Vol. 42 n. 4 July . August, 2016

The July-August 2016 issue of the International Braz J Urol presents original contributions with a lot of interesting papers in different fields: Urinary Incontinence, Pyelonephritis, Bladder Cancer, BPH, Prostate Cancer, Renal stones, Renal Cell

Open retropubic prostatectomy for large prostates (Millin Surgery): Why not? It is safe! It is rapid! Complications are few and the learning curve is short!

Vol. 42 (4): 635-636, July – August, 2016

doi: 10.1590/S1677-5538.IBJU.2016.04.01

EDITORIAL In this issue

 Luciano A. Favorito 1-3

1 Professor Associado da Unidade de Pesquisa Urogenital da Universidade do Estado de Rio de Janeiro, RJ, Brasil; 2 Urologista do Hospital da Lagoa Federal,Rio de Janeiro RJ, Brasil; 3 Editor Associado do International Braz J Urol, RJ, Brasil


The July-August 2016 issue of the International Braz J Urol presents original contributions with a lot of interesting papers in different fields: Urinary Incontinence, Pyelonephritis, Bladder Cancer, BPH, Prostate Cancer, Renal stones, Renal Cell Carcinoma, Uroginecology, Pediatric Urology and basic research. The papers come from many different countries such as Brazil, USA, Turkey, Italy, Israel, India, China, Iran, Thailand, Egypt, Korea and Colombia, and as usual the editor’s comment highlights some papers.

We decided to comment 3 papers about a very usual topic in urologic practice: Benign Prostatic Hyperplasia.

Doctor Kobayashi and collegues from Japan performed on page 740 an interesting study about the predictive risk factors of postoperative urinary incontinence following holmium laser enucleation (HoLEP). The authors evaluated 127 patients with benign prostatic hyperplasia who underwent HoLEP. The authors observed that a postoperative urinary incontinence (UI) occurred in 31 patients (24.4%), but it cured in 29 patients (93.5%) after a mean duration of 12 weeks. They concluded that longer enucleation time and increased blood loss were independent predictors of postoperative UI in patients who underwent HoLEP during the initial learning period.

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Are syntetic slings safe?

Vol. 42 (4): 637-639, July – August, 2016

doi: 10.1590/S1677-5538.IBJU.2016.04.02


Are syntetic slings safe?
Opinion: Yes
Caio Cesar Cintra 1, Carlos Eduardo Bonafe Oliveira 1

1 Departamento de Urologia, Faculdade de Medicina do ABC, SP, Brasil

Keywords: Suburethral Slings; Surgical Mesh; Pelvic Floor; Prolapse

Nowadays, synthetic meshes are widely used in reconstructive surgeries of the pelvic floor. However, since the publication of the FDA warning about associated complications in 2011 (1), several discussions and contrary opinions have been published about its usefulness. The fear of court lawsuits related to side effects, common in some settings, has contributed to the widening of global discussion.

Doubtless, these slings are associated to specific complications, such as exposition and erosion, and impact on sexual performance of treated patients. However, the big question is: is the use of meshes in pelvic surgery always problematic?

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Are syntetic slings safe?

Vol. 42 (4): 640-644, July – August, 2016

doi: 10.1590/S1677-5538.IBJU.2016.04.03


Are syntetic slings safe?
Opinion: No
Lenore Ackerman 1, Shlomo Raz 2

1 Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; 2 Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

Keywords: Suburethral Slings; Surgical Mesh; Pelvic Floor; Prolapse

Urinary incontinence is a highly prevalent condition affecting up to half of all women, most of whom have a component of stress urinary incontinence (SUI) (1). Approximately 10% of these women will undergo surgical treatment. While for decades the standard of care was the Burch colposuspension or autologous fascial pubovaginal sling, rapid advances in the development of augmented polypropylene products (APM) for medical use led to the widespread adoption of synthetic midurethral slings (SMUS) for the treatment of SUI.

