Relation between Delay Time to Surgical Treatment of Prostate Cancer and Disease Recurrence Risk / Relação entre Tempo de Atraso no Tratamento Cirúrgico do Câncer de Próstata e Risco de Recorrência da Doença

De acordo com a literatura, não há consenso sobre um tempo de atraso razoável desde o diagnóstico até a operação da prostatectomia radical (PR) sem piora do prognóstico. Objetivo: Avaliar a influência desse tempo no risco de recorrência da doença em pacientes com adenocarcinoma acinar da próstata tratados com PR. Método: Quatrocentos e doze pacientes submetidos à PR foram avaliados retrospectivamente. Destes, 172 foram excluídos por dados incompletos e outros 28, por estadiamento pré- -operatório como câncer de próstata de alto risco (PSA > 10 ng/mL ou escore de Gleason na biópsia > 7). Os estadiamentos pré e pós-operatórios foram comparados, e a análise de sobrevida feita pelo método de Kaplan-Meier para examinar a influência do tempo na discordância entre os estadiamentos pré e pós-operatórios. Resultados: Para os 212 pacientes da amostra, o tempo médio desde o diagnóstico até a PR foi de 176,1 ± 120,2 dias (mediana de 145,5 dias), variando de 29 a um máximo de 798 dias. A curva de Kaplan-Meier indicou que o câncer piorava quanto maior o atraso entre o diagnóstico e a operação. Pacientes submetidos à cirurgia dentro de 60 dias tiveram cerca de 95% de probabilidade de não aumentarem o risco inicial de recorrência. Esse número caiu para 80%, 70% e 50% nos pacientes operados em até 100, 120 e 180 dias, respectivamente. Conclusão: O atraso na realização da PR representa risco contínuo de recorrência da neoplasia. O tempo ideal para PR é de até 60 dias a partir da biópsia da próstata, uma vez que a probabilidade de upstaging é inferior a 5% nesse período.

There is no consensus in the literature on a reasonable delay time from diagnosis to radical prostatectomy (RP) surgery, without worsening the prognosis. Objective: To evaluate the influence of the delay on the risk of disease recurrence in patients with acinar adenocarcinoma of the prostate treated with RP. Method: Four hundred and twelve patients undergoing RP were retrospectively evaluated. Of these, 172 were excluded due to incomplete data and another 28 due to preoperative staging as high-risk prostate cancer (PSA > 10 ng/mL or Gleason score on biopsy > 7). Pre-and postoperative stagings were compared and survival analysis was performed using the Kaplan-Meier method to investigate the influence of time on discordance between pre- and postoperative stagings. Results:For the 212 patients of the sample, the average time from diagnosis to RP was 176.1 ± 120.2 days (median 145.5 days), ranging from 29 to a maximum of 798 days. The Kaplan-Meier curve indicated that the cancer worsened the longer the delay between diagnosis and surgery. Patients undergoing surgery within 60 days had an approximately 95% probability of not increasing the initial risk of recurrence. This number fell to 80%, 70% and 50% in patients operated on up to 100, 120 and 180 days, respectively. Conclusion:Delay in performing RP represents a continuous risk of relapse. The ideal time for RP is up to 60 days from prostate biopsy, as the probability of upstaging is less than 5% in this period

