_______________________________________________________________________________________Background: Nephron sparing surgery (NSS) is well established as the standard of care for most surgical small renal tumors when technically feasible. While the majority of sporadic renal tumors are solitary, multifocal tumors have been reported in 5.4% to 25% of patients with tumors smaller than 5cm. We present a video where we approach, through laparoscopy, four tumors on the same kidney. Case study: Male, 58y, went through a routine abdominal ultrasound which showed a 5cm left kidney nodule. His MRI pointed a total of 4 nodules on his left kidney. The aspect suggested a papillary cancer due to high cellularity and low vascularization. The patient was submitted to partial nephrectomy under ischemia to remove the two largest tumors (inferior pole) and a resection without clamping of the other two ipsilateral tumors. Result: We performed the surgery in 2 stages. In the first one, we approached the 2 tumors located on the inferior pole inducing warm ischemia, whereas in the second stage we resected the 2 remaining tumors using the technique without clamping. The surgery lasted 220 minutes, with 800mL of blood loss, not requiring blood transfusion. Ischemia time was 35 minutes. The histopathological analysis confirmed that the 4 tumors were papillary cancer, with free margins. Conclusion: NSS can be performed and should be tried in patients with multiple kidney tumors, preferably through laparoscopy or assisted by robot. It can be made either using or not clamping of the pedicle, depending on the RENAL score.

The laparoscopic resection of recurrent tumor should be encouraged in highly selected cases. The minimally invasive method, with its known advantages, especially for more debilitated patients, can be advantageous when applied to suitable cases.

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Introduction:The main structures involved in maintaining the integrity of the pelvis include the ureterosacral ligament, pubocervical fascia, and the paracervical tissues. A compromise to any of these areas can promote a weakness leading to herniation or prolapse of the urethra, bladder, and/or rectum. Hydronephrosis can range from 5% in first-degree to 40% in patients with third-degree prolapse. A variety of laparoscopic techniques has been described and some have used meshes as an integral part for the repair. This approach aims to restore normal voiding function while preserving female sexual function. Here, we provide a video of a pelvic organ prolapse (POP) female patient with bilateral pyelocaliceal dilation, that was corrected through a laparascopic sacrocolpopexy with mesh technique. Methods: A 56 year-old female, complained of a ball in your vagina and just evacuated fezzes with aid of the fingers introduced inside the vagina. Her physic exam evidenced a grade 4 pelvic prolapse, bringing down rectum, bladder and urethra and probably kinking bilaterally the ureters, since IVP exam showed a dilated right kidney, almost without function, and the left with a delayed excretion. A laparoscopic correction of the POP was proposed. A 4 ports pneumoperitoneum was utilized. We dissected the retovaginal and bladder vaginal spaces. The mesh was sutured posterolaterally to the distal levator ani muscles, and centrally to central perineum tendon. Anteriorly, the mesh was sutured to the anterior vaginal wall and then passed through the broad ligaments. Both meshes were trimmed and sutured to the anterior longitudinal ligaments of the sacral promontory. The Douglas pouch and peritoneal incision were closed and a transobturator sub-urethral sling was positioned. Results: The surgery lasted 240 minutes, with a minimum blood loss and just paracetamol was used for postoperative pain. She was discharged in 3 days and her 2 months contrast exam showed pelvic organs in a correct location and better contrast elimination of both kidneys. After a follow up of 12 months, she is continent, with no prolapse recurrence. Conclusion: Despite some authors contesting the type of access required to correct the pelvic prolapse, undoubtedly the laparoscopic approach provides more anatomic detail, a clear surgical field, better cosmesis, and an early return to physical activity. Moreover, we showed that laparoscopic mesh approach for sacrocolpopexy is feasible, with a minimum morbidity, even in the context of bilateral hydronephrosis secondary to POP. To our knowledge, this is the first published case approached in such a manner in the scientific literature.

A hiperplasia prostática benigna (HPB) é uma das doenças mais frequentes do homem. Devido à alta prevalência, considera-se uma condição natural do envelhecimento masculino. Nem todos os pacientes com HPB terão sintomas relacionados à alteração prostática.