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Semi-rigid ureteroscopic lithotripsy versus laparoscopic ureterolithotomy for large upper ureteral stones: a meta – analysis of randomized controlled trials

Vol. 42 (4): 645-654, July – August, 2016

doi: 10.1590/S1677-5538.IBJU.2015.0696


Fabio C. M. Torricelli 1,2, Manoj Monga 2, Giovanni S. Marchini 1, Miguel Srougi 1, William C. Nahas 1, Eduardo Mazzucchi 1

1 Departamento de Urologia do Hospital das Clínicas da Universidade de São Paulo Faculdade de Medicina São Paulo, SP,  Brasil; 2 Stevan B. Streem Center for Endourology & Stone Disease; Glickman Urological & Kidney Institute, The Cleveland Clinic, Cleveland, OH, USA


Introduction: To provide a systematic review and meta-analysis of randomized controlled trials (RCT) comparing semi-rigid ureteroscopic lithotripsy (URS) with laparoscopic ureterolithotomy (LU) for the treatment of the large proximal ureteral stone.
Materials and methods: A systematic literature review was performed in June 2015 using the PubMed, Scopus, and Web of Science databases to identify relevant studies.
Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria.
Results: Six RCT including 646 patients were analyzed, 325 URS cases (50.3%) and 321 LU cases (49.7%). URS provided a significantly shorter operative time (weighted mean difference [WMD] = -31.26 min; 95%CI -46.88 to -15.64; p<0.0001) and length of hospital stay (WMD = -1.48 days; 95%CI -2.78 to -0.18; p=0.03) than LU. There were no significant differences in terms of overall complications (OR = 0.78; 95%CI 0.21-2.92; p=0.71) and major complications – Clavien ≥3 – (OR = 1.79; 95%CI 0.59-5.42; p=0.30).
LU led to a significantly higher initial stone-free rate (OR = 8.65; 95%CI 4.18-17.91; p<0.00001) and final stone-free rate (OR = 6.41; 95%CI 2.24-18.32; p=0.0005) than URS. There was a significantly higher need for auxiliary procedures in URS cases (OR = 6.58; 95%CI 3.42-12.68; p<0.00001).
Conclusions: Outcomes with LU for larger proximal ureteral calculi are favorable compared to semi-rigid URS and should be considered as a first-line alternative if flexible ureteroscopy is not available. Utilization of flexible ureteroscopy in conjunction with semi-rigid ureteroscopy may impact these outcomes, and deserves further systematic evaluation.

Keywords: Laparoscopy; Lithotripsy; Ureter; Ureteroscopy; Urinary Calculi

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Extraperitoneal versus transperitoneal laparoscopic radical cystectomy for selected elderly bladder cancer patients: a single center experience

Vol. 42 (4): 655-662, July – August, 2016

doi: 10.1590/S1677-5538.IBJU.2015.0608


Lang Feng 1, Jian Song 1, Menghua Wu 1, Ye Tian 1, Daoxin Zhang 1

1 Department of Urology, Beijing Friendship Hospital, Capital Medical University, Beijing, China


Objective: This study reports the initial experience of extraperitoneal laparoscopic radical cystectomy (ELRC) and compared with transperitoneal laparoscopic radical cystectomy (TLRC) in the treatment of selected elderly bladder cancer patients.
Patients and Methods: A total of forty male bladder cancer patients who underwent ELRC (n=19) or TLRC (n=21) with ureterocutaneostomy were investigated. Demographic parameters, perioperative variables, oncological outcomes and follow-up data were retrospectively analyzed.
Results: A significantly shorter time to exsufflation (1.5±0.7 vs 2.1±1.1 d; p=0.026) and liquid intake (1.8±0.9 vs 2.8±1.9 d; p=0.035) were observed in the ELRC group compared with the TLRC group. The incidence of postoperative ileus in the ELRC group was lower than the TLRC group (0 vs 9.5%). However, the difference had no statistical significance (p>0.05). The removed lymph node number in the ELRC group was significantly lower than the TLRC group (p<0.001). No significant differences were observed between the two groups in the overall and cancer-free survival rates (p>0.05).
Conclusions: ELRC seems to be a safe and feasible surgical strategy for the selected elderly bladder cancer patients with ≤ T2 disease. The surgical and oncological efficacy of the ELRC is similar to that of the TLRC, but with faster intestinal function recovery. Further studies with a large series including different urinary diversions are needed to confirm our results and to better evaluate the benefit of ELRC in bladder cancer patients.