Según la literatura, no existe consenso sobre un tiempo razonable de retraso desde el diagnóstico hasta la cirugía de prostatectomía radical (PR), sin empeorar el pronóstico. Objetivo: Evaluar la influencia de este tiempo sobre el riesgo de recurrencia de la enfermedad en pacientes con adenocarcinoma acinar de próstata tratados con PR. Método: Se evaluaron retrospectivamente 412 pacientes sometidos a PR. De ellos, 172 fueron excluidos por datos incompletos y otros 28 por estadificación preoperatoria como cáncer de próstata de alto riesgo (PSA > 10 ng/mL o puntuación de Gleason en la biopsia > 7). Se compararon las estadificaciones pre y posoperatorias y se realizó un análisis de supervivencia utilizando el método de Kaplan-Meier para examinar la influencia del tiempo en la discordancia entre las estadificaciones pre y posoperatorias. Resultados: Para los 212 pacientes de la muestra, el tiempo promedio desde el diagnóstico hasta la PR fue de 176,1 ± 120,2 días (mediana 145,5 días), oscilando entre 29 y 798 días. La curva de Kaplan-Meier indicó que el cáncer empeoraba cuanto mayor era el retraso entre el diagnóstico y la cirugía. Los pacientes sometidos a cirugía dentro de los 60 días tenían aproximadamente un 95% de probabilidad de no aumentar el riesgo inicial de recurrencia. Esta cifra cayó al 80%, 70% y 50% en los pacientes operados hasta 100, 120 y 180 días, respectivamente. Conclusión: El retraso en la realización de la PR representa un riesgo continuo de restablecimiento de la neoplasia. El momento ideal para la PR es hasta los 60 días desde la biopsia de próstata, ya que la probabilidad de upstaging es inferior al 5% en este periodo.

Antibiotics prophylaxis at the time of catheter removal after radical prostatectomy: a systematic review of the literature and meta-analysis

Purpose: To conduct a systematic literature review with meta-analysis to identify whether antibiotic prophylaxis after removal of the indwelling urinary catheter reduces posterior infections. Methods: A systematic literature review was conducted in the databases PubMed, Embase, Cochrane, Google Scholar, and Latin American and Caribbean Health Sciences Literature, using the keywords "antibiotics" AND "prostatectomy" AND "urinary catheter." Results: Three articles were identified having the scope of our review, with 1,040 patients, which were subjected to our meta-analysis revealing a marginally significant decrease in the risk of urinary infection after indwelling urinary catheter removal (odds ratio-OR = 0.51; 95% confidence interval-95%CI 0.27-0.98; p = 0.04; I2 = 0%). No difference was found regarding the presence of bacteriuria (OR = 0.39; 95%CI 0.12-1.24; p = 0.11; I2 = 73%). Conclusions: In our meta-analysis, there was a significant decrease in urinary tract infection with antibiotic prophylaxis after indwelling urinary catheter removal following radical prostatectomy.

Tumor fibroso solitario de próstata: informe de caso y revisión de la literatura / Solitary fibrous tumor of the prostate: case report and literature review

El tumor fibroso solitario (TFS) es una neoplasia mesenquimatosa de tipo fibroblástico que, a pesar de ser localizado principalmente en pleura, se ha observado en otros órganos como la próstata. Por su parte, el tumor fibroso solitario de la próstata es una neoplasia de baja incidencia, crecimiento lento y potencial maligno incierto, que generalmente se compone de células fusiformes de apariencia citológicamente benignas, dispuestas en una arquitectura desorganizada, mezcladas con colágeno y pequeños vasos sanguíneos. Establecer su diagnóstico se ha vuelto más reproducible desde la identificación de la fusión de los genes NAB2-STAT6 por biología molecular, que lleva a la sobreexpresión de STAT6 por inmunohistoquímica, el cual es un marcador muy sensible y específico para TFS. Presentamos el caso clínico de un paciente que debutó con síntomas de compresión vesical, en quien se identificó una masa con epicentro en la próstata que infiltraba la vejiga y llegaba a la pared rectal, y que luego de estudios de patología, inmunohistoquímica y pruebas moleculares se clasificó como un TFS de la próstata, finalmente tratado con cistoprostatectomía radical más derivación urinaria

Solitary fibrous tumor (SFT) is a mesenchymal neoplasm of fibroblastic type, which despite being located mainly in the pleura, has been observed in other organs such as the prostate. On the other hand, solitary fibrous tumor of the prostate is a rare neoplasm, slow growing, and of uncertain malignant potential, which is generally composed of spindle cells of cytologically benign appearance, arranged in a disorganized architecture, mixed with collagen and small blood vessels. Establishing its diagnosis has become more reproducible since the identification of the NAB2-STAT6 gene fusion by molecular biology, leading to the overexpression of STAT6 by immunohistochemistry, a very sensitive and specific marker for SFT. We present a clinical report of a patient who consulted with symptoms of bladder compression, in whom a mass was identified with the epicenter in the prostate infiltrating into the bladder and reaching the rectal wall. Following histopathology study, immunohistochemistry and molecular tests it was classified as a SFT of the prostate, finally treated with radical cystoprostatectomy plus urinary shunt

