Volume 43 | number 4 | July . August, 2017 – As it is been daily debated, the dilemmas on to treat or not to treat patients with localized prostate cancer are under the scope of the “Difference of opinion section”:…
Vol. 43 (4): 577-578, July – August, 2017
EDITORIAL in this Issue
Stênio de Cássio Zequi
Editor Associado, International Braz J Urol
Divisão de Urologia do A.C. Camargo Cancer Center
Fundação A. Prudente, São Paulo, Brasil
As it is been daily debated, the dilemmas on to treat or not to treat patients with localized prostate cancer are under the scope of the “Difference of opinion section”: Between two extremes: the radical whole gland treatments versus the active surveillance protocols, the “middle term”, probably will be arise from judicious and individualized patient selection. Using biomolecular markers, nomograms, modern magnetic resonance evaluations and the individual patient preferences and payment capacities, the urologists will be able to decide a personalized approach’s, varying from traditional whole gland therapies, passing by the emerging focal treatments until exclusive surveillance. Concomitantly, in the future, less patients will be overdiagnosed and overtreated. Our readers will be able the get their self “middle term decisions”, after reading the favorable arguments (Dell´Oglio and Sanchez Salas, from Paris) and contrary to treatment (Schulman and Polascyck, from North Carolina)…
Vol. 43 (4): 579-583, July – August, 2017
DIFFERENCE OF OPINION
Paolo Dell’Oglio 1,2, Rafael Sanchez-Salas 1
1 Department of Urology, Institut Mutualiste Montsouris, Paris, France; 2 Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
Keywords: Prostatic Neoplasms; Patients; Epidemiology
Localized prostate cancer (LPCa) is an heterogeneous disease extending from individuals who harbor indolent cancer, that are highly unlikely to develop metastases, to individuals with more aggressive disease, that have higher risk of metastatic burden. This would translates into different oncologic outcomes and have implications for disease management.
Once the diagnosis of LPCa is established, remains challenging to identify those patients who may benefit from delayed or immediate treatment. Several options exist, from active surveillance (AS) to the whole-gland treatments (1). However, the optimal one is still unclear. To date, the percentage distribution of treatment for LPCa is around 8.4% for observation, 13.1% for ablative therapies, 28.1% for external beam radiotherapy (RT), 1.6% for brachytherapy, 45% for radical prostatectomy (RP) and 3.7% for primary androgen deprivation therapy (2)…
Vol. 43 (4): 584-587, July – August, 2017
DIFFERENCE OF OPINION
Ariel A. Schulman 1, Thomas J. Polascik 1
1 Division of Urology, Duke University Medical Center, Durham, NC, USA
Keywords: Prostatic Neoplasms; Patients; Epidemiology
We are in the midst of a major shift in the diagnosis and management of localized prostate cancer. The prevailing approach of the 1980’s and 1990’s focused on widespread population-based prostate specific antigen (PSA) testing and curative-intent treatment for any detected cancer. The philosophical approach in the most recent decade is now defined by risk-adapted PSA screening, and integration of novel imaging techniques and biomarkers to increase the detection of clinically significant cancer. Concomitantly, we are witnessing the expanding utilization of active surveillance and partial ablation trategies to avoid overtreatment. We believe that continued development in each of these areas will continue to decrease the number of patients with localized disease treated with traditional whole gland surgery or radiation in the future…
Impact of local treatment on overall survival of patients with metastatic prostate cancer: systematic review and meta-analysis
Vol. 43 (4): 588-599, July – August, 2017
Arie Carneiro 1,2, Willy Baccaglini 2, Felipe P.A. Glina 3, Paulo P. Kayano 1, Victor M. Nunes 4, Oren Smaletz 5, Wanderley Marques Bernardo 4, Icaro Thiago de Carvalho 6, Gustavo Caserta Lemos 1
1 Departamento de Urologia, Hospital Israelita Albert Einstein, SP, Brasil; 2 Departamento de Urologia, Faculdade de Medicina do ABC, SP, Brasil; 3 Faculdade de Ciências Médicas, Universidade Metropolitana de Santos, SP, Brasil; 4 Centro Universitário Lusiada, Faculdade de Ciências Médicas de Santos, SP, Brasil; 5 Departamento de Oncologia, Hospital Israelita Albert Einstein, São Paulo, Brasil; 6 Departamento de Radioterapia, Hospital Israelita Albert Einstein, São Paulo, Brasil
Context: Currently, standard treatment of metastatic prostatic cancer (MPCa) is androgen-deprivation therapy (ADT). Recent studies suggested that local treatment of MPCa is related to increase of survival of those patients, as observed in other tumors.
Objective: To evaluate the impact of local treatment on overall survival and cancer specific survival in 3 and 5 years in patients with MPCa.
Materials and Methods: Systematic review and meta-analysis of population studies published at PubMed, Scielo, Lilacs, Cochrane and EMBASE databases until June 2016. Several large cohorts and Post-Roc studies were included, that evaluated patients with MPCa submitted to local treatment (LT) using radiotherapy (RDT), surgery (RP) or brachytherapy (BCT) or not submitted to local treatment (NLT).
Results: 34.338 patients were analyzed in six included papers, 31.653 submitted to NLT and 2.685 to LT. Overall survival in three years was significantly higher in patients submitted to LT versus NLT (64.2% vs. 44.5%; RD 0.19, 95% CI, 0.17-0.21; p<0.00001; I²=0%), as well as in five years (51.9% vs. 23.6%; RD 0.30, 95% CI, 0.11-0.49; p<0.00001; I²=97%). Sensitive analysis according to type of local treatment showed that surgery (78.2% and 45.0%; RD 0.31, 95% CI, 0.26-0.35; p<0.00001; I²=50%) and radiotherapy (60.4% and 44.5%; RD 0.17, 95% CI, 0.12-0.22; p<0.00001; I²=67%) presented better outcomes.
Conclusion: LT using RDT, RP or BCT seems to significantly improve overall survival and cancer-specific survival of patients with metastatic prostatic cancer. Prospective and randomized studies must be performed in order to confirm our results.
Keywords: Prostate; Survival; Radiation Oncology; Prostatic Neoplasms
Vol. 43 (4): 600-606, July – August, 2017
Snir Dekalo 1, Haim Matzkin 1, Nicola J Mabjeesh 1
1 Department of Urology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
Objective MRI of the prostate improves diagnostic accuracy of prostate cancer. Different fusion approaches with transrectal ultrasound images are employed. Objective: To determine detection rate of prostate cancer in men undergoing transperineal MRI-based cognitive fusion biopsy.
Materials and Methods: One hundred and sixty-four consecutive men underwent a multiple-core prostate transperineal biopsy. Univariable and multivariable logistic regression analyses were used to address the relationship between clinical parameters and prostate cancer detection rate.
Results: One hundred and fourteen patients underwent mpMRI prior to the transperineal biopsy, 52 (45%) were diagnosed with prostate cancer, of them, 36 had Gleason score ≥7 (69%). Among these 114 patients, 82 had suspicious lesions on MRI, and 43 of them were diagnosed with cancer (52%). On multivariate analysis, the most significant independent predictive factors were PSA density (P<0.001) and suspicious MRI lesion (P=0.006). Men with a PSA density of more than 0.22 and a suspicious lesion on MRI had a detection rate of 78%. Detection rate among 50 patients with no MRI study prior to this biopsy was 26%.