Keywords: Laparoscopy; Oncology; Bladder; cystectomy

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A comparison of preliminary oncologic outcome and postoperative complications between patients undergoing either open or robotic radical cystectomy

Vol. 42 (4): 663-670, July – August, 2016

doi: 10.1590/S1677-5538.IBJU.2015.0393


Antonio Cusano 1, Peter Haddock 1, Max Jackson 1, Ilene Staff 1, Joseph Wagner 1, Anoop Meraney 1

1 Urology Division, Hartford Healthcare Medical Group, Hartford, USA


Purpose: To compare complications and outcomes in patients undergoing either open radical cystectomy (ORC) or robotic-assisted radical cystectomy (RRC).
Materials and Methods: We retrospectively identified patients that underwent ORC or RRC between 2003- 2013. We statistically compared preliminary oncologic outcomes of patients for each surgical modality.
Results: 92 (43.2%) and 121 (56.8%) patients underwent ORC and RRC, respectively. While operative time was shorter for ORC patients (403 vs. 508 min; p<0.001), surgical blood loss and transfusion rates were significantly lower in RRC patients (p<0.001 and 0.006). Length of stay was not different between groups (p=0.221). There was no difference in the proportion of lymph node-positive patients between groups. However, RRC patients had a greater number of lymph nodes removed during surgery (18 vs. 11.5; p<0.001). There was no significant difference in the incidence of pre-existing comorbidities or in the Clavien distribution of complications between groups.
ORC and RRC patients were followed for a median of 1.38 (0.55-2.7) and 1.40 (0.58-2.59) years, respectively (p=0.850). During this period, a lower proportion (22.3%) of RRC patients experienced disease recurrence vs. ORC patients (34.8%). However, there was no significant difference in time to recurrence between groups. While ORC was associated with a higher all-cause mortality rate (p=0.049), there was no significant difference in disease-free survival time between groups.
Conclusions: ORC and RRC patients experience postoperative complications of similar rates and severity. However, RRC may offer indirect benefits via reduced surgical blood loss and need for transfusion.

Keywords: Oncology Nursing; Postoperative Period; Robotics; Cystectomy; Urinary Bladder Neoplasms

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Presentation and surgery outcomes in elderly with pheocromocytoma: a comparative analysis with young patients

Vol. 42 (4): 671-677, July – August, 2016

doi: 10.1590/S1677-5538.IBJU.2015.0503


Victor Srougi 1, Jose L. Chambo 1, Fabio Y. Tanno 1, Iracy S. Soares 2, Madson Q. Almeida 3, Maria A. A. Pereira 3, Miguel Srougi 1, Maria C. Fragoso 3

1 Divisão de Urologia do Hospital das Clínicas da Universidade de São Paulo, Faculdade de Medicina, São Paulo, Brasil; 2 Divisão de Anestesiologia do Hospital das Clínicas da Universidade de São Paulo, Faculdade de Medicina, São Paulo, Brasil; 3 Divisão de Endocrinologia do Hospital das Clínicas da Universidade de São Paulo, Faculdade de Medicina, São Paulo, Brasil