Sexualidade comprometida em pacientes prostatectomizados: mito ou verdade? / Compromised sexuality in prostatectomy patients: myth or truth? / Sexualidad comprometida en pacientes con prostatectomía: mito o verdad?

Objetivo: Verificar se os pacientes prostatectomizados são informados sobre a possibilidade de superação da perda da função erétil pelos benefícios da sexualidade humana após a intervenção cirúrgica. Métodos: A técnica utilizada foi a análise temática que consiste na busca dos núcleos de sentido para se construir uma comunicação. O estudo foi realizado em um hospital de referência no tratamento de câncer e envolveu pacientes prostatectomizados no pós-operatório mediato. Resultados: A perda da função erétil pode ser superada pela utilização da sexualidade humana materializada no amor, carinho e compreensão. Conclusão: A escassez de informações sobre os efeitos da prostatectomia em pacientes cirúrgicos inaugura uma contradição no processo de atenção à saúde aos portadores de câncer de próstata. A contradição, advém do fato de que a resposta a esta questão admite as duas possibilidades, mito e verdade. (AU)

Objective: To verify whether prostatectomy patients are informed about the possibility of overcoming the loss of erectile function due to the benefits of human sexuality after surgical intervention. Methods: The technique used was thematic analysis, which consists of the search for meaning cores to build communication. The study was carried out in a reference hospital for the treatment of cancer and involved patients undergoing prostatectomy in the immediate postoperative period. Results: The loss of erectile function can be overcome by the use of human sexuality materialized in love, affection and understanding. Conclusion: The scarcity of information about the effects of prostatectomy in surgical patients opens a contradiction in the health care process for patients with cancer of prostate. The contradiction comes from the fact that the answer to this question admits the two possibilities, myth and truth. (AU)

Objetivo: Verificar si los pacientes prostatectomizados están informados sobre la posibilidad de superar la pérdida de la función eréctil por los beneficios de la sexualidad humana tras la intervención quirúrgica. Métodos: La técnica utilizada fue el análisis temático, que consiste en la búsqueda de núcleos de significado para construir la comunicación. El estudio se llevó a cabo en un hospital de referencia para el tratamiento del cáncer e involucró a pacientes sometidos a prostatectomía en el postoperatorio inmediato. Resultados: La pérdida de la función eréctil puede superarse mediante el uso de la sexualidad humana materializada en el amor, el afecto y la comprensión. Conclusión: La escasez de información sobre los efectos de la prostatectomía en pacientes quirúrgicos abre una contradicción en el proceso de atención de la salud de los pacientes con cáncer de próstata. La contradicción proviene del hecho de que la respuesta a esta pregunta admite las dos posibilidades, mito y verdad. (AU)

Thulium laser enucleation of prostate versus laparoscopic trans-vesical simple prostatectomy in the treatment of large benign prostatic hyperplasia: head-to-head comparison

