Vol. 44 n. 6 Nov . Dec, 2018

Volume 44 | number 6 | Nov . Dec, 2018 -The November-December 2018 issue of the International Braz J Urol presents original contributions with a lot of interesting papers…

The current status of renal cell carcinoma and prostate carcinoma grading

Vol. 44 (6): 1057-1062, November – December, 2018 doi: 10.1590/S1677-5538.IBJU.2018.06.01 EDITORIAL In this issue Brett Delahunt 1, Lars Egevad 2, 3, John Yaxley 4, 5, Hemamali Samaratunga 5, 6 1 Department of Pathology and Molecular Medicine, Wellington School of Medicine and Health Sciences, Wellington, New Zealand; 2 Department of Pathology, Karolinska Institute, Stockholm, Sweden; 3 Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden; 4 Wesley Hospital, Brisbane, Queensland, Australia; 5 University of Queensland School of Medicine, Brisbane, Queensland, Australia; 6 Aquesta Uropathology , Brisbane, Queensland, Australia INTRODUCTION Grading is an important prognostic indicator for tumors and for most malignancies provides information additional to staging. As with staging, grading criteria for individual tumors are subject to change, with developments reflecting contemporary advances in our understanding of the behavior of tumors. In the field of urological pathology, the grading classifications most commonly utilized for both renal cell carcinoma (RCC) and prostate adenocarcinoma (PCa) have undergone radical change. This evolution has, most recently, led to the establishment of novel grading systems for both of these tumors, under the auspices of the International Society of Urological Pathology (ISUP) (1, 2). The release of the Fourth Edition of the World Health Organization (WHO) Bluebook on the Classification of Tumours of the Urinary Tract and Male Genital Organs in 2016 (3), followed on from the development of these contemporary grading classifications. In this publication these novel classifications, relating to the two most common morphotypes of RCC and for PCa, were endorsed for international implementation. Subsequently both grading classifications have been incorporated into the reporting datasets issued by the International Collaboration on Cancer Reporting (4, 5). [Read...

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Microdissection is the best way to perform sperm retrieval in men with non-obstructive azoospermy? | Opinion: Yes

Vol. 44 (6): 1063-1066, November – December, 2018 doi: 10.1590/S1677-5538.IBJU.2018.06.02 DIFFERENCE OF OPINION Renato Fraietta 1 1 Setor Integrado de Reprodução Humana, Universidade Federal de São Paulo, São Paulo, SP, Brasil  Keywords: Azoospermia; Microdissection; Sperm Retrieval; Fertility Non-obstructive azoospermia (NOA) is the diagnosis of one percent of all men and 10% of men complaining about infertility (1, 2). All NOA patients should be evaluated with complete history and physical examination, with genetic testing (karyotype analysis and Y chromosome microdeletion testing) being offered and performed, which will identify the causes of NOA in up to 17% of men (3, 4). Hormonal profile is also important as up to 47% of men that have impaired spermatogenesis with NOA were found to have hypogonadism (4,5). [Read...

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Microdissection is the best way to perform sperm retrieval in men with non-obstructive azoospermy? | Opinion: No, there are other options

Vol. 44 (6): 1067-1070, November – December, 2018 doi: 10.1590/S1677-5538.IBJU.2018.06.03 DIFFERENCE OF OPINION Marcelo Vieira 1, 2 1 Membro Titular da Sociedade Brasileira de Urologia, Rio de Janeiro, RJ, Brasil; 2 Urologista do Projeto ALFA, Sao Paulo, SP, Brasil Keywords: Azoospermia; Microdissection; Sperm Retrieval; Fertility In the last 23 years, Intracitoplasmic Sperm Injection (ICSI) has given non-obstructive azoospermic man the opportunity to become biological fathers, if sperm could be found in their testicles. These men present the biggest challenge in the routine of infertility clinics around the World, since there are no positive, clinical or laboratory, prognostic factors for sperm recovery. Once testicular sperm has been regularly used for ICSI, discussion about which technique for testicular sperm retrieval has been done. Sperm can be harvest from testicular parenchyma by: open biopsy (Testicular Sperm Extraction-TESE), percutaneous aspiration (Testicular Sperm Aspiration), open guided biopsy by previous cytology (Testicular fine-needle Aspiration) and open biopsy using microsurgery technique (Testicular Microdissection). The proposed techniques have the same objective, to find sperm with minimal testicular damage and in a reproducible way (1). [Read...