Purpose: To evaluate the presentation and early surgical outcomes of elderly patients undergoing adrenalectomy for phaeochromocytoma.
Patients and Methods: A retrospective search was performed of our adrenal disorders database for patients who underwent surgery for phaeochromocytoma or paraganglioma between 2009 and 2014. Patients >60 years old were classified as elderly. The clinical manifestations, intraoperative course, and early postoperative outcomes of elderly patients were compared to those of younger individuals (<60 years old).
Results: The mean (±standard deviation) age in the older (n=10) and younger (n=36) groups was 69.6±5.3 years and 34.0±12.9 years. Germ-line mutations were more common in younger patients (50.0% versus 0%; p=0.004), whereas incidental lesions were more common in the elderly (40.0% versus 5.3%; p=0.003). In both groups, surgery was most commonly performed by videolaparoscopy (90% in the elderly and 82% in the younger group), with similar intraoperative anesthetic and surgical outcomes. Postoperatively, the older group more commonly received vasoactive drugs (60.0% versus 10.5%; p<0.001) and had a longer intensive care unit stay (3.1±2.8 versus 1.4±1.0 days; p=0.014), more clinical complications (60% versus 18.9%; p=0.01), and longer hospital stay (10.2±8.4 versus 5.7±4.9 days; p=0.028).
Conclusions: Although all patients received the same preoperative preparation, the elderly group exhibited a slower and more complicated recovery after adrenalectomy. Meticulous perioperative care should be used in the elderly when treating phaeochromocytoma; nevertheless, adrenalectomy is a relatively safe procedure in this patient population.

Keywords: Pheochromocytoma; Adrenalectomy; Surgical Procedures, Operative

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Clinical Significance of Preoperative Neutrophil – to – Lymphocyte Ratio in Renal Cell Carcinoma

Vol. 42 (4): 678-684, July – August, 2016

doi: 10.1590/S1677-5538.IBJU.2015.0397


Alper Otunctemur 1, Murat Dursun 1, Huseyin Besiroglu 1, Kutan Ozer 2, Ozan Horsanali 2, Emin Ozbek 1

1 Department of Urology, Okmeydani Training and Research Hospital, Istanbul, Turkey; 2 Department of Urology, Ataturk Training and Research Hospital, Izmir, Turkey


Introduction: We investigated the prognostic significance of the neutrophil-to-lymphocyte ratio on tumor stage and Fuhrman nuclear grade in renal cell carcinoma.
Methods: The records of 432 patients with RCC who underwent radical or partial nephrectomy between 2005 and 2014 were retrospectively reviewed. Patients were classified as group lower tumor stage (T1 + T2) and higher (T3 + T4). As like tumor stage, Fuhrman nuclear grade were classified lower (G1+G2) and higher (G3+G4) too. The best NLR cut off value was 3.01.Two sample t-test or Mann–Whitney U-test used for the continuous variables and a chi-square test or Fisher’s exact test used for the categorical variables.
Results: Among the 432 total patients analyzed in our study, there were 275 males (63.7%) and 157 females (36.3%). Mean laboratory values were CRP 2.73 ± 1.93 mg/ dL (normal less than 0.3), neutrophil count 4.23 ± 1.46/μL, lymphocyte count 1,61 ± 0.61/μL and NLR 2.64 ± 1.24. According to our data, statistically pretreatment NLR significantly
correlated with CRP (p<0.0001). And tumor patologic stage(p=008), tumor histologic grade (p<0.001) was significantly associated with NLR.
Discussion: We compared the relationship of preoperative NLR and NC parameters with RCC tumor stage and grade. And NLR were found to have statistically significant higher T stage and grade at RCC. Further studies with more patients are needed to confirm our study.

Keywords: Neutrophils; Lymphocytes; Carcinoma, Renal Cell; Epithelium

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Neutrophil to lymphocyte ratio, a biomarker in non-muscle invasive bladder cancer: a single-institutional longitudinal study

Vol. 42 (4): 685-693, July – August, 2016

doi: 10.1590/S1677-5538.IBJU.2015.0243


Vincenzo Favilla 1, Tommaso Castelli 1, Daniele Urzì 1, Giulio Reale 1, Salvatore Privitera 1, Antonio Salici 1, Giorgio Ivan Russo 1, Sebastiano Cimino 1, Giuseppe Morgia 1

