Vol. 42 n. 6 November . December, 2016

Volume 42 | number 6 | November . December, 2016 The November-December 2016 issue of the International Braz J Urol presents original contributions with a lot of interesting papers in different fields: Bladder Cancer, BPH, Prostate Cancer, Renal stones, Renal Cell Carcinoma, Pediatric Urology, Peyronie Disease, Erectile Disfunction, Penile Cancer…/span>

Penile Cancer: The Importance to predict lymph node metastasis

Vol. 42 (6): 1056-1057, November – December, 2016

doi: 10.1590/S1677-5538.IBJU.2016.06.01

EDITORIAL in this Issue

Luciano A. Favorito

Professor Associado da Unidade de Pesquisa Urogenital da Universidade do Estado de Rio de Janeiro
Urologista do Hospital da Lagoa Federal, Rio de Janeiro
Editor Associado da International Braz J Urol

No Abstract Available

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Data vs Dogma in Peyronie’s Disease

Vol. 42 (6): 1058-1061, November – December, 2016

doi: 10.1590/S1677-5538.IBJU.2016.06.02


Ryan P. Terlecki 1, Alison M. Rasper 1

1 Wake Forest Baptist Health, NY, USA

Curvature of the erect penis from elements of internal fibrosis has been recognized for centuries (first described in 1743), yet our understanding still seems limited. Guidelines exist in both the United States and Europe, with most based on low level evidence and opinion (1, 2). Men afflicted by this situation are typically lumped together and labeled with the singular descriptor of Peyronie’s disease. The level of evidence for the pathophysiology and natural history of this affliction is poor, as is the awareness of data surrounding treatment modalities. This is evidenced by the fact that one of the most commonly provided interventions is Vitamin E, which has not been shown to provide benefit and is not recommended by existing guidelines. In medical practice, it is dangerous to equate shared assumptions with fact, as this may limit pursuit of additional knowledge. Additionally, in the absence of evidence, logic should prevail.

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MRI should be routine for all patients with localized prostate cancer? | Opinion: Yes

Vol. 42 (6): 1062-1064, November – December, 2016

doi: 10.1590/S1677-5538.IBJU.2016.06.03


Ronaldo Hueb Baroni 1

1 Hospital Israelita Albert Einstein, SP, Brasil

Keywords: Magnetic Resonance Imaging; Prostatic Neoplasms; Diagnosis; Watchful Waiting

Magnetic resonance imaging (MRI) has been used for staging prostate cancer (PCa) since the 1990’s, more precisely after the advent of the endorectal coil, which enabled significant improvement in the quality of the examination. Also, the standardization of prostate MRI with multiparametric sequences (including high resolution T2-weighted, diffusion and dynamic contrast-enhanced or perfusion images), together with the progressive learning curve by uro-radiologists, contributed to include the method definitively in the list of available procedures for staging prostate cancer (1).

The accuracy of multiparametric MRI (mpMRI) is greater than that of other isolated clinical, laboratory and imaging methods available, with specificities around 85% for detection of extracapsular extension and seminal vesicle invasion (2). Moreover, the incremental value of MRI has been validated around a decade ago in three articles by the interdisciplinary group of Memorial Sloan Kettering Cancer Center, demonstrating that the addition of MRI to the commonly used clinical nomograms significantly increases the accuracy for prediction of organ-confined disease, extracapsular extension and seminal vesicle invasion (3-5).

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MRI should be routine for all patients with localized prostate cancer? | Opinion: No

Vol. 42 (6): 1065-1068, November – December, 2016

doi: 10.1590/S1677-5538.IBJU.2016.06.04


Joel B. Nelson 1

1 Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

Keywords: Therapeutics: Neoplasms; Cryosurgery; Nephrectomy

One of the basic principles of medical care is that a diagnostic test should inform a clinical decision. If the test is uninformative, it is not useful; if no decision is to be made then a diagnostic test is not necessary. Indeed, performing a diagnostic test when it adds nothing to the decision-making process is not only a waste of healthcare resources, it is potentially harmful, leading to incorrect conclusions or more unnecessary testing. From this perspective, how could mp-MRI potentially inform the initial management of localized prostate cancer?

Men who are candidates for active surveillance based on low-risk prostate cancer (cT1c, PSA<10, Grade Group 1 (Gleason 3+3=6)) may be harboring a higher grade tumor that eluded the initial biopsy, particularly if it is anteriorly placed. mp-MRI has the promise of detecting this potentially more serious cancer and avoiding the risk of inappropriate observation.