Conclusions: This study showed that among a group of mostly multi-biopsied patients, the presence of mpMRI lesions and high PSA density values helped to detect clinically significant prostate cancer using cognitive MRI/TRUS fusion biopsies.
Keywords: Magnetic Resonance Imaging; Prostatic Neoplasms; Biopsy
The awareness of patients with non – muscle invasive bladder cancer regarding the importance of smoking cessation and their access to smoking cessation programs
Vol. 43 (4): 607-614, July – August, 2017
Emrah Yuruk 1, Murat Tuken 1, Aykut Colakerol 1, Ege Can Serefoglu 1
1 Department of Urology, Bagcilar Training and Research Hospital, Istanbul, Turkey
Objectives: Smoking is the most important risk factor for bladder cancer and smoking cessation is associated with reduced risk of tumor recurrence and progression. The aim of this study is to assess the awareness of non-muscle invasive bladder cancer (NMIBC) patients regarding the importance of smoking cessation, determine their access to smoking cessation programs and the effects of smoking cessation on recurrence rates of NMIBC.
Materials and Methods: NMIBC patients who were followed with cystoscopy were included in the study. Their demographic properties were recorded, along with their smoking habits, awareness regarding the effects of smoking on bladder cancer and previous attempts for smoking cessation. Moreover, the patients were asked whether they applied for a smoking cessation program. Recurrence of bladder cancer during the follow-up period was also noted.
Results: A total of 187 patients were included in the study. The mean age was 64.68±12.05 (range: 15-90) and the male to female ratio was 167/20. At the time of diagnosis, 114 patients (61.0%) were active smokers, 35 patients (18.7%) were ex-smokers and 38 patients (20.3%) had never smoked before. After the diagnosis, 83.3% of the actively smoking patients were advised to quit smoking and 57.9% of them quit smoking. At the time of the study, 46.52% of the NMIBC patients were aware of the link between smoking and bladder cancer, whereas only 4.1% of the smoking patients were referred to smoking cessation programs. After a mean follow-up of 32.28±11.42 months, 84 patients (44.91%) had recurrence; however, current smoking status or awareness of the causative role of smoking on NMIBC did not affect the recurrence.
Conclusion: In our study group, the majority of the NMIBC patients were not aware of the association between smoking and bladder cancer. Although most of the physicians advised patients to quit smoking, a significant amount of the patients were still active smokers during follow-up. Only a small proportion of patients were referred to smoking cessation programs. Urologists should take a more active role in the battle against smoking and refer those patients to smoking cessation programs. Larger study populations with longer follow-up periods are needed to better demonstrate the beneficial effects of smoking cessation on recurrence rates.
Keywords: Urinary Bladder Neoplasms; Patients; Epidemiologic Studies
Generation of potent cytotoxic T lymphocytes against in male patients with non-muscle invasive bladder cancer by dendritic cells loaded with dying T24 bladder cancer cells
Vol. 43 (4): 615-627, July – August, 2017
Eu Chang Hwang 1,2, Seung Il Jung 2, Hyun-Ju Lee 1, Je-Jung Lee 1,3,4,5, Dong Deuk Kwon 2
1 Research Center for Cancer Immunotherapy, Chonnam National University Hwasun Hospital, Hwasun, Jeollanamdo, Republic of Korea; 2 Department of Urology and 3 Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Jeollanamdo, Republic of Korea; 4 Vaxcell-Bio Therapeutics, Hwasun, Jeollanamdo, Republic of Korea; 5 The Brain Korea 21 Project, Center forBiomedical Human Resources at Chonnam National University, Gwangju, Republic of Korea
Background: In order to induce a potent cytotoxic T lymphocyte (CTL) response in dendritic cell (DC)-based immunotherapy for bladder cancer, various tumor antigens can be loaded onto DCs.
Objective: The aim of this study was to establish a method of immunotherapy for male patients with non-muscle invasive bladder cancer (NMIBC), using bladder cancer-spe¬cific CTLs generated in vitro by DCs.
Materials and Methods: Monocyte-derived DCs from bladder cancer patients were in¬duced to mature in a standard cytokine cocktail (IL-1β, TNF-α, IL-6, and PGE2: standard DCs, sDCs) or anα-type 1-polarized DC (αDC1) cocktail (IL-1β, TNF-α, IFN-α, IFN-γ, and polyinosinic:polycytidylic acid) and loaded with the UVB-irradiated bladder cancer cell line, T24. Antigen-loaded αDC1s were evaluated by morphological and functional assays, and the bladder cancer-specific CTL response was analyzed by cytotoxic assay.
Results: The αDC1s significantly increased the expression of several molecules pertain¬ing to DC maturation, regardless of whether or not the αDC1s were loaded with tumor antigens, relative to sDCs. The αDC1s demonstrated increased production of interleukin-12 both during maturation and after subsequent stimulation with CD40L that was not significantly affected by loading with tumor antigens as compared to that of sDCs. Bladder cancer-specific CTLs targeting autologous bladder cancer cells were success¬fully induced by αDC1s loaded with dying T24 cells.
Conclusion: Autologous αDC1s loaded with an allogeneic bladder cancer cell line re¬sulted in increased bladder cancer-specific CTL responses as compared to that with sDCs, and therefore, may provide a novel source of DC-based vaccines that canbe used in immunotherapy for male patients with NMIBC.
Keywords: Dendritic Cells; Urinary Bladder Neoplasms; T-Lymphocytes, Cytotoxic
Quality of Life after post-prostatectomy intensity modulated radiation therapy to the prostate bed with or without the use of gold fiducial markers for image guidance or higher total radiotherapy doses
Vol. 43 (4): 628-637, July – August, 2017
Yazan A. Abuodeh 1, Arash O. Naghavi 1, Tzu-Hua Juan 1, Zhenjun Ma 1, Richard B. Wilder 2
1 Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA; 2 Cancer Treatment Centers of America, Newnan, Georgia, USA
Purpose: To evaluate quality of life (QoL) after post-prostatectomy intensity modulated radiation therapy (IMRT) in the “adjuvant” setting starting within 4 months of radical prostatectomy for adverse features; and “salvage” setting for a PSA≥0.2ng/mL.
Materials and Methods: Retrospective review of 130 patients who underwent IMRT to the prostate bed±gold fiducial marker placement for image guidance to 64.8-72.0Gy (median, 70.2Gy) between 2004 and 2013. Higher doses were defined as 70.2-72.0Gy and lower doses were defined as 64.8-68.4Gy. Androgen deprivation therapy (ADT) was given to 4/48 (8%) adjuvant patients and 9/82 (11%) salvage patients. International Prostate Symptom Score (IPSS), Sexual Health Inventory for Men (SHIM), and Expanded Prostate Cancer Index Composite-26-bowel (EPIC-26-bowel) questionnaires were used to assess urinary, sexual, and bowel QoL, respectively.