1 Sezione Urologia, Dipartimento di Chirurgia, Università di Catania, Italia


Background: Bladder cancer represents one of the most important clinical challenges in urologic practice. In this context, inflammation has an important role in the development and progression of many malignancies. The objective of the present study was to evaluate the prognostic value of pre-treatment Neutrophil to lymphocyte ratio (NLR) on the risk of recurrence and progression in patients with primary non-muscle invasive bladder cancer.
Materials and Methods: Data obtained from 178 bladder cancer patients who underwent transurethral resection of bladder tumor (TURB) between July 2008 and December 2014 were evaluated prospectively. NLR was obtained from each patient before TURB and defined as the absolute neutrophil count divided by the absolute lymphocyte count. Cox proportional hazards regression model was performed to calculate disease recurrence and progression including NLR.
Results: During the follow-up study (median: 53 months), 14 (23.3%) and 44 (37.9%) (p=0.04) patients respectively with NLR<3 and ≥3experienced recurrence and 2 (3.3%) and 14 (11.9%) experienced progression (p=0.06), respectively. At the multivariate Cox regression analysis, NLR ≥3 was associated with worse disease recurrence (HR: 2.84; p<0.01). No association was found regarding disease progression. The 5-year recurrence free survival was 49% and 62% in patients with NLR≥3 and <3 (p<0.01). The 5-year progression free survival was 77% and 93% in patients with NLR≥3 and <3 (p=0.69).
Conclusion: NLR predicts disease recurrence but not disease progression in NMIBC patients. NLR alterations may depend of tumor inflammatory microenvironment.

Keywords: Urinary Bladder Neoplasms; Urinary Bladder Neoplasms; Neutrophils; Biomarkers

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Sunitinib treatment in patients with advanced renal cell cancer: the Brazilian national cancer institute (Inca) experience

Vol. 42 (4): 694-703, July – August, 2016

doi: 10.1590/S1677-5538.IBJU.2015.0226


Rafael Corrêa Coelho 1, Tomás Reinert 1, Franz Campos 2, Fábio Affonso Peixoto 1, Carlos Augusto de Andrade 1, Thalita Castro 3, Daniel Herchenhorn 1

1 Departamento de Clínica Oncologia, Instituto Nacional de Câncer José de Alencar Gomes da Silva (INCA), SP, Brasil; 2 Departamento de Urologia – Instituto Nacional de Câncer José de Alencar Gomes da Silva (INCA), SP, Brasil; 3 Departamento de Estatística – Centro de Pesquisa Clínica (CPQ) – Instituto Nacional de Câncer José de Alencar Gomes da Silva (INCA), SP, Brasil


Purpose: The aim of this study was to assess the impact of sunitinib treatment in a non-screened group of patients with metastatic renal cell cancer (mRCC) treated by the Brazilian Unified Health System (SUS) at a single reference institution.
Material and Methods: Retrospective cohort study, which evaluated patients with mRCC who received sunitinib between May 2010 and December 2013.
Results: Fifty-eight patients were eligible. Most patients were male 41 (71%), with a median age of 58 years. Nephrectomy was performed in 41 (71%) patients with a median interval of 16 months between the surgery and initiation of sunitinib. The most prevalent histological subtype was clear cell carcinoma, present in 52 (91.2%) patients. In 50 patients (86%), sunitinib was the first line of systemic treatment. The main adverse effects were fatigue (57%), hypothyroidism (43%), mucositis (33%) and diarrhea (29%). Grade 3 and 4 adverse effects were infrequent: fatigue (12%), hypertension (12%), thrombocytopenia (7%), neutropenia (5%) and hand-foot syndrome (5%). Forty-three percent of patients achieved a partial response and 34% stable disease, with a disease control rate of 77%. Median progression free survival was 7.6 months and median overall survival was 14.1 months.
Conclusion: Sunitinib treatment was active in the majority of patients, especially those with low and intermediate risk by MSKCC score, with manageable toxicity. Survival rates were inferior in this non-screened population with mRCC treated in the SUS.

Keywords: Neoplasm Metastasis; Kidney Neoplasms; sunitinib [Supplementary Concept]; Retrospective Studies

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