ABSTRACT Objectives: To compare thulium laser enucleation of prostate (ThuLEP) versus laparoscopic trans-vesical simple prostatectomy (LSP) in the treatment of benign prostatic hyperplasia (BPH). Materials and Methods: Data of patients who underwent surgery for "large" BPH (>80mL) at three Institutions were collected and analyzed. Two institutions performed ThuLEP only; the third institution performed LSP only. Preoperative (indwelling catheter status, prostate volume (PVol), hemoglobin (Hb), Qmax, post-voiding residual volume (PVR), IPSS, QoL, IIEF-5) and perioperative data (operative time, enucleated adenoma, catheterization time, length of stay, Hb-drop, complications) were compared. Functional (Qmax, PVR, %ΔQmax) and patient-reported outcomes (IPSS, QoL, IIEF-5, %ΔIPSS, %ΔQoL) were compared at last follow-up. Results: 80 and 115 patients underwent LSP and ThuLEP, respectively. At baseline, median PVol was 130 versus 120mL, p <0.001; Qmax 9.6 vs. 7.1mL/s, p=0.005; IPSS 21 versus 25, p <0.001. Groups were comparable in terms of intraoperative complications (1 during LSP vs. 3 during ThuLEP) and transfusions (1 per group). Differences in terms of operative time (156 vs. 92 minutes, p <0.001), Hb-drop (-2.5 vs. −0.9g/dL, p <0.001), catheterization time (5 vs. 2 days, p <0.001) and postoperative complications (13.8% vs. 0, p <0.001) favored ThuLEP. At median follow-up of 40 months after LSP versus 30 after ThuLEP (p <0.001), Qmax improved by 226% vs. 205% (p=0.5), IPSS decreased by 88% versus 85% (p=0.9), QoL decreased by 80% with IIEF-5 remaining almost unmodified for both the approaches. Conclusions: Our analysis showed that LSP and ThuLEP are comparable in relieving from BPO and improving the patient-reported outcomes. Invasiveness of LSP is more significant.

Neurovascular bundle preservation in robotic-assisted radical prostatectomy: How I do it after 15. 000 cases

ABSTRACT Despite the neuroanatomy knowledge of the prostate described initially in the 1980's and the robotic surgery advantages in terms of operative view magnification, potency outcomes following robotic-assisted radical prostatectomy still challenge surgeons and patients due to its multifactorial etiology. Recent studies performed in our center have described that, in addition to the surgical technique, some important factors are associated with erectile dysfunction (ED) following robotic-assisted radical prostatectomy (RARP). These include preoperative Sexual Health Inventory for Men (SHIM) score, age, preoperative Gleason score, and Charlson Comorbidity Index (CCI). After performing 15,000 cases, in this article we described our current Robotic-assisted Radical Prostatectomy technique with details and considerations regarding the optimal approach to neurovascular bundle preservation.

Minimally invasive lymphocele drainage using the Da Vinci® single port platform: step-by- step technique

ABSTRACT Background: Reports in the literature describe lymphocele formation in up to half of patients following pelvic lymph node dissection (PLND) (1) in robotic-assisted radical prostatectomy (RARP), with 1-2% requiring intervention (2). The advantage of surgical approach is permanent excision of the lymphocele capsule and fewer days with pelvic drains compared to percutaneous drainage. This study aims to describe the step-by-step surgical management of symptomatic lymphoceles using a less invasive robotic platform, the Da Vinci® Single Port (SP). Material and Methods: We describe the technique of lymphocelectomy and marsupialization with the Da Vinci® SP for symptomatic lymphocele. For this study, several treatment modalities for symptomatic lymphoceles were available, including percutaneous drainage, sclerosing agents, and surgical marsupialization. All the data for this study were obtained through the procedure via Da Vinci® SP. Results: Operative time for the case was 84 minutes. Blood loss was 25ml. No intra- or post- operative complications were reported. The patient had his drain removed in under 24 hours after surgery. The mean follow-up period was 7.7 months. There were no complications or lymphocele recurrence. Conclusion: Da Vinci® SP lymphocelectomy is safe and feasible with satisfactory outcomes. The SP enables definitive treatment of the lymphocele sac (3), reducing the number of days with abdominal drains and allows further decrease in surgical invasiveness with fewer incisions and better cosmesis.