Results: Median follow-up was 46 months. There were better urinary (p=0.03) and sexual (p=0.002) QoL scores with adjuvant IMRT relative to salvage IMRT. The use of prostate bed fiducial markers did not significantly affect urinary, sexual, or bowel QoL (p=0.39, p=0.49, and p=0.40, respectively). Higher total radiotherapy doses did not significantly affect urinary, sexual, or bowel QoL (p=0.21, p=0.61, and p=0.36, respectively).
Conclusions: There was no significant change in urinary, sexual, and bowel sexual QoL with post-prostatectomy IMRT regardless of whether prostate bed fiducial markers or higher total radiotherapy doses were used. QoL with IMRT in the present study compares favorably with prior reports for three-dimensional conformal radiation therapy.
Keywords: Prostate; Postoperative Care; Radiotherapy; Quality of Life
Vol. 43 (4): 638-643, July – August, 2017
Ersagun Karagüzel 1, Ahmet Menteşe 2, İlke O.Kazaz 1, Selim Demir 3, Asım Örem 4, Ali Ertan Okatan 1, Diler Us Altay 5, Serap Özer Yaman 4
1 Department of Urology, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey; 2 Program of Medical Laboratory Techniques, Karadeniz Technical University, Vocational School of Health Sciences, Trabzon, Turkey; 3 Department of Nutrition and Dietetics, Karadeniz Technical University, Faculty of Health Sciences, Trabzon, Turkey; 4 Department of Medical Biochemistry, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey 5 Department of Chemistry and Chemical Processing Technology, Ordu University, Ulubey Vocational School, Ordu, Turkey
Purpose: To investigate the efficacy of signal peptide-CUB-EGF domain-containing protein 1 (SCUBE-1) as a novel biomarker of renal tumors.
Materials and Methods: 48 individuals were included in the study. The patient group (Group-1) consisted of 23 subjects diagnosed with renal tumor, and the control group (Group-2) of 25 healthy individuals. Patients diagnosed with renal tumor received surgical treatment consisting of radical or partial nephrectomy. Blood specimens were collected following overnight fasting. Signal peptide-CUB-EGF domain-containing protein 1 (SCUBE-1), soluble urokinase plasminogen activator receptor (suPAR) and carbonic anhydrase IX (CA IX) levels were measured from plasma samples. Patients in groups 1 and 2 were compared in terms of these biochemical parameters.
Results: The 23-member renal tumor group was made up of 17 (73.91%) male and 6 (26.08%) female patients with a mean age of 58.5±15.7 years (range 25 to 80). The 24-member healthy control group was made up of 16 (64%) male and 9 (36%) female subjects with a mean age of 52.4±9.12 years (range 40 to 67). Analysis revealed significant elevation in SCUBE-1 levels in the renal tumor group (p=0.005). No significant differences were detected between the groups with regard to CA IX or suPAR measurements (p=0.062 vs. p=0.176).
Conclusions: SCUBE-1 appears to represent a promising biomarker in the diagnosis and follow-up of patients with renal tumor.
Keywords: Carcinoma, Renal Cell; Biomarkers
Antioxidant enzyme profile and lipid peroxidation products in semen samples of testicular germ cell tumor patients submitted to orchiectomy
Vol. 43 (4): 644-651 July – August, 2017
Camila Sposito 1, Mariana Camargo 1,Danielle Spinola Tibaldi 1, Valéria Barradas 1, Agnaldo Pereira Cedenho 1, Marcílio Nichi 2, Ricardo Pimenta Bertolla 1, Deborah Montagnini Spaine 1
1 Departamento de Cirurgia, Divisão de Urologia, Setor de Reprodução Humana, Universidade Federal de São Paulo, SP, Brasil; 2 Departamento de Reprodução Animal, Faculdade de Medicina Veterinária, Universidade de São Paulo, SP, Brasil
Purpose: To determine enzymatic antioxidant and lipid peroxidation levels in seminal plasma of patients orchiectomized for testicular tumors.
Materials and Methods: The study included 52 patients: 26 control men and 26 orchiectomized patients for testicular tumor, of which 12 men had seminoma tumor and 14 men non-seminoma tumor. After semen analysis performed according to the WHO guidelines, an aliquot of semen was centrifuged and the seminal plasma was collected. Lipid peroxidation was performed by thiobarbituric acid reactive substances(TBARS) assay and antioxidant profile was assessed by analyzing catalase, glutathione peroxidase (GPx) and superoxide anion (SOD) activities using colorimetric assays with a standard spectrophotometer. Data were tested for normality and compared using one-way ANOVA (p<0.05).
Results: Seminoma and non-seminoma groups presented lower sperm concentration and morphology when compared to control group (p=0.0001). Both study groups (seminoma and non-seminoma) presented higher TBARS levels when compared to control group (p=0.0000013). No differences were observed for SOD (p=0.646) andGPx (p=0.328). It was not possible to access the enzymatic activity of catalase in any group.
Conclusion: Patients with testicular tumor present increased semen oxidative stress, but no differences were observed in antioxidant levels, even after orchiectomy. This indicates that most likely an increased generation of oxidative products takes place in these patients.
Keywords: Antioxidants; Oxidative Stress; Testicular Germ Cell Tumor; Orchiectomy; Semen
Editorial Comment: Antioxidant enzyme profile and lipid peroxidation products in semen samples of testicular germ cell tumor patients submitted to orchiectomy
Vol. 43 (4): 652-654, July – August, 2017
Sandro C. Esteves 1
1 ANDROFERT, Centro de Refêrencia para Reprodução Masculina, Campinas, SP, Brasil
No abstract available
Histopathological analysis of the non – tumour parenchyma following radical nephrectomy: can it predict renal functional outcome?
Vol. 43 (4): 655-660, July – August, 2017
Rana Birendra 1, Nirmal Thampi John 2, Neelaveni Duhli 2, Antony Devasia 1, Nitin Kekre 1, Ramani Manojkumar 2
1 Department of Urology, Christian Medical College, Vellore; 2 Department of Pathology, Christian Medical College, Vellore
Introduction: Radical nephrectomy (RN), a recommended treatment option for patients with Renal cell carcinoma (RCC) leads to an inevitable decline in global renal function. Pathological changes in the non-tumour parenchyma of the kidney may help predict the function of the remaining kidney.
Materials and Methods: Aim of this prospective, observational study was to find histopathological factors in the non-tumor renal parenchyma that could predict the decline in global renal function postoperatively and its association with co-morbidities like diabetes (DM). Data of consecutive patients undergoing RN from December-2013 to January-2015 was collected. Non-tumor parenchyma of the specimen was reported by a dedicated histopathologist. eGFR was calculated using Cockcroft-Gault formula before the surgery and at last follow up of at least 12 months.
Results: 73 RN specimens were analyzed. Mean follow up was 12.3 months. The mean decrease in eGFR was 22% (p=.0001). Percent decrease in eGFR did not show association with any of the histopathological parameters studied. DM was significantly associated with decrease in percent eGFR (p<0.05) and increase in arteriolar hyalinosis (p=0.004), Glomerulosclerosis (p=0.03) and Interstitial fibrosis/ Tubular atrophy (p=.0001). Maximum size of the tumor showed a negative correlation with percentage change in eGFR (p=.028).
Conclusion: Histological parameters in the non-tumour portion of the RN specimen may not be able to predict renal function outcome over a short follow up. However, presence of DM was associated with adverse pathological changes and significant decrease in renal function postoperatively.
