually are nonspecific in these tumors, but some of these clinical and imaging characteristics may aid in narrowing the differential diagnosis. Imaging studies are important in determining the location of the tumor, its relation to adjacent structures, and for staging and follow-up. Ultrasound is the first imaging study performed in pediatric patients, but Magnetic Resonance Imaging is the method of choice, because of its excellent soft-tissue contrast and lack of ionizing radiation. The aim of this article is to review some malignant tumors that are rare in the neck of children, namely synovial sarcoma, primitive neuroectodermal tumor, rhabdoid tumor, myoepithelial carcinoma, dermatofibrosarcoma protuberans, and malignant peripheral nerve sheath tumor. Special emphasis is given to the imaging findings of each of these tumors.

Objetivo: A radioterapia é uma opção terapêutica no carcinoma da próstata. Pretendemos avaliar o contributo da PET/CT com Fluorocolina-F18(FCH-F18) na identificação dos doentes com indicação para essa estratégia terapêutica e o impacto no seu planeamento. Material e Métodos: Analisámos retrospetivamente 282 PET/CT com FCH-F18. Seleccionámos 187 doentes sem antecedentes de radioterapia prévia (41 estadiamentos iniciais/146 recidivas bioquímicas). Registámos os resultados da PET/CT com FCH-F18 (doença localizada com indicação para radioterapia versus doença à distância) e investigámos a opção terapêutica assumida em cada doente. No grupo que realizou radioterapia identificámos as situações em que a PET/CT com FCH-F18 otimizou o planeamento e anotámos os valores do PSA após radioterapia. Resultados: Apresentavam doença localizada 139 doentes (34 estadiamentos/105 recidivas). Destes, 54 realizaram radioterapia (8 estadiamentos/46 recidivas). A PET/CT com FCH-F18 contribuiu para a otimização de 22 (41%) planeamentos com intuito curativo ou de salvação, e, ainda, de 3 doentes para radioterapia paliativa. Os valores do PSA após radioterapia diminuiram significativamente sugerindo uma evolução favorável. Conclusão: A PET/CT com FCH-F18 foi útil na orientação terapêutica dos doentes com carcinoma da próstata, nomeadamente na seleção daqueles que tinham indicação para radioterapia e contribuiu para a optimização do seu planeamento numa percentagem significativa de casos.

African histoplasmosis (AH) is a fungal infection due to Histoplasma capsulatum var. duboisii. Unlike classic histoplasmosis, infections caused by H. duboisii most commonly affects the skin, subcutaneous tissues, lymph nodes and bones. Till present, in Europe, all published cases have been from natives from Africa who moved to Europe. There are few reports in the literature describing the radiologic features of AH. The authors report a case of a 7-year-old girl, from Guine-Bissau, who had multiple skin and subcutaneous lesions and left lower limb deformity. The presence of H. duboisii was confirmed by culture and histologic examination. Imaging studies were performed and showed multiple calcified and non-calcified subcutaneous lesions compatible with granulomas/abscesses; axillary and thoracic lymphadenopathies; and signs of chronic osteomyelitis. Although these imaging features are not pathognomic they should raise awareness for the diagnosis of AH in patients that are African or people who have travelled from this continent. Imaging plays a crucial role not only in the diagnosis of this disease but also in monitoring the response to therapy and detecting recurrence.

Quistos na articulação acrômio-clavicular são apresentações extremamente raras de doença no ombro e podem desenvolver-se tanto no tecido subcutâneo superficial quando limitados à articulação acrômio-clavicular ou resultar de alterações degenerativas da articulação gleno-umeral.  O "sinal do Geiser" é um sinal radiológico raramente encontrado. Existem duas etiologias distintas para o quisto que recobre a articulação acrômio-clavicular. Quando a coifa dos rotadores está intacta, um quisto da articulação acrômio-clavicular pode formar-se superficialmente não tendo comunicação líquida com a articulação gleno-umeral (tipo 1). Diferentemente, após uma lesão maciça da coifa dos rotadores, pode ocorrer a artropatia da coifa dos rotadores, que causa o aumento da produção intra-articular de fluido sinovial e o deslocamento para cima da cabeça umeral – corroendo a articulação acrômio-clavicular e permitindo a formação de um gêiser de líquido com fluxo da articulação gleno-umeral para a articulação acrômio-clavicular (tipo 2). O tratamento para o quisto tipo 1 pode incluir ressecção da clavícula distal e bursectomia subacromial. O tratamento para o quisto tipo 2 apresenta algumas opções.

Os tumores desmóides da mama são raros, benignos e sem potencial de metastização, no entanto, são localmente agressivos, com margens infiltrativas e alta taxa de recidiva. Apresentam-se clínica e radiologicamente como neoplasias malignas da mama. A biopsia está sempre indicada para determinar a natureza do tumor. A excisão cirúrgica completa é o tratamento de escolha.

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A radioembolização hepática (RH), também designada como braquiterapia endoluminal seletiva (SIRT), é um procedimento terapêutico que consiste na administração endovascular de partículas carregadas com um emissor de radiação beta, o ytrium 90, com o objetivo de alcançar uma elevada dose de radioterapia seletiva na área tumoral. Embora atualmente a sua aplicação seja exclusiva para tumores hepáticos primitivos e metastáticos, estão em investigação aplicações em outros órgãos.

A descoberta dos Raios X por Roentgen em 1895 revolucionou a Medicina e transformou toda a nossa saúde. O impacto foi imediato e a progressão consistente, num longo processo de experimentação e aperfeiçoamento. Em contrapartida assistiu-se nos últimos 30 anos a um crescimento exponencial, com constantes avanços tecnológicos e explorando todas as potencialidades de uma nova base digital. E a Radiologia conquistou naturalmente a posição central que hoje detém em todos os procedimentos clínicos.

A síndrome de insensibilidade a androgénios é uma doença recessiva ligada ao cromossoma X, que leva a alterações no receptor de androgénios. Na forma completa é caracterizada por um cariótipo XY com fenótipo feminino. Os indivíduos têm genitália externa feminina, testículos e ausência de estruturas com origem nos ductos mullerianos. O diagnóstico inicial e a abordagem cirúrgica são em parte determinadas por métodos de imagem, como a ecografia e a ressonância magnética.

Os linfomas são as neoplasias extra-cranianas não epiteliais mais comuns da cabeça e pescoço, podendo manifestar-se como doença ganglionar ou extra-ganglionar. Os linfomas não-Hodgkin (LNH) são mais frequentes que os linfomas de Hodgkin, representando 5% das neoplasias da cabeça e pescoço. Em até 33% dos casos os LNH podem ter uma apresentação extra-ganglionar que pode ser classificada, de acordo com a localização, em linfóide - com origem no anel de Waldeyer - ou extra-linfóide. A tomografia computorizada (TC) e a ressonância magnética (RM) desempenham um papel importante no estadiamento clínico, permitindo inferir o prognóstico e influenciar o tratamento. Apesar de não existirem achados radiológicos patognomónicos nesta doença, estes exames de imagem são imprescindíveis na marcha diagnóstica, ao destacar lesões suspeitas e ao caracterizá-las relativamente à localização, dimensões, morfologia e extensão, expandindo o diagnóstico diferencial. Neste artigo, os autores pretendem fazer uma revisão sobre os achados imagiológicos que possam contribuir para a suspeição e/ou diagnóstico dos linfomas da cabeça e pescoço, com particular ênfase na diversidade de apresentação e tendo por base os casos de linfoma diagnosticados no Serviço de Otorrinolaringologia do Hospital Garcia de Orta em cinco anos, de 2008 a 2012.