Nerve-sparing robotic-assisted radical prostatectomy: how I do it after 15. 000 cases

ABSTRACT Introduction: Over the years, since Binder and Kramer described the first Robotic-assisted Radical Prostatectomy (RARP) in 2000, different Nerve-sparing (NS) techniques have been proposed by several authors (1). However, even with the robotic surgery advantages, functional outcomes following RARP, especially erection recovery, still challenge surgeons and patients (2, 3). In this scenario, we have described different ways and grades of neurovascular bundle preservation (NVB) using the prostatic artery as a landmark until our most recent technique with lateral prostatic fascia preservation and modified apical dissection (4-6). In this video compilation, we have illustrated the anatomical and technical details of different grades of NVB preservation. Surgical technique: After the anterior and posterior bladder neck dissection, we lift the prostate by the seminal vesicles to access the posterior aspect of the prostate. Then, we incise the Denonvilliers layers and work between an avascular plane to release the posterior NVB from 5 to 1 and 7 to 11 o'clock positions on the right and left sides, respectively6. In sequence, we access the prostate anteriorly by incising the endopelvic fascia bilaterally (close to the prostate) until communicating the anterior and posterior planes. Finally, we control the prostatic pedicles with Hem-o-lok clips and then proceed for the apical dissection preserving the maximum amount of urethra length and periurethral tissues. Considerations: Potency recovery following radical prostatectomy remains a challenge due to its multifactorial etiology. However, basic concepts for nerve-sparing are crucial to achieving optimal outcomes, such as minimizing the amount of traction used on dissection, avoiding excessive cautery, and neural preservation based on anatomical landmarks (arteries and planes of dissection).

Aplicación tópica de ácido tranexámico en urología: ¿Una alternativa de manejo? / Topical Application of Tranexamic Acid in Urology: An Alternative Management?

Los agentes antifibrinolíticos, como el ácido tranexámico, por medio de su administración endovenosa se usan en distintos procedimientos quirúrgicos para prevenir la pérdida de sangrado perioperatorio.[1] Este medicamento es un derivado sintético análogo de la lisina que bloquea los sititos de unión de la lisina en el plasminógeno, inhibiendo su conversión a plasmina e interfiriendo en la fibrinólisis.[2] La aplicación del ácido tranexámico para disminuir el riesgo de sangrado ha sido utilizado en procedimientos urológicos como la resección transuretral prostática (RTUP), prostatectomía radical y nefrolitotomía percutánea (NLP),[3] [4] [5] también se emplea para disminuir las hematurias persistentes en pacientes con poliquistosis renal y en otras hematurias macroscópicas de origen urológico.

Antifibrinolytic agents, such as tranexamic acid, by intravenous administration are used in various surgical procedures to prevent perioperative bleeding loss.[1] This drug is a synthetic lysine analog derivative that blocks the lysine binding sites on plasminogen, inhibiting its conversion to plasmin and interfering with fibrinolysis.[2] The application of tranexamic acid to reduce the risk of bleeding has been used in urological procedures such as transurethral resection of the prostate (TURP), radical prostatectomy and nephrolithotomy. The application of tranexamic acid to reduce the risk of bleeding has been used in urological procedures such as transurethral resection of the prostate (TURP), radical prostatectomy and percutaneous nephrolithotomy (PNL),[3] [4] [5] it is also used to reduce persistent hematuria in patients with polycystic kidney disease and other macroscopic hematuria of urological origin.

Factores asociados a infección de vías urinarias luego de una prostatectomía / Factors Associated with Urinary Tract Infection after Prostatectomy