Keywords: Nephrectomy; Arteriosclerosis; Glomerulosclerosis, Focal Segmental
Towards development and validation of an intraoperative assessment tool for robot-assisted radical prostatectomy training: results of a Delphi study
Vol. 43 (4): 661-670, July – August, 2017
Christopher Morris 1, Jen Hoogenes 1, Bobby Shayegan 1, Edward D. Matsumoto 1
1 Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada
Introduction: As urology training shifts toward competency-based frameworks, the need for tools for high stakes assessment of trainees is crucial. Validated assessment metrics are lacking for many robot-assisted radical prostatectomy (RARP). As it is quickly becoming the gold standard for treatment of localized prostate cancer, the development and validation of a RARP assessment tool for training is timely.
Materials and methods: We recruited 13 expert RARP surgeons from the United States and Canada to serve as our Delphi panel. Using an initial inventory developed via a modified Delphi process with urology residents, fellows, and staff at our institution, panelists iteratively rated each step and sub-step on a 5-point Likert scale of agreement for inclusion in the final assessment tool. Qualitative feedback was elicited for each item to determine proper step placement, wording, and suggestions.
Results: Panelist’s responses were compiled and the inventory was edited through three iterations, after which 100% consensus was achieved. The initial inventory steps were decreased by 13% and a skip pattern was incorporated. The final RARP stepwise inventory was comprised of 13 critical steps with 52 sub-steps. There was no attrition throughout the Delphi process.
Conclusions: Our Delphi study resulted in a comprehensive inventory of intraoperative RARP steps with excellent consensus. This final inventory will be used to develop a valid and psychometrically sound intraoperative assessment tool for use during RARP training and evaluation, with the aim of increasing competency of all trainees.
Keywords: Delphi Technique; Prostatectomy; Robotic Surgical Procedures
Vol. 43 (4): 671-678, July – August, 2017
Avinash Bapusaheb Patil 1,Tarun Dilip Javali 1,Harohalli K. Nagaraj 1, S. M. L. Prakash Babu 1, Arvind Nayak 1
1 Department of Urology, M.S. Ramaiah Hospital, Bangalore
Objectives: Laparoscopic donor nephrectomy is now a commonly performed procedure in most of renal transplantation centers. However, the suitability of laparoscopy for donors with abnormal venous anatomy is still a subject of debate.
Materials and methods: Between August 2007 and August 2014, 243 laparoscopic donor nephrectomies were performed in our institution. All donors were evaluated with preoperative three-dimensional spiral computed tomography (CT) angiography Thirteen (5.35%) donors had a left renal vein anomaly. A retrospective analysis was performed to collect donor and recipient demographics and perioperative data.
Results: Four donors had a type I retroaortic vein, seven had type II retroaortic vein and a circumaortic vein was seen in three donors. The mean operative time was 114±11 minutes and mean warm ischemia time was 202±12 seconds. The mean blood loss was 52.7±18.4mL and no donor required blood transfusion. Mean recipient creatinine at the time of discharge was 1.15±0.18mg/dL, and creatinine at six months and one year follow-up was 1.12±0.13mg/dL and 1.2±0.14mg/dL, respectively. There were no significant differences in operative time, blood loss, warm ischemia time, donor hospital stay or recipient creatinine at 6 months follow-up, following laparoscopic donor nephrectomy in patients with or without left renal vein anomalies.
Conclusion: Preoperative delineation of venous anatomy using CT angiography is as important as arterial anatomy. Laparoscopic donor nephrectomy is safe and feasible in patients with retroaortic or circumaortic renal vein with good recipient outcome.
Keywords: Laparoscopy; Veins; Kidney Transplantation
Skin to calyx distance is not a predictive factor for miniaturized percutaneous nephrolithotomy outcomes
Vol. 43 (4): 679-685, July – August, 2017
Faruk Ozgor 1, Onur Kucuktopcu 1, Burak Ucpinar 1, Fatih Yanaral 1, Murat Binbay 1
1 Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey
Objective: To evaluate the predictive value of the distance from skin to calyx (SCD) on the outcome and complication rates of patients undergoing mPNL.
Materials and Methods: Patient’s charts, who had undergone mPNL between June 2012 and June 2015, were analyzed retrospectively. Patients who had a preoperative computerized tomography (CT) were enrolled into the study. Two separateurologists evaluated the CT scans and calculated the SCD defined as the distance between the skin and surface/lateral edge of the calyx, which was the preferred site of entry for percutaneous access. The average value of the two measurements was included inthe final analysis to avoid bias. The mean SCD was 75mm. According to the median SCD value, patients were divided into two groups: group 1 (SCD ≤75) and group 2 (SCD >75).
Results: A total of 140 patients and 130 patients were enrolled in groups 1 and 2, respectively.
The mean operation time and the mean fluoroscopy time was significantly longer in group 2 (p:0.004 vs. p:0.021). The rate of blood transfusion was significantly higher in group 1 (6 patients). None of patientsin group 2required blood transfusion (p:0.017). Stone-free status after a single session of mPNL was 67.1% in group 1 and 75.4% in group 2 (p:0.112). After additional procedures, stone-free rates increased to 84.3% and 85.4% in group 1 and group 2, respectively (p:0.802).
Conclusion: Our study demonstrated that longer SCD was not a predictive factor for stone-free rates after mPNL. However, SCD over 75mm was associated with longer operation time and fluoroscopy time with lower rates of transfusion.
Keywords: Obesity; Nephrostomy, Percutaneous; Kidney Calculi
Vol. 43 (4): 686-697, July – August, 2017
Athanase Billis 1, Leandro L. L. Freitas 1, Larissa B. E. Costa 1, Camila M. de Angelis 1, Kelson R. Carvalho 1, Luis A. Magna 2, Ubirajara Ferreira 3
1 Departamento de Patologia, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil; 2 Departamento de Genética Médica/Bioestatística, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil; 3 Departamento Urologia, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
Purpose: To find any influence on prognostic factors of index tumor according to predominant location.
Materials and Methods: Prostate surgical specimens from 499 patients submitted to radical retropubic prostatectomy were step-sectioned. Each transverse section was subdivided into 2 anterolateral and 2 posterolateral quadrants. Tumor extent was evaluated by a semi-quantitative point-count method. The index tumor (dominant nodule) was recorded as the maximal number of positive points of the most extensive tumor area from the quadrants and the predominant location was considered anterior (anterolateral quadrants), posterior (posterolateral quadrants), basal (quadrants in upper half of the prostate), apical (quadrants in lower half of the prostate), left (left quadrants) or right (right quadrants). Time to biochemical recurrence was analyzed by Kaplan-Meier product-limit analysis and prediction of shorter time to biochemical recurrence using univariate and multivariate Cox proportional hazards model.
Results: Index tumors with predominant posterior location were significantly associated with higher total tumor extent, needle and radical prostatectomy Gleason score, positive lymph nodes and preoperative prostate-specific antigen. Index tumors with predominant basal location were significantly associated with higher preoperative prostate-specific antigen, pathological stage higher than pT2, extra-prostatic extension, and seminal vesicle invasion. Index tumors with predominant basal location were significantly associated with time to biochemical recurrence in Kaplan-Meier estimates and significantly predicted shorter time to biochemical recurrence on univariate analysis but not on multivariate analysis.