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A review of the possibility of adopting financially driven live donor kidney transplantation

Vol. 44 (6): 1071-1080, November – December, 2018 doi: 10.1590/S1677-5538.IBJU.2017.0693 REVIEW ARTICLE Aline Adour Yacoubian 1, 2, Rana Abu Dargham 1, 2, Raja B. Khauli 1, 2 1 Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon; 2 Division of Urology and Renal Transplantation, American University of Beirut Medical Center, Beirut, Lebanon ABSTRACT Kidney transplantation for end-stage renal disease remains the preferred solution due to its survival advantage, enhanced quality of life and cost-effectiveness. The main obstacle worldwide with this modality of treatment is the scarcity of organs. The de­mand has always exceeded the supply resulting in different types of donations. Kidney donation includes pure living related donors, deceased donors, living unrelated do­nors (altruistic), paired kidney donation and more recently compensated kidney dona­tion. Ethical considerations in live donor kidney transplantation have always created a debate especially when rewarding unrelated donors. In this paper, we examine the problems of financially driven kidney transplantation, the ethical legitimacy of this practice, and propose some innovative methods and policies that could be adopted to ensure a better practice with accepted ethical guidelines. Keywords:  Kidney Transplantation; Kidney Diseases; Review [Publication Type] [Full Text]...

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Lowering positive margin rates at radical prostatectomy by color coding of biopsy specimens to permit individualized preservation of the neurovascular bundles: is it feasible? a pilot investigation

Vol. 44 (6): 1081-1088, November – December, 2018 doi: 10.1590/S1677-5538.IBJU.2017.0328 ORIGINAL ARTICLE Leslie A. Deane 1, Wei Phin Tan 1, Andrea Strong 1, Megan Lowe 1, Nency Antoine 1, Ritu Ghai 1, Shahid Ekbal 1 1 Department of Urology, Rush University Medical Center, Chicago, IL, USA   ABSTRACT Objective: To evaluate whether color-coding of prostate core biopsy specimens aids in preservation of the neurovascular bundles from an oncological perspective. Materials and Methods: MRI guided transrectal ultrasound and biopsy of the prostate were performed in 51 consecutive patients suspected of being at high risk for harboring prostate cancer. Core specimens were labeled with blue dye at the deep aspect and red dye at the superficial peripheral aspect of the core. The distance from the tumor to the end of the dyed specimen was measured to determine if there was an area of normal tissue between the prostate capsule and tumor. Results: Of the 51 patients undergoing prostate biopsy, 30 (58.8%) were found to have cancer of the prostate: grade group 1 in 13.7%, 2 in 25.5%, 3 in 7.8%, 4 in 7.8% and 5 in 3.9% of the cohort. A total of 461 cores were analyzed in the cohort, of which 122 showed cancer. Five patients opted to undergo robotic assisted laparoscopic radical prostatectomy. No patients had a positive surgical margin (PSM) or extra prostatic ex­tension (EPE) on radical prostatectomy if there was a margin of normal prostatic tissue seen between the dye and the tumor on prostate biopsy. Conclusion: Color-coding of prostate biopsy core specimens may assist in tailoring the approach for preservation of the neurovascular bundles without compromising early oncological efficacy. Further study is required to determine whether this simple modi­fication of the prostate biopsy protocol is valuable in larger groups of patients. Keywords: Robotic Surgical Procedures; Prostatectomy; Laparoscopy [Full Text]...