Some have argued men with low-risk prostate cancer with a “normal” mp-MRI (PI-RADS 1) have very little risk of cancer progression. The promise of mp-MRI to provide a better risk assessment in men considering active surveillance is alluring.


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Prostate cancer screening in Brazil: should it be done or not?

Vol. 42 (6): 1069-1080, November – December, 2016

doi: 10.1590/S1677-5538.IBJU.2015.0709


Wilson F. S. Busato Jr 1, Gilberto L. Almeida 1,2

1 Departamento de Urologia, UNIVALI –Itajai, SC, Brasil; 2 Instituto Catarinense de Urologia, Itajaí, SC, Brasil


The use of PSA in the screening, detection and prognosis of prostate cancer (PCa) has revolutionized the diagnosis and treatment of this disorder with an increase in detection rates and PCa organ-confined. Despite these benefits and ease of implementation, tracking PCa remains a matter of great controversy. We conducted a literature review and demographic and epidemiological data in Brazil feeling to assess the current state of screening and whether there is justification for population programs. the diferences are valued between developed and underdeveloped countries as the incidence, mortality, screening and access to health. an analysis of the advantages and disadvantages of screening is made as well as a critical analysis of existing studies on screening and some recommendations on a rational screening.

Keywords: Prostatic Neoplasms; Mass Screening; Brazil

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Prostate cancer in Brazil and Latin America: epidemiology and screening

Vol. 42 (6): 1081-1090, November – December, 2016

doi: 10.1590/S1677-5538.IBJU.2015.0690


Rafael Rocha Tourinho-Barbosa 1, Antonio Carlos Lima Pompeo 1, Sidney Glina 1

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


Introduction: Prostate cancer is one of the tumors with higher incidence and mortality among men in the World. Epidemiological data are influenced by life expectancy of population, available diagnostic methods, correct collection of data and quality of health services. Screening of the disease is not standardized around the World. Up till now there is no consensus about the risks versus benefits of early detection. There are still missing data about this pathology in Latin America.

Objective: to revise current epidemiologic situation and early diagnosis policies of prostate cancer in Brazil and Latin America.

Materials and Methods: Medline, Cochrane Library and SciELO databases were reviewed on the subject of epidemiology and screening of prostate cancer. Screening research was performed in websites on national public health organizations and Latin America. Screening recommendations were obtained from those governmental organizations and from Latin American urological societies and compared to the most prominent regulatory agencies and societies of specialists and generalists from around the World.

Results: Brazil and Latin America have a special position in relation to incidence and mortality of prostate cancer. In Brazil, it occupies the first position regarding incidence of cancer in men and the second cause of mortality. Central America has the highest rate of mortality of the continent with lower incidence/mortality ratios. Screening recommendations are very distinct, mainly among regulatory organs and urological societies.

Conclusion: prostate cancer epidemiology is an important health public topic. Data collection related to incidence and mortality is still precarious, especially in less developed countries. It is necessary to follow-up long term screening studies results in order to conclude its benefits.

Keywords: Prostatic Neoplasms; Epidemiology; Early Diagnosis; Latin America

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Oncological outcomes following radical prostatectomy for patients with pT4 prostate cancer

Vol. 42 (6): 1091-1098, November – December, 2016

doi: 10.1590/S1677-5538.IBJU.2016.0290


Dharam Kaushik 1,2, Stephen A. Boorjian 1, R. Houston Thompson 1, Manuel S. Eisenberg 1, Rachel E. Carlson 3, Eric J. Bergstralh 3, Igor Frank 1, Matthew T. Gettman 1, Matthew K. Tollefson 1, R. Jeffrey Karnes 1

1 Department of Urology, Mayo Clinic, Rochester, Minnesota, USA; 2 Department of Urology, University of Texas Health Science Center, San Antonio, Texas, USA; 3 Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA


Objectives: Radical prostatectomy (RP) for locally advanced prostate cancer may reduce the risk of metastasis and cancer-specific death. Herein, we evaluated the outcomes for patients with pT4 disease treated with RP.