Conclusions: The study suggests that index tumor predominant location is associated with prognosis in radical prostatectomies, however, in multivariate analysis do not offer advantage over other well-established prognostic factors.
Keywords: Neoplasms; Prostate; Prostatectomy; Prostate-Specific Antigen
Vol. 43 (4): 698-703, July – August, 2017
Cemal Selcuk Isoglu 1,Tufan Suelozgen 1, Hayal Boyacioglu 2, Gokhan Koc 1
1 Department of Urology, Tepecik Education and Research Hospital, Izmir, Turkey; 2 Department of Statistics, Ege University Faculty of Science, Izmir, Turkey
Objective: To examine the the effect of body mass index (BMI) on PNL results and complications with a large number of patients.
Materials and Methods: A total of 958 patients were included in the study, who underwent percutaneous nephrolithotomy in our clinic between 2008 and 2015. Patients were divided into 2 groups according to their body mass index. Patients with a BMI < 30 kg/m2 were classified as group 1 (n:676) and patients with a BMI ≥ 30 kg/m2 were classified as group 2 (n:282). Achieving stone-free status or having residual stones of ≤ 4 mm were considered as operational success.
Results: The mean age was 47.9 years for group 1 and 48.9 years for group 2 patients. At postoperative first month CT analysis, residual stone was not observed in 466 patients (69%) of group 1 and 20 (72%) patients of group 2. There was no significant difference between the groups in terms of stone-free status (p=0.348). There was no significant difference between two groups complications. Also, there was no difference between the groups for requiring additional intervention (p=0.924). No other complications were observed in the patients.
Conclusions: BMI does not affect the outcomes of percutaneous nephrolithotomy as well as complication rate.
Keywords: Body Mass Index; Nephrostomy, Percutaneous; Calculi
Complications after prone PCNL in pediatric, adult and geriatric patients – a single center experience over 7 years
Vol. 43 (4): 704-712, July – August, 2017
Sumit Kumar 1, Ramaiah Keshavamurthy 1, Vilvapathy Senguttuvan Karthikeyan 1, Ashwin Mallya 1
1 Department of Urology, Institute of Nephrourology, Bangalore, India
Introduction: CROES-Clavien system (CCS) for grading complications in percutaneous nephrolithotomy (PCNL) is a step towards standardization of outcomes. We categorized complications based on CCS and predicted risk factors across the entire cohort and individually for pediatric (P: ≤18 years), adult (A: 19-65 years) and geriatric (G: ≥65 years) subgroups to assess the risk factors in each subset. We assessed association of complications with length of hospitalization (LOH) and operation time (OT).
Materials and Methods: Retrospective record review of unilateral PCNL performed between January 2009-September 2015 at a tertiary care center in India, performing around 150 PCNL per year.
Results: Out of 922 (P=61; A=794; G=67) PCNL, 259 (28.09%) complications occurred with CCS I, II, III and IV constituting 152 (16.49%), 72 (7.81%), 31 (3.36%) and 4 (0.43%) respectively and its distribution was similar across the subsets and majority (224; 24.3%) were minor (CCS-1, 2). Placement of a nephrostomy (47.4%; 18/38) in Group P, supracostal access, ≥2 punctures, higher GSS, nephrostomy, staghorn stones, ≥2 stones, stone size in Group A and hydronephrosis and prolonged OT in Group G were significantly associated with complications. On logistic regression, need of nephrostomy (adj. OR – 4.549), OT (adj. OR – 1.364) and supracostal access (adj. OR – 1.471) significantly contributed to complications in the study population. LOH was found to be significantly associated with complications (p<0.001).
Conclusions: Contrary to the belief that extremes of ages are associated with complications of prone PCNL, we found age does not alter the incidence or grade of complications and LOH.
Keywords: Kidney Calculi; Nephrostomy, Percutaneous; complications [Subheading]
The effect of extended release tolterodine used for overactive bladder treatment on female sexual function
Vol. 43 (4): 713-720, July – August, 2017
Athanasios Zachariou 1, Maria Filiponi 2
1 Department of Urology, Elpis Hospital, Volos, Greece; 2 Laboratory of Endocrinology and Metabolic Disorders, Department of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
Introduction: Overactive bladder (OAB) is a common condition, especially in middle aged women, requiring long term therapy with anticholinergics to maintain symptoms relief. The aim of the study was to determine the effect of tolterodine extended release (ER) used for OAB treatment on the sexual function of women.
Materials and Methods: Between August 2010 and August 2014, 220 women with confirmed OAB, attended Urogynecology Outpatient Clinic and were prospectively enrolled in this study. 158 women were evaluated, with a comprehensive history, physical examination, urodynamic studies and Female Sexual Function Index (FSFI) questionnaire. 73 patients of group A (control group) received no treatment and 85 patients of group B received an anticholinergic regimen – tolterodine ER 4mg once daily. Data were evaluated again in accordance with FSFI after three months, using SPSS software.
Results: A statistically significant increase was noted in group B in domains of desire (pre-treatment 2.5±0.2 to 4.5±0.2 post-treatment), arousal (3.1±0.2 to 3.1±0.2 respectively), lubrication (3.4±0.3 to 4.3±0.3 respectively), orgasm (3.5±0.3 to 4.5±0.3 respectively), satisfaction (2.6±0.2 to 4.2±0.3 respectively) and pain (2.4±0.2 to 4.6±0.4 respectively) after three months treatment with tolterodine ER. In group A there were no statistically significant changes in pre and post treatment values (p>0.05). Total FSFI score for group B was significantly higher after tolterodine treatment (26.5±1.5) compared to pre-treatment values (17.4±1.4, p<0.01) and to control group A (17.7±1.2 and 17.9±1.5, p>0,05) respectively.
Conclusions: This preliminary study demonstrates that treatment of OAB with tolterodine ER was found to have positive effect on sexual function of patients with OAB.
Keywords: Urinary Bladder, Overactive; Tolterodine Tartrate; Female
Long-term response of different Botulinum toxins in refractory neurogenic detrusor overactivity due to spinal cord injury
Vol. 43 (4): 721-729, July – August, 2017
Giuseppe Lombardi 1, Stefania Musco 1, Giovanni Bacci 2, Maria Celso 1, Valerio Bellio 1, Giulio Del Popolo 1
1 Department of Neuro-Urology, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy; 2 Department of Biology, Universita Degli Studi di Firenze, Toscana, Italy
Purpose: To assess the response in spinal cord injured patients alternatively treated with different types and dosages of Botulinum neurotoxin type A (BoNT/A) over 15 years.
Material and methods: Patients who underwent first BoNT/A from 1999-2001 and practiced intermittent catheterization were included. Baseline 3-day bladder diary (BD) and urodynamics were collected. BoNT/A failure was defined when patients asked for re-injection ≤ 3 months post-treatment. Criteria for re-injection was at least one daily episode of urinary incontinence at BD. Before re-injection, patients were asked if they had reached 6 months of dryness without antimuscarinics (YES response).