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Predictive factors for prolonged hospital stay after retropubic radical prostatectomy in a high-volume teaching center

Vol. 44 (6): 1089-1105, November – December, 2018 doi: 10.1590/S1677-5538.IBJU.2017.0339 ORIGINAL ARTICLE Rafael F. Coelho 1, Mauricio D. Cordeiro 1, Guilherme P. Padovani 1, Rafael Localli 1, Limirio Fonseca 1, José Pontes Junior 1, Giuliano B. Guglielmetti 1, Miguel Srougi 1, William Carlos Nahas 1 1 Divisão de Urologia, Instituto do Câncer de Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil ABSTRACT Objective: To evaluate the length hospital stay and predictors of prolonged hospitaliza­tion after RRP performed in a high-surgical volume teaching institution, and analyze the rate of unplanned visits to the office, emergency care, hospital readmissions and perioperative complications rates. Materials and Methods: Retrospective analysis of prospectively collected data in a standardized database for patients with localized prostate cancer undergoing RRP in our institution between January/2010 – January/2012. A logistic regression model including preoperative variables was initially built in order to determine the factors that predict prolonged hospital stay before the surgical pro­cedure; subsequently, a second model including both pre and intraoperative variables was analyzed. Results: 1011 patients underwent RRP at our institution were evaluated. The median hospital stay was 2 days, and 217 (21.5%) patients had prolonged hospitalization. Predictors of prolonged hospital stay among the preoperative variables were ICC (OR. 1.40 p=0.003), age (OR 1.050 p<0.001), ASA score of 3 (OR. 3.260 p<0.001), pros­tate volume on USG-TR (OR, 1.005 p=0.038) and African-American race (OR 2.235 p=0.004); among intra and postoperative factors, operative time (OR 1.007 p=0.022) and the presence of any complications (OR 2.013 p=0.009) or major complications (OR 2.357 p=0.01) were also correlated independently with prolonged hospital stay. The complication rate was 14.5%. Conclusions: The independent predictors of prolonged hospitalization among preop­erative variables were CCI, age, ASA score of 3, prostate volume on USG-TR and African-American race; amongst intra and postoperative factors, operative time, pres­ence of any complications and major complications were correlated independently with prolonged hospital stay. Keywords: rostatectomy; Therapeutics; Retrospective Studies [Full Text]...

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Comparison of Gleason upgrading rates in transrectal ultrasound systematic random biopsies versus US-MRI fusion biopsies for prostate cancer

Vol. 44 (6): 1106-1113, November – December, 2018 doi: 10.1590/S1677-5538.IBJU.2017.0552 ORIGINAL ARTICLE Paulo Priante Kayano ¹, Arie Carneiro ¹, Tiago Mendonça Lopez Castilho 1, Arjun Sivaraman ², Oliver Rojas Claros ¹, Ronaldo Hueb Baroni ¹, Rodrigo Gobbo Garcia ¹, Guilherme Cayres Mariotti ¹, Oren Smaletz ¹, Renne Zon Filippi ¹, Gustavo Caserta Lemos 1 1 Hospital Israelita Albert Einstein, São Paulo, SP, Brasil; 2 Memorial Sloan Kettering Cancer Center – USA, New York, NY, EUA ABSTRACT Purpose: Ultrasound-magnetic resonance imaging (US-MRI) fusion biopsy (FB) im­proves the detection of clinically significant prostate cancer (PCa). We aimed to compare the Gleason upgrading (GU) rates and the concordance of the Gleason scores in the biopsy versus final pathology after surgery in patients who underwent transrectal ultrasound (TRUS) systematic random biopsies (SRB) versus US-MRI FB for PCa. Materials and Methods: A retrospective analysis of data that were collected prospec­tively from January 2011 to June 2016 from patients who underwent prostate biopsy and subsequent radical prostatectomy. The study cohort was divided into two groups: US-MRI FB (Group A) and TRUS SRB (Group B). US-MRI FB was performed in patients with a previous MRI with a focal lesion with a Likert score ≥3; otherwise, a TRUS SRB was performed. Results: In total, 73 men underwent US-MRI FB, and 89 underwent TRUS SRB. The GU rate was higher in Group B (31.5% vs. 16.4%; p=0.027). According to the Gleason grade pattern, GU was higher in Group B than in Group A (40.4% vs. 23.3%; p=0.020). Analyses of the Gleason grading patterns showed that Gleason scores 3+4 presented less GU in Group A (24.1% vs. 52.6%; p=0.043). The Bland-Altman plot analysis showed a higher bias in Group B than in Group A (-0.27 [-1.40 to 0.86] vs. -0.01 [-1.42 to 1.39]). In the multivariable logistic regression analysis, the only independent predictor of GU was the use of TRUS SRB (2.64 [1.11 – 6.28]; p=0.024). Conclusions: US-MRI FB appears to be related to a decrease in GU rate and an increase in concordance between biopsy and final pathology compared to TRUS SRB, sug­gesting that performing US-MRI FB leads to greater accuracy of diagnosis and better treatment decisions. Keywords: Prostatic Neoplasms; Magnetic Resonance Spectroscopy; Image-Guided Biopsy [Full Text]...

