_______________________________________________________________________________________Introduction: Ganglioneuromas are rare benign neoplasms of the sympathetic nervous system. We describe the case of an incidentally found ganglioneuroma in a woman. To our knowledge this is the first described case of robotic excision of a retroperitoneal ganglioneuroma. Case: A 41-year-old female had an incidental retroperitoneal mass found during a routine US. CT scan and MRI showed an 8.3cm homogeneous mass, adjacent to left kidney upper pole, with peripheral contrast enhancement. Metabolic tests were normal. Patient was positioned in a left flank position and five ports were introduced transperitoneally. A 4-arm Da Vinci SI was docked at a 45º angle to the table. Lesion was dissected along with left adrenal gland, beginning at the left renal hilum and proceeding cephalad. Results: Operating time was 325min and blood loss was 50ml. Patient was discharged after 72hours. There were no postoperative complications. Pathology showed ganglionic cells with neural tissue, and normal adrenal. Discussion: Ganglioneuromas rare benign tumors originating from neural crest and typically affect young adults. Most frequent locations are posterior mediastinum, retroperitoneum and adrenal gland. As in this case, ganglioneuromas are usually silent, slow growing tumors discovered incidentally or by mass effect. US and CT imaging may suggest the diagnosis while MRI findings can be specific for ganglioneuroma. Percutaneous biopsy is an option. Although benign, usually requires surgical excision for treatment. Conclusions: Our case shows that a robotic approach is feasible and allows for meticulous and safe dissection of vascular structures, facilitating adequate hemostasis while maintaining oncological principles.

Acute decompensated heart failure (ADHF) is the leading cause of hospitalization in patients aged 65 years or older, and most of them present with congestion. The use of hydrochlorothiazide (HCTZ) may increase the response to loop diuretics. To evaluate the effect of adding HCTZ to furosemide on congestion and symptoms in patients with ADHF. This randomized clinical trial compared HCTZ 50 mg versus placebo for 3 days in patients with ADHF and signs of congestion. The primary outcome of the study was daily weight reduction. Secondary outcomes were change in creatinine, need for vasoactive drugs, change in natriuretic peptides, congestion score, dyspnea, thirst, and length of stay. Fifty-one patients were randomized—26 to the HCTZ group and 25 to the placebo group. There was an increment of 0.73 kg/day towards additional weight reduction in the HCTZ group (HCTZ: − 1.78 ± 1.08 kg/day vs placebo: − 1.05 ± 1.51 kg/day; p = 0.062). In post hoc analysis, the HCTZ group demonstrated significant weight reduction for every 40 mg of intravenous furosemide (HCTZ: − 0.74 ± 0.47 kg/40 mg vs placebo: − 0.33 ± 0.80 kg/40 mg; p = 0.032). There was a trend to increase in creatinine in the HCTZ group (HCTZ: 0.50 ± 0.37 vs placebo: 0.27 ± 0.40; p = 0.05) but no significant difference in onset of acute renal failure (HCTZ: 58% vs placebo: 41%; p = 0.38). No differences were found in the remaining outcomes. Adding hydrochlorothiazide to usual treatment of patients with acute decompensated heart failure did not cause significant difference in daily body weight reduction compared to placebo. In analysis adjusted to the dose of intravenous furosemide, adding HCTZ 50 mg to furosemide resulted in a significant synergistic effect on weight loss.Trial registration: The Brazilian Clinical Trials Registry (ReBEC), a publically accessible primary register that participates in the World Health Organization International Clinical Trial Registry Platform; number RBR-5qkn8h. Registered in 23/07/2019 (retrospectively), http://www.ensaiosclinicos.gov.br/rg/RBR-5qkn8h/.

Introduction: Acute decompensated heart failure (ADHF) is the leading cause of hospitalization in patients aged 65 years or older, and most of them present with congestion. The use of hydrochlorothiazide (HCTZ) may increase the response to loop diuretics. Objective To evaluate the effect of adding HCTZ to furosemide on congestion and symptoms in patients with ADHF. Methods This randomized clinical trial compared HCTZ 50 mg versus placebo for 3 days in patients with ADHF and signs of congestion. The primary outcome of the study was daily weight reduction. Secondary outcomes were change in creatinine, need for vasoactive drugs, change in natriuretic peptides, congestion score, dyspnea, thirst, and length of stay. Results Fifty-one patients were randomized — 26 to the HCTZ group and 25 to the placebo group. There was a trend towards additional weight reduction in the HCTZ group (HCTZ: -1.78 ± 1.08 kg/day vs placebo: -1.05 ± 1.51 kg/day; p = 0.062). In post hoc analysis, the HCTZ group demonstrated significant weight reduction for every 40 mg of intravenous furosemide (HCTZ: -0.74 ± 0.47 kg/40 mg vs placebo: -0.33 ± 0.80 kg/40 mg; p = 0.032). There was a trend to increase in creatinine in the HCTZ group (HCTZ: 0.50 ± 0.37 vs placebo: 0.27 ± 0.40; p = 0.05) but no significant difference in onset of acute renal failure (HCTZ: 58% vs placebo: 41%; p = 0.38). No differences were found in the remaining outcomes. Conclusion There was a trend towards greater daily weight reduction in the HCTZ group. In analysis adjusted to the dose of intravenous furosemide, adding HCTZ 50 mg to furosemide resulted in a significant synergistic effect on weight loss.

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