Results: Overall, 32/60 (53.4%) “No failure” (NF) group; 16 (26.6%) “occasional failure” (OF) and 12 (20%) “consecutive failure” (CF) were included. A total of 822 BoNT/A infiltrations were performed. The mean interval from previous injection to treatment re-scheduling was 8 months. No significant differences between treatments were found within the three groups (p>0.05).
The percentage of YES responses increased from 19% (AboBoNT/A 500IU) to 29 % (OnaBoNT/A 300IU) in NF, and from 18% (AboBoNT/A 500IU) to 25% (OnaBoNT/A 300IU) for OF. Five NF cases (15.6%) maintained 6 months of dryness after each injection. Among the baseline variables, only low compliance (< 20mL/cmH2O) was found as predictor for failure (p=0.006).
Conclusions: Long term BoNT/A for NDO did not increase failures, independent of the types of treatments and switching. Definition of failure and other criteria for continuing repetitive BoNT/A treatment is mandatory. CF was predictable for no response in earlier follow-up.
Keywords: Botulinum Toxins, Type A; Spinal Cord Compression; Urinary Bladder, Neurogenic
Vol. 43 (4): 730-735, July – August, 2017
Thiago Santana 1, Thelma Skare 1, Vitor Steil Delboni 1, Juliana Simione 1, Ana Paula B. Campos 1 , Renato Nisihara 1,2
1 Unidade de Reumatologia, Hospital Evangélico, Padre Anchieta, Curitiba, PR, Brasil; 2 Departamento de Medicina, Universidade Positivo, Curitiba, PR, Brasil
Background: Rheumatic diseases such as ankylosing spondylitis (AS) may be associated with sexual dysfunction.
Aim: To study erectile function of a group of Brazilian AS patients comparing them with controls.
Materials and Methods: This was a cross sectional study approved by the local Committee of Ethics in Research. The questionnaire IIEF (International Index of Erectile Function) was applied to 40 AS patients and 40 healthy controls. AS patients had determination of disease activity (through BASDAI or Bath Ankylosing Spondylitis Disease activity index), ASDAS (Ankylosing Spondylitis Disease Activity Score, MASES or Maastricht Ankylosing Spondylitis Score and SPARCC or Spondyloarthritis Research Consortium of Canada), function (through BASFI or Bath Ankylosing Spondylitis Functional Index and HAQ or Health Assessment Questionnaire) and BASMI (Bath Ankylosing Spondylitis Metrological Index).
Results: AS patients had a median score on IIEF of 22.0 (IQR=18-25) while controls had 29 (IQR=27-30) with p<0.0001 Only 17.5% of the AS patients had no erectile dysfunction, in opposite to 87.5% of controls (p<0.0001). IIEF scores had a negative association with BASDAI (p<0.0001), HAQ (p=0.05), body mass index (P=0.03), MASES (P=0.02) and SPARCC (P=0.02) in a univariate analysis. Multiple regression showed that BASDAI was the only variable independently associated with IIEF.
Conclusion: There is a high prevalence of erectile dysfunction among AS patients that is associated with disease activity measured by BASDAI.
Keywords: Erectile Dysfunction; Spondylitis, Ankylosing; Disease
Novel penile circumcision suturing devices versus the shang ring for adult male circumcision: a prospective study
Vol. 43 (4): 736-745, July – August, 2017
Hu Han 1, Da-wei Xie 1, Xiao-guang Zhou 1, Xiao-dong Zhang 1
1 Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
Introduction: To evaluate the safety and efficacy of a novel penile circumcision suturing devices PCSD and Shang ring (SR) for circumcision in an adult population.
Materials and Methods: A total of 124 outpatients were randomly assigned to receive PCSD (n=62) or SR (n=62). Patient characteristics, operative time, blood loss, return to normal activities time (RNAT), visual analogue scale (VAS), scar width, wound healing time, cosmetic result, and complications were recorded.
Results: There were no significant differences in blood loss, RNAT, or complications between the two groups. There were no significant differences in the VAS scores at theduring operation, and 6 or 24 hours after surgery (P>0.05). The wound scar width was wider in the SR group than in the PCSD group (P<0.01). Patients in the SR group had significantly longer wound healing time compared with those in the PCSD group (P<0.01). Patients who underwent PCSD wereere significantly more satisfied with the cosmetic results (P<0.01).
Conclusions: SR and PCSD are safe and effective minimally invasive techniques for adult male circumcision. Compared with SRs, PCSDs have the advantages of faster postoperative incision healing and a good effect on wound cosmetics.
Keywords: Circumcision, Male; Penis; Surgical Procedures, Operative
Effect of platelet-rich plasma on polypropylene meshes implanted in the rabbit vagina: histological analysis
Vol. 43 (4): 746-752, July – August, 2017
Natália Gomes Parizzi 1, Oscar Ávila Rubini 2, Silvio Henrique Maia de Almeida 1, Lais Caetano Ireno 1, Roger Mitio Tashiro 1, Victor Hugo Tolotto de Carvalho 1
1 Departamento de Cirurgia, Universidade Estadual de Londrina, Londrina, PR, Brasil; 2 Departamento de Cirurgia, Universidade do Oeste Paulista, Presidente Prudente, SP, Brasil
Purpose: The polypropylene mesh (PPM) is used in many surgical interventions because of its good incorporation and accessibility. However, potential mesh-related complications are common. Platelet-rich plasma (PRP) improves the healing of wounds and is inexpensive. Thus, the purpose of this study was to analyze the effect of the PRP-gel coating of a PPM on inflammation, production of collagen, and smooth muscle in the rabbit vagina.
Materials and Methods: The intervention consisted of a 1.5cm incision and divulsion of the vaginal mucosa for the implantation of a PRP-coated PPM. The PRP-coated mesh was implanted in 15 rabbits, and in the second group, the same implant was used without the PRP coating. In the sham group, the intervention consisted of the incision, divulsion, and suture. The rabbits were euthanized at 7, 30 and 90 days, and full-thickness sagittal sections of the posterior vaginal wall and rectum were scored.
The inflammatory infiltrate was evaluated using hematoxylin and eosin staining. The Sirius Red stain was used to examine deposition of collagen I and III, and Masson’s trichrome staining was used to visualize the smooth muscle.
Results: The group with PRP-coated meshes had a lower inflammatory infiltrate count at 30 days. Deposition of collagen III increased with the use of PRP-coating at 90 days.
Conclusions: The area of inflammatory infiltrate was significantly increased in the group without the PRP-coated mesh at 30 days but not in the group with the PRPcoated mesh, indicating a less intense inflammatory response. In addition, a significant increase in collagen III occurred at 90 days.
Keywords: Platelet-Rich Plasma; Collagen; Rabbits; Inflammation
Vol. 43 (4): 753-761, July – August, 2017
Mingfang Tao 1, Cemal Tasdemir 1,2, Seda Tasdemir 1,3, Ali Shahabi 1,4, Guiming Liu 1,4
1 Department of Urology, Case Western Reserve University School of Medicine, Cleveland, OH, USA; 2 Department of Urology, Inonu University, Medical Faculty, Malatya, Turkey; 3 Department of Pharmacology, Inonu University, Medical Faculty, Malatya, Turkey; 4 Department of Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
Objective: Diabetes affects the erectile function significantly. However, the penile alterations in the early stage of diabetes in experimental animal models have not been well studied. We examined the changes of the penis and its main erectile components in diabetic rats.