Materials and methods: Among 19,800 men treated with RP at Mayo Clinic from 1987 to 2010, 87 were found to have pT4 tumors. Biochemical recurrence (BCR)-free survival, systemic progression (SP) free survival and overall survival (OS) were estimated using the Kaplan-Meier method and compared with the log-rank test. Cox proportional hazards regression models were used to assess the association of clinic-pathological features with outcome.

Results: Median follow-up was 9.8 years (IQR 3.6, 13.4). Of the 87 patients, 50 (57.5%) were diagnosed with BCR, 30 (34.5%) developed SP, and 38 (43.7%) died, with 11 (12.6%) dying of prostate cancer. Adjuvant androgen deprivation therapy was administered to 77 men, while 32 received adjuvant external beam radiation therapy. Tenyear BCR-free survival, SP-free survival, and OS was 37%, 64%, and 70% respectively. On multivariate analysis, the presence of positive lymph nodes was marginally significantly associated with patients’ risk of BCR (HR: 1.94; p=0.05), while both positive lymph nodes (HR 2.96; p=0.02) and high pathologic Gleason score (HR 1.95; p=0.03) were associated with SP.

Conclusions: Patients with pT4 disease may experience long-term survival following RP, and as such, when technically feasible, surgical resection should be considered in the multimodal treatment approach to these men.

Keywords: Prostatic Neoplasms; Prostatectomy; Neoplasm Metastasis

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Laparoscopic Radical Cystectomy in the Elderly – Results of a Single Center LRC only Series

Vol. 42 (6): 1099-1108, November – December, 2016

doi: 10.1590/S1677-5538.IBJU.2015.0419


Laparoscopic Radical Cystectomy in the Elderly – Results of a Single Center LRC only Series

Tom J. N. Hermans 1, Laurent M. C. L. Fossion 1, Rob Verhoeven 2, Simon Horenblas 3

1 Department of Urology, Maxima Medical Center Veldhoven, Veldhoven, The Netherlands; 2 Eindhoven Cancer Registry/Comprehensive Cancer Centre South, Eindhoven, Netherlands; 3 Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands


Objective: To compare outcome of laparoscopic radical cystectomy (LRC) with ileal conduit in 22 elderly (≥75 years.) versus 51 younger (<75 years.) patients.

Materials and Methods: Analysis of prospectively gathered data of a single institution LRC only series was performed. Selection bias for LRC versus non-surgical treatments was assessed with data retrieved from the Netherlands Cancer Registry.

Results: Median age difference between LRC groups was 9.0 years. (77.0 versus 68.0 years.). Both groups had similar surgical indications, body mass index and gender distribution. Charlson Comorbidity Index score was 3 versus 4 in ≥50% of younger and elderly patients. Median operative time (340 versus 341 min) and estimated blood loss (<500 versus >500mL) did not differ between groups. Median total hospital stay was 12.0 versus 14.0 days for younger and elderly patients. Grade I-II 90-d compli­cation rate was higher for elderly patients (68 versus 43%, p=0.05). Grade III-V 90-d complication rate was equal for both groups (23 versus 29%, p=0.557). 90-d mortality rate was higher for elderly patients (14 versus 4%, p=0.157). Median follow-up was 40.0 months for younger and 57.0 months for elderly patients. Estimated overall and cancer-specific survival at 5years. was 46% versus 35% and 64% versus 64% for youn­ger and elderly patients respectively.

Conclusions: Our results suggest that LRC is feasible in elderly patients, where a non­-surgical treatment is usually favoured.

Keywords:  Cystectomy; Geriatrics; Minimally Invasive Surgical Procedures; Survival; Urinary Bladder Neoplasms

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Prognostic features for quality of life after radical cystectomy and orthotopic neobladder

Vol. 42 (6): 1109-1120, November – December, 2016

doi: 10.1590/S1677-5538.IBJU.2015.0491


Prognostic features for quality of life after radical cystectomy and orthotopic neobladder

Alexander Kretschmer 1, Tobias Grimm 1, Alexander Buchner 1, Christian G. Stief 1, Alexander Karl 1

1 Department of Urology, Ludwig – Maximilians – University, Munich, Germany


Purpose: To analyse prognostic features on quality of life (QoL) following radical cystectomy and urinary diversion via orthotopic neobladder in a single-centre patient cohort.