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PSA kinetics before 40 years of age

Vol. 44 (6): 1114-1121, November – December, 2018 doi: 10.1590/S1677-5538.IBJU.2017.0710 ORIGINAL ARTICLE Cristiano Linck Pazeto 1, Thiago Fernandes Negris Lima 1, José Carlos Truzzi 2, Nairo Sumita 2, José de Sá 2, Fernando R. Oliveira3, Sidney Glina 1 1 Departamento de Urologia, Faculdade de Medicina do ABC, Santo André, SP, Brasil; 2 Fleury Medicina e Saúde São Paulo, SP, Brasil; 3 Departamento de Epidemiologia, Universidade de São Paulo, São Paulo, SP, Brasil ABSTRACT Purpose: The baseline PSA has been proposed as a possible marker for prostate cancer. The PSA determination before 40 years seems interesting because it not suffers yet the drawbacks related to more advanced ages. Considering the scarcity of data on this topic, an analysis of PSA kinetics in this period seems interesting. Materials and Methods: A retrospective assay in a database of a private diagnostic center was performed from 2003 to 2016. All subjects with a PSA before 40 years were included. Results: 92995 patients performed PSA between the ages of 21 – 39. The mean value ranged from 0.66 ng / mL (at age 22) to 0.76 ng / mL (at age 39) and the overall mean was 0.73 ng / mL. As for outliers, 3783 individuals presented a baseline PSA > 1.6 ng / mL (p95). A linear regression model showed that each year there is a PSA increase of 0.0055 ng / mL (β = 0.0055; r² = 0.0020; p < 0.001). A plateau in PSA between 23 and 32 years was found and there were only minimal variations among the ages regardless of the evaluated percentile. Conclusion: It was demonstrated that PSA kinetics before 40 years is a very slow and progressive phenomenon regardless of the assessed percentile. Considering our results, it could be suggested that any PSA performed in this period could represent the baseline value without significant distortions. Keywords: Prostate-Specific Antigen; Kinetics, Prostatic Neoplasms [Full Text]...

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Adequate rectal preparation reduces hospital admission for urosepsis after transrectal ultrasound – guided prostate biopsy