Materials and methods: Male Sprague-Dawley rats were divided into 2 groups: streptozotocin (STZ)-induced diabetics and age-matched controls. Three or nine weeks after diabetes induction, the penis was removed for immunohistochemical staining of smooth muscle and neuronal nitric oxide synthase (nNOS) in midshaft penile tissues.
The cross-sectional areas of the whole midshaft penis and the corpora cavernosa were quantified. The smooth muscle in the corpora cavernosa and nNOS in the dorsal nerves were quantified.
Results: The weight, but not the length, of the penis was lower in diabetics. The crosssectional areas of the total midshaft penis and the corpora cavernosa were lower in diabetic rats compared with controls 9 weeks, but not 3 weeks after diabetes induction.
The cross-sectional area of smooth muscle in the corpora cavernosa as percentage of the overall area of the corpora cavernosa was lower in diabetic rats than in controls 9 weeks, but not 3 weeks after diabetes induction. Percentage change of nNOS in dorsal nerves was similar at 3 weeks, and has a decreased trend at 9 weeks in diabetic rats compared with controls.
Conclusions: Diabetes causes temporal alterations in the penis, and the significant changes in STZ rat model begin 3-9 weeks after induction. Further studies on the reversibility of the observed changes are warranted.
Keywords: Diabetes Mellitus; Penis; Erectile Dysfunction
Vol. 43 (4): 762-765, July – August, 2017
Fabio C. Vicentini 1, Luiz A. A. Botelho 1, José L. M. Braz 2, Ernane de S. Almeida 3, Marcelo Hisano 1
1 Departamento de Urologia, Centro do Cálculo Renal do Hospital 9 de Julho, São Paulo, Brasil; 2 Departamento de Anestesia, Hospital 9 de Julho, São Paulo, Brasil; 3 Departamento de Enfermagem, Centro Cirúrgico do Hospital 9 de Julho, São Paulo, Brasil
We describe the use of the Uro Dyna-CT, an imaging system used in the operating room that produces real-time three-dimensional (3D) imaging and cross-sectional image reconstructions similar to an intraoperative computerized tomography, during a percutaneous nephrolithotomy and a contralateral flexible ureteroscopy in a complete supine position. A 65 year-old female patient had an incomplete calyceal staghorn stone in the right kidney and a 10mm in the left one. The procedure was uneventful and the intraoperative use of the Uro Dyna-CT identified 2 residual stones that were not found by digital fluoroscopy and flexible nephroscopy at the end of surgery, helping us to render the patient stone-free in one procedure, which was confirmed by a postoperative CT scan. Prospective studies will define the real role of the Uro Dyna-CT for endourological procedures, but its use seems to be a very promising tool for improving stone free rates and decreasing auxiliary procedures, especially for complex cases.
Keywords: Nephrostomy, Percutaneous; Radiation; Ureteroscopy
Vol. 43 (4): 766-769, July – August, 2017
CHALLENGING CLINICAL CASES
Lucas Schreiner 1, Thais Guimarães dos Santos 1, Christiana Campani Nygaard 2, Daniele Sparemberger Oliveira 2
1 Departamento de Obstetrícia e Ginecologia do Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, RS, Brasil; 2 Serviço de Uroginecologia do Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, RS, Brasil
Background: Vaginal evisceration is a rare problem, usually related to a previous hysterectomy. We report a case of spontaneous rupture of the cul-de-sac in a premenopausal woman under treatment with glucocorticoids to treat Systemic Lupus Erythematosus (SLE), with uterine prolapse that occurred during evacuation.
Case Report: A 40-year-old woman with SLE, using glucocorticoids, with uterine prolapse grade 4 (POP-Q), awaiting surgery presented at the emergency room with vaginal bleeding after Valsalva during defaction. Uterine prolapse associated with vaginal evisceration was identified. Under vaginal examination, we confirmed the bowel viability and performed a vaginal hysterectomy and sacrospinous fixation.
Case hypothesis: This case draws attention to the extreme risk of untreated uterine prolapse, as well as the importance of multidisciplinary care of patients with vaginal prolapse and chronic diseases.
Keywords: Prolapse; Vagina; Lupus Erythematosus, Systemic
Vol. 43 (4): 770-775, July – August, 2017
CHALLENGING CLINICAL CASES
Akinsal, Emre Can 1, Baydilli, Numan 1, Demirtas, Abdullah 1, Saatci, Cetin 2, Ekmekcioglu, Oguz 1
1 Department of Urology, Erciyes University Medical Faculty, Kayseri, Turkey; 2 Department of Genetics, Erciyes University Medical Faculty Medical, Kayseri, Turkey
Objective: To present clinical, chromosomal and hormonal features of ten cases with SRY-positive 46,XX testicular disorder of sex development who were admitted to our infertility clinic.
Cases and Methods: Records of the cases who were admitted to our infertility clinic between 2004 and 2015 were investigated. Ten 46,XX testicular disorder of sex development cases were detected. Clinical, hormonal and chromosomal assessments were analized.
Results: Mean age at diagnosis was 30.4, mean body height was 166.9cm. Hormonal data indicated that the patients had a higher FSH, LH levels, lower TT level and normal E2, PRL levels. Karyotype analysis of all patients confirmed 46,XX karyotype, and FISH analysis showed that SRY gene was positive and translocated to Xp. The AZFa, AZFb and AZFc regions were absent in 8 cases. In one case AZFb and AZFc incomplete deletion and normal AZFa region was present. In the other one all AZF regions were present.
Conclusion: Gonadal development disorders such as SRY-positive 46,XX testicular disorder of sex development can be diagnosed in infertility clinics during infertility workup. Although these cases had no chance of bearing a child, they should be protected from negative effects of testosterone deficiency by replacement therapies.
Keywords: Chromosomal abnormality, infertility, 46,XX testicular disorder of sex development
Minimally Invasive Radiologic Uretero-calycostomy; a salvage procedure for late transplant rejection ureter necrosis
Vol. 43 (4): 776-778, July – August, 2017
Erich K. Lang 1
1 Department of Radiology, Tulane School Medicine, New Orleans, LA, USA
No abstract available
Feasibility of Robot – assisted Segmental Ureterectomy and Ureteroureterostomy in Patient with High Medical Comorbidity
Vol. 43 (4): 779-780 July – August, 2017
Ali Abdel Raheem 1, Atalla Alatawi 2, Dae Keun Kim 3, Abulhasan Sheikh 2, Koon Ho Rha 2
1 Department of Urology, Tanta University Medical School, Egypt; 2 Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, South Korea; 3 Department of Urology, CHA Seoul Station Medical Center, CHA University Medical School, Seoul, Republic of Korea
Introduction and objectives: Nephroureterectomy remains the gold standard treatment option for upper tract tumors.
However, segmental ureterectomy may be another option in patients with single kidney, borderline renal function or high medical comorbidities. The aim of this video is to assess the feasibility of robotic surgery as a minimally invasive technique in treatment of a high comorbid patient with ureteric tumor.
Materials and Methods: Eighty-year old male patient, with a medical history of chronic hypertensive and uncontrolled Diabetes Mellitus, was referred to our department for treatment of ureteric tumor. Patient underwent robot-assisted radical prostatectomy 5 years ago. Patient’s Charlson comorbidity index score was 9. Computed tomography showed a 2.5cm right ureteral luminal filling enhancing lesion at lower part of upper 1/3 ureter. We performed diagnostic flexible cystoscopy under local anesthesia to exclude associated lower urinary tract carcinoma, and bladder wash was negative for malignancy. Under general anesthesia patient underwent diagnostic flexible ureteroscopy to confirm mass location, and a retrograde pyelography to rule out additional tumors on the right collecting system. Then, the patient was placed in the full lateral flank position without Table flexion. Ports placement were inserted as follow: a “12mm” optical trocar at pararectal line superior and lateral to umbilicus, two “8mm” robotic trocars cranial and caudal to optical trocar (8cm distance), a “8mm” robotic trocar towards anterior superior ischial spine, and a “12mm” assistant trocar was inserted between umbilicus and pubic bone. The surgical steps are shown in the video.
Results: The procedure was performed easily. The total operative time and consol time were 100 and 60 minutes, respectively. Blood loss was 50ml. No reported intraoperative or postoperative complications. Notably, we took full precautions in case of intraoperative failure to complete the procedure successfully, nephroureterectomy was our second option.
Postoperative serum creatinine was 1.2mg/dL and length of hospital stay was 2 days. The frozen biopsy showed that the tumor was resected with safe proximal and distal surgical margins. Final histopathology revealed high grade (G3) urothelial carcinoma (pT3), measures (1.3×1.2×0.2cm), associated with carcinoma in situ.
Conclusion: We affirm that robotic segmental ureterectomy and ureteroureterostomy could be offered safely as a minimally invasive treatment for patients with ureteric tumors and high-risk medical comorbidities. It provides excelente perioperative outcomes and early oncological safety with regard to surgical margins.
Editorial Comment: Feasibility of Robot – assisted Segmental Ureterectomy and Ureteroureterostomy in Patient with High Medical Comorbidity
Vol. 43 (4): 781-781, July – August, 2017
Alejandro R. Rodriguez 1
1 Department of Urology and Urology Oncology, Samaritan Medical Center, Watertown, New York, USA
No abstract available
Robot-assisted laparoscopic radical prostatectomy with early retrograde release of the neurovascular bundle and endopelvic fascia sparing
Vol. 43 (4): 782-782, July – August, 2017
George Augusto Monteiro Lins de Albuquerque 1,2, Giuliano Betoni Guglielmetti 1,2, Maurício Dener Cordeiro 1,2, William Carlos Nahas 1,2, Rafael Ferreira Coelho 1,2
1 Instituto do Câncer de São Paulo, SP. Brasil; 2 Divisão de Urologia, Faculdade de Medicina, Universidade de São Paulo, SP, Brasil
Introduction: Robotic-assisted radical prostatectomy (RAP) is the dominant minimally invasive surgical treatment for patients with localized prostate cancer. The introduction of robotic assistance has the potential to improve surgical outcomes and reduce the steep learning curve associated with conventional laparoscopic radical prostatectomy. The purpose of this video is to demonstrate the early retrograde release of the neurovascular bundle without open the endopelvic fascia during RAP.
Materials and Methods: A 51-year old male, presenting histological diagnosis of prostate adenocarcinoma, Gleason 6 (3+3), in 4 cores of 12, with an initial PSA=3.41ng/dl and the digital rectal examination demonstrating a prostate with hardened nodule in the right lobe of the prostate base (clinical stage T2a). Surgical treatment with the robot-assisted technique was offered as initial therapeutic option and the critical technical point was the early retrograde release of the neurovascular bundle with endopelvic fascia preservation, during radical prostatectomy.
Results: The operative time was of 89 minutes, blood loss was 100ml. No drain was left in the peritoneal cavity. The patient was discharged within 24 hours. There were no intraoperative or immediate postoperative complications. The pathological evaluation revealed prostate adenocarcinoma, Gleason 6, with free surgical margins and seminal vesicles free of neoplastic involvement (pathologic stage T2a). At 3-month-follow-up, the patient lies with undetectable PSA, continent and potent.
Conclusion: This is a feasible technique combining the benefits of retrograde release of the neurovascular bundle, the preservation of the pubo-prostatic collar and the preservation of the antero-lateral cavernous nerves.
Vol. 43 (4): 783-783, July – August, 2017
Marcos Figueiredo Mello 1, Hiury Silva Andrade 1, Victor Srougi 1, Marco Antonio Arap 1, Anuar Ibrahim Mitre 1, Ricardo Jordão Duarte 1, Miguel Srougi 1
1 Divisão de Urologia do Departamento de Cirurgia, Universidade de São Paulo, SP, Brasil
Hemospermia has been considered as a benign and self-limiting condition. It usually has an inflammatory or infectious cause. However, recurrent or persistent hemospermia may indicate a more serious underlying pathology, especially over 40 years of age.
Biopsy or surgical excision is indicated in cases of suspicious findings during investigation, such as cysts or masses. Open surgery has been considered the definitive form of treatment, however, it can be associated with significant morbidity. With growing experience in laparoscopics, this approach is becoming the preferable way to access the seminal vesicles.
Our objective is to demonstrate a step-by-step operative technique for laparoscopic unilateral vesiculectomy approach in a man with hemospermia.
Case: A 61 year-old man presented with 1 year of hemospermia. He was treated empirically with a fluoroquinolone plus a nonsteroidal anti-inflammatory without resolution of symptoms. Ultrasonography and MRI showed a solid-cystic mass in the right seminal vesicle. The patient was submitted to a laparoscopic unilateral vesiculectomy. Histopathological analysis showed intraluminal dilatation with blood content. During follow-up, complete resolution of symptoms was seen.
Results: Three patients composed our cohort. Mean age was 53 years-old (range 45-61 years), the right side was more commonly affected (two unilateral on the right and bilateral). Mean operative time was 55 minutes (range 40-120min). One patient presented amyloidosis in the histopathological analysis. All cases presented complete resolution of symptoms.
Conclusions: Laparoscopic vesiculectomy is a safe and feasible approach in cases of hemospermia. This technique showed good outcomes and minimal morbidity.
Vol. 43 (4): 784-784, July – August, 2017
Tariq S. Hakky 1
1 Department of Urology, University of Southern Florida, Moffitt Cancer Center, USA
No abstract available
Image-guided percutaneous targeting of lymph nodes: a novel approach for salvage pelvic lymphadenectomy in recurrent prostate cancer
Vol. 43 (4): 785-787, July – August, 2017
LETTER TO EDITOR
Gustavo Caserta Lemos 1, Arie Carneiro 1, Guilherme Cayres Mariotti 1, Jose Roberto Colombo 1, Marcelo Apezzato 1, Marcelo Livorsi da Cunha 1, Fernado Cotait Maluf 1, Rodrigo Gobbo Garcia 1
1 Hospital Israelita Albert Einstein – Oncology Center, São Paulo, Brasil
No abstract available
Vol. 43 (4): 788-790, July – August, 2017
LETTER TO THE EDITOR
Fernando Korkes 1
1 Departamento de Urologia, Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
No abstract available