Introducción y Objetivo La cirugía de próstata es un procedimiento frecuente en varones mayores. Existen diferentes técnicas, cuya elección depende de la patología a tratar, de la experiencia del especialista, y de la disponibilidad técnica. Entre sus complicaciones se encuentra la infección del tracto urinario, que ocasiona incremento en morbimortalidad y costos para el sistema de salud. El objetivo principal de este estudio fue evaluar los factores relacionados con la aparición de infección urinaria luego de este tipo de cirugía. Materiales y Métodos Se realizó un estudio de casos y controles en una población de pacientes sometidos a prostatectomía del 2018 hasta principios del 2020 en Medellín, Colombia. Los casos correspondieron a los pacientes que presentaron infección de vías urinarias hasta 30 días tras la prostatectomía. Se estimó la asociación entre casos y controles por medio del cálculo de la razón de disparidad (RD), la cual se ajustó con una regresión logística y con un modelo aditivo generalizado multivariado. Resultados Se identificaron 96 casos incidentes de infección del trato urinario luego de la prostatectomía, con una prevalencia de 8.99%. La frecuencia de solicitud de urocultivo preoperatorio fue de 52,92% (intervalo de confianza del 95% [IC95%]: 48,34­ 57,44%). Las variables independientemente asociadas con la aparición de infección urinaria fueron: solicitud de urocultivo prequirúrgico, número de dosis, y tipo de antibiótico usado para la profilaxis. Particularmente, se encontró como factor protector el uso de aminoglucósidos. En los pacientes con infección urinaria, los principales gérmenes aislados fueron: Eschirichia coli, Pseudomonas aeruginosa, Klepsiella pneumoniae, Enterococos faecalis y Serratia marcescens.

Introduction and Objective Prostate surgery is a common procedure among older men. There are different techniques, and the choice depends on the pathology to be treated, the experience of the specialist, and the technical availability. Among its complications is urinary tract infection, which causes increased morbidity and mortality and costs for the health system. The main objective of the present study was to evaluate the factors related to the onset of urinary tract infection after prostate surgery. Materials and Methods A case-control study was conducted in a population of patients undergoing prostatectomy from 2018 to early 2020 in the city of Medellín, Colombia. The cases corresponded to patients who presented urinary tract infection up to 30 days after prostatectomy. The association between cases and controls was estimated by calculating the odds ratio (OR), which was adjusted with logistic regression and a multivariate generalized additive model. Results We identified 96 incident cases of urinary tract infection after prostatectomy, with a prevalence of 8.99%. The frequency of requests for preoperative urine culture was of 52.92% (95% confidence interval [95%CI]: 48.34 - 57.44). The independently associated variables were: request for preoperative urine culture, number of doses, and type of antibiotic used for prophylaxis. In particular, the use of aminoglycosides in prophylaxis schemes was found to be a protective factor. The main germs isolated were: Eschirichia coli, Pseudomonas aeruginosa, Klepsiella pneumoniae, Enterococos faecalis, and Serratia marcescens. Conclusion The present study shows that factors such as the preoperative request for urine culture and the use of aminoglycosides for surgical prophylaxis influence the probability of developing urinary tract infection after prostatectomy.

Should obesity be associated with worse urinary continence outcomes after robotic-assisted radical prostatectomy? a propensity score matching analysis

ABSTRACT Purpose: To analyze the association between obesity and urinary incontinence rate in men submitted to robot-assisted radical prostatectomy (RARP) in a high-volume cancer center. Materials and Methods: We reported 1.077 men who underwent RARP as the primary treatment for localized prostate cancer from 2013 to 2017. Patients were classified as non-obese (normal BMI or overweight) or obese men (BMI ≥30kg/m2). They were grouped according to the age, PSA level, D'Amico risk group, Gleason score, ASA classification, pathological stage, prostate volume, salvage/adjuvant radiotherapy, perioperative complications, and follow-up time. Urinary continence was defined as the use of no pads. For the analysis of long-term urinary continence recovery, we conducted a 1:1 propensity-score matching to control confounders. Results: Among the obese patients, mean BMI was 32.8kg/m2, ranging 30 - 45.7kg/m2. Only 2% was morbidly obese. Obese presented more comorbidities and larger prostates. Median follow-up time was 15 months for the obese. Complications classified as Clavien ≥3 were reported in 5.6% of the obese and in 4.4% of the non-obese men (p=0.423). Median time for continence recovery was 4 months in both groups. In this analysis, HR was 0.989 for urinary continence recovery in obese (95%CI=0.789 - 1.240; p=0.927). Conclusions: Obese can safely undergo RARP with similar continence outcomes comparing to the non-obese men when performed by surgeons with a standardized operative technique. Future studies should perform a subgroup analysis regarding the association of obesity with other comorbidities, intending to optimize patient counseling.

Pelvic lymph node dissection in high-risk prostate cancer

ABSTRACT Introduction: The therapeutic role of pelvic lymph node dissection (PLND) in prostate cancer (PCa) is unknown due to absence of randomized trials. Objective: to present a critical review on the therapeutic benefits of PLND in high risk localized PCa patients. Materials and Methods: A search of the literature on PLND was performed using PubMed, Cochrane, and Medline database. Articles obtained regarding diagnostic imaging and sentinel lymph node dissection, PLND extension, impact of PLND on survival, PLND in node positive "only" disease and PLND surgical risks were critically reviewed. Results: High-risk PCa commonly develops metastases. In these patients, the possibility of presenting lymph node disease is high. Thus, extended PLND during radical prostatectomy may be recommended in selected patients with localized high-risk PCa for both accurate staging and therapeutic intent. Although recent advances in detecting patients with lymph node involvement (LNI) with novel imaging and sentinel node dissection, extended PLND continues to be the most accurate method to stage lymph node disease, which may be related to the number of nodes removed. However, extended PLND increases surgical time, with potential impact on perioperative complications, hospital length of stay, rehospitalization and healthcare costs. Controversy persists on its therapeutic benefit, particularly in patients with high node burden. Conclusion: The impact of PLND on biochemical recurrence and PCa survival is unclear yet. Selection of patients may benefit from extended PLND but the challenge remains to identify them accurately. Only prospective randomized study would answer the precise role of PLND in high-risk pelvis confined PCa patients.

Holmium laser ablation of the prostate (HoLAP) with moses technology for the surgical treatment of benign prostatic hyperplasia

ABSTRACT Purpose: The expansion of technology is leading to a paradigm shift in several urological fields (1, 2). In particular, the adoption of lasers within the surgical treatment of patients with benign prostatic hyperplasia (BPH) is considered one of the most relevant innovations (3-5). In this video, we aimed to report our experience with holmium laser for the ablation of the prostate (HoLAP) in patients with obstructive lower urinary tract symptoms (LUTS) due to BPH. Materials and Methods: From 2018 to 2020, 10 patients with obstructive LUTS secondary to BPH were treated at our Institution with HoLAP (120W Holmium laser Lumenis® with Moses® technology). Main inclusion criteria were: 1) International Prostate Symptom Score ≥12; 2) prostate volume ≤65mL, 3) maximal flow rate (Qmax) ≤15ml/s at preoperative non-invasive uroflowmetry. Results: Mean patient age was 65 (range: 59-72) years. Preoperative mean prostate volume was 50 (range: 35-65) mL. Mean operative time was 66 (range: 45-85) minutes with a mean laser time/operative time ratio of 0.51 (range: 0.44-0.60). Voiding symptoms, Qmax and post voiding residual were significantly improved after 3 and 12 months (all p <0.05). No postoperative urinary incontinence was detected. Conclusions: The present findings suggest that HoLAP is a slightly time-spending procedure, thus its use should be limited to prostate volume <70-80mL. However, no postoperative complications were recorded at all. This technique showed to be a safe option in patients with low-intermediate prostate volume, also in patients whose antiaggregant/anticoagulant therapy is maintained.

Effectiveness of systemic acupuncture in the control of urinary incontinence following radical prostatectomy: a randomized clinical trial / Efectividad de la acupuntura sistémica en el control de la incontinencia urinaria post-prostatectomía radical: ensayo clínico randomizado / Efetividade da acupuntura sistêmica no controle da incontinência urinária pós-prostatectomia radical: ensaio clínico randomizado

ABSTRACT Objective: To evaluate the effectiveness of acupuncture associated with pelvic floor muscle training for the control of urinary incontinence following radical prostatectomy. Method: Open-label, parallel randomized clinical trial. The intervention group (n = 33) underwent eight sessions of systemic acupuncture associated with pelvic floor muscle training and the control group (n = 31) performed only pelvic floor muscle training. The outcome variable was urinