Background: We aim to evaluate the distribution in the upper urinary tract of intravesical-delivered fluids, after inducing vesicoureteral reflux (VUR) with a double J stent. Methods: In group 1 ( n = 35) patients were maintained in a 20° Trendelenburg position and were evaluated after immediate insertion of ureteral stent, while in group 2 ( n = 16) patients were evaluated after several days with ureteral stent placement. Patients in both groups were submitted to a cystogram with progressive volumes of iodine contrast and were evaluated according to VUR of contrast medium to the renal pelvis. Additionally, in group 2 visual confirmation was performed by endoscopic inspection of upper tract mucosal impregnation with methylene blue. Results: In group 1, after immediate insertion of ureteral stent reflux occurred in 51.4% ( n = 18/35), and after several days with ureteral stent placement reflux was observed in 87.5% ( n = 14/16) of patients. Reflux was progressively more frequent according to increasing bladder volume ( p < 0.001). At 60 ml bladder volume no reflux was observed, while at 120 ml, 180 ml, 240 ml, 300 ml and 360 ml bladder volume reflux was observed in 14%, 25%, 41%, 55% and 63% of patients, respectively. Conclusion: Retrograde delivery of fluids such as bacillus Calmette-Guérin to the upper urinary tract through double J stents can be effective; however, it is mainly effective after several days with ureteral stent and relatively large volumes might be instilled into the bladder.

Nutcracker syndrome refers to the complex of clinical symptoms caused by the compression of the left renal vein (LRV) between the abdominal aorta and the superior mesenteric artery, leading to stenosis of the aortomesenteric portion of the LRV and dilatation of the distal portion. Hematuria, proteinuria, flank pain, varicocele and pelvic congestion may occur, occurring more frequently in young adults. Conservative management, might be the option whenever it is possible. When surgical treatment is required, classically open surgery have been performed, with major surgeries as LRV transposition or bypass techniques. The main caveats regards the fact that these are large and risky surgeries. Endovascular surgery with venous stent placement has gained some space as it is minimally invasive alternative. However, venous stents are associated with a high number of trombotic complications and in many cases requirement of life-long anticoagulants. External stenting of the LRV with this “shield technique” is a minimally invasive alternative, with good medium term results. We herein demonstrate our second experience with the technique of this surgery in a patient with 12 months of follow up and excellent results.

PURPOSE Muscle-invasive bladder cancer (MIBC) is an aggressive disease with a complex treatment. In Brazil, as in most developing countries, data are scarce, but mortality seems exceedingly high. We have created a centralization program involving a multidisciplinary clinic in a region comprising seven municipalities. The aim of this study is to evaluate the impact of a multidisciplinary clinic and a centralization-of-care program (CABEM program) on MIBC treatment in Brazil. PATIENTS AND METHODS A total of 116 consecutive patients were evaluated. In group 1, 58 patients treated for MIBC before establishing a bladder cancer program from 2011 to 2017 were retrospectively evaluated. Group 2 represented 58 patients treated for MIBC after the implementation of the CABEM centralization program. Age, sex, staging, comorbidity indexes, mortality rates, type of treatment, and perioperative outcomes were compared. RESULTS Patients from group 2 versus 1 were older (68 v 64.2 years, P = .02) with a higher body mass index (25.5 v 22.6 kg/m2, P = .017) and had more comorbidities according to both age-adjusted Charlson Comorbidity Index (4.2 v 2.8, P = .0007) and Isbarn index (60.6 v 43.9, P = .0027). Radical cystectomy (RC) was the only treatment modality for patients in group 1, whereas in group 2, there were 31 (53%) RC; three (5%) partial cystectomies; seven (12%) trimodal therapies; 13 (22%) palliative chemotherapies; and three (5%) exclusive transurethral resections of the bladder tumor. No patient in group 1 received neoadjuvant chemotherapy, whereas it was offered to 69% of patients treated with RC. Ninety-day mortality rates were 34.5% versus 5% for groups 1 versus 2 ( P < .002). One-year mortality was also lower in group 2. CONCLUSION Our data support that a centralization program, a structured bladder clinic associated with protocols, a multidisciplinary team, and inclusion of chemotherapy and radiotherapy treatments can pleasingly improve outcomes for patients with MIBC.

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