Vol. 44 (6): 1122-1128, November – December, 2018 doi: 10.1590/S1677-5538.IBJU.2018.0181 ORIGINAL ARTICLE Yu-Chen Chen 1, 2, Hao-Wei Chen 1, 2, Shu-Pin Huang 2, Hsin-Chin Yeh 3, Ching-Chia Li 2 1 Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; 2 Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; 3 Department of Urology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan ABSTRACT Objectives: Previous studies have compared infectious outcomes on the basis of whether rectal preparation was performed; however, they failed to evaluate the quality of each rectal preparation, which may have led to confounding results. This study aimed to com­pare hospitalizations for urosepsis within 1 month after transrectal ultrasound-guided prostate biopsy between patients with adequate and traditional rectal preparations. Materials and Methods: Between January 2011 and December 2016, a total of 510 patients who underwent transrectal ultrasound – guided prostate biopsy at our in­stitutions and were orally administered prophylactic antibiotics (levofloxacin) were included. Two rectal preparations were performed: (1) adequate rectal preparation con­firmed by digital rectal examination and transrectal ultrasound (Group A, n = 310) and (2) traditional rectal preparation (Group B, n = 200). All patient characteristics were recorded. A logistic regression model was used to assess the effects of the two different rectal preparations on urosepsis, adjusted by patient characteristics. Results: There were a total of three and nine hospitalizations for urosepsis in Groups A and B, respectively. Differences in the demographic data between the two groups were insignificant. Logistic regression showed that adequate rectal preparation before biopsy significantly decreased the risk for urosepsis after biopsy (adjusted odds ratio: 0.2; 95% confidence interval: 0.05 – 0.78; P = 0.021). Conclusions: Adequate rectal preparation could significantly reduce hospitalizations for urosepsis within 1 month after transrectal ultrasound-guided prostate biopsy. The quality of rectal preparation should be evaluated before biopsy. If adequate rectal preparation is not achieved, postponing the biopsy and adjusting the rectal preparation regimen are suggested. Keywords: Prostate; Prostatic Neoplasms; Ultrasound, High-Intensity Focused, Transrectal [Full Text]...

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Comparison between multiparametric MRI with and without post – contrast sequences for clinically significant prostate cancer detection

Vol. 44 (6): 1129-1138, November – December, 2018 doi: 10.1590/S1677-5538.IBJU.2018.0102 ORIGINAL ARTICLE Thais Caldara Mussi 1,Tatiana Martins 1, 2, George Caldas Dantas 1, Rodrigo Gobbo Garcia 3, Renee Zon Filippi 4, Gustavo Caserta Lemos 5, Ronaldo Hueb Baroni 1 1 Departamento de Radiologia e Diagnóstico por Imagem, Hospital Israelita Albert Einstein, SP, Brasil; 2 Ecoar Medicina Diagnóstica, Lourdes, Belo Horizonte, MG, Brasil; 3 Departamento de Intervenção Guiada por Imagens, Hospital Israelita Albert Einstein, SP, Brasil; 4 Departamento de Patologia, Hospital Israelita Albert Einstein, SP, Brasil; 5 Departamento de Urologia, Hospital Israelita Albert Einstein, SP, Brasil ABSTRACT   Background: Dynamic-contrast enhanced (DCE) sequence is used to increase detection of small lesions, based on increased vascularization. However, literature is controversy about the real incremental value of DCE in detection of clinically significant (CS) prostate cancer (PCa), since absence of enhancement does not exclude cancer, and enhancement alone is not definitive for tumor. Purpose: To test the hypothesis that DCE images do not increase CS PCa detection on MRI prior to biopsy, comparing exams without and with contrast sequences. Material and Materials and Methods: All men who come to our institution to perform MRI on a 3T scanner without a prior diagnosis of CS PCa were invited to participate in this study. Reference standard was transrectal prostate US with systematic biopsy and MRI/US fusion biopsy of suspicious areas. Radiologists read the MRI images prospectively and independently (first only sequences without contrast, and subsequently the entire exam) and graded them on 5-points scale of cancer suspicion. Results: 102 patients were included. Overall detection on biopsy showed CS cancer in 43 patients (42.2%), clinically non-significant cancer in 11 (10.8%) and negative results in 48 patients (47%). Positivities for CS PCa ranged from 8.9% to 9.8% for low suspicion and 75.0% to 88.9% for very high suspicion. There was no statistical difference regarding detection of CS PCa (no statistical difference was found when compared accuracies, sensitivities, specificities, PPV and NPV in both types of exams). Inter-reader agreement was 0.59. Conclusion: Exams with and without contrast-enhanced sequences were similar for detection of CS PCa on MRI.  Keywords: Magnetic Resonance Imaging; Prostatic Neoplasms; Men [Full Text]...

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