Materials and Methods: Postoperative QoL of 152 patients was assessed retrospectively using the validated QLQ-C30 questionnaire. Potential associations of patient’s quality of life including pre-and intraoperative characteristics, surgeon experience, postoperative time course, adjuvant therapies, and functional outcome were defined a priori and evaluated. Mann-Whitney-U-, Kruskal-Wallis-, Spearman correlation and post hoctesting were used. A multivariate analysis using a multiple logistic regression model was performed. A p value <0.05 was considered to be statistically significant.

Results: Median follow-up was 48 months. Univariate analysis of prognostic features for health-related QoL revealed a significant impact of gender (p=0.019), performance status (p<0.001), experience of surgeon (>100 previous cystectomies, p=0.007), and nerve-sparing surgery (p=0.001). Patients who underwent secondary chemotherapy or radiotherapy had significant lower QLQ-C30 scores (p=0.04, p=0.02 respectively). Patients who were asymptomatic had a significantly higher quality of life (p<0.001). A significant impact of severity of incontinence based on ICIQ-SF score (p<0.001) and daily pad usage (p<0.001), existence of daytime incontinence (p<0.001), existence of urgency symptoms (p=0.007), and IIEF-5 score (p<0.001) could be observed. In multivariate analysis, independent prognostic relevance could be confirmed for preoperative ECOG performance status of 0 (p=0.020 vs. ECOG 1, p=0.047 vs. ECOG 2), experience of the respective surgeon (≥100 vs. <100 previous cystectomies, p=0.021), and daytime continence (p=0.032).

Conclusion: In the present study, we report health-related QoL outcomes in a contemporary patient cohort and confirm preoperative ECOG status, surgeon experience and daytime incontinence as independent prognostic features for a good postoperative QoL.

 Keywords: Quality of Life; Cystectomy; Urinary Bladder Neoplasms; Urinary Incontinence

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MCM – 2 and Ki – 67 as proliferation markers in renal cell carcinoma: A quantitative and semi – quantitative analysis

Vol. 42 (6): 1121-1128, November – December, 2016

doi: 10.1590/S1677-5538.IBJU.2015.0388


Muhammad Zain Mehdi 1, Abdul Hanan Nagi 2, Nadia Naseem 2

1 Department of Pathology, University of Health Sciences, Lahore, Punjab, Pakistan; 2 Department of Morbid anatomy and Histopathology, University of Health Sciences, Lahore, Punjab, Pakistan


Introduction/Background: Fuhrman nuclear grade is the most important histological parameter to predict prognosis in a patient of renal cell carcinoma (RCC). However, it suffers from inter-observer and intra-observer variation giving rise to need of a parameter that not only correlates with nuclear grade but is also objective and reproducible.
Proliferation is the measure of aggressiveness of a tumour and it is strongly correlated with Fuhrman nuclear grade, clinical survival and recurrence in RCC. Ki-67 is conventionally used to assess proliferation. Mini-chromosome maintenance 2 (MCM-2) is a lesser known marker of proliferation and identifies a greater proliferation faction. This study was designed to assess the prognostic significance of MCM-2 by comparing it with Fuhrman nuclear grade and Ki-67.
Material and Methods: n=50 cases of various ages, stages, histological subtypes and grades of RCC were selected for this study. Immunohistochemical staining using Ki-67(MIB-1, Mouse monoclonal antibody, Dako) and MCM-2 (Mouse monoclonal antibody, Thermo) was performed on the paraffin embedded blocks in the department of Morbid anatomy and Histopathology, University of Health Sciences, Lahore. Labeling indices (LI) were determined by two pathologists independently using quantitative and semi-quantitative analysis. Statistical analysis was carried out using SPSS 20.0. Kruskall-Wallis test was used to determine a correlation of proliferation markers with grade, and Pearson’s correlate was used to determine correlation between the two proliferation markers.
Results: Labeling index of MCM-2 (median=24.29%) was found to be much higher than Ki-67(median=13.05%). Both markers were significantly related with grade (p=0.00; Kruskall-Wallis test). LI of MCM-2 was found to correlate significantly with LI of Ki-67(r=0.0934;p=0.01 with Pearson’s correlate). Results of semi-quantitative analysis correlated well with quantitative analysis.
Conclusion: Both Ki-67 and MCM-2 are markers of proliferation which are closely linked to grade. Therefore, they can act as surrogate markers for grade in a manner that is more objective and reproducible.

Keywords: Carcinoma, Renal Cell; Ki-67 Antigen; Minichromosome Maintenance Complex Component 2; Cell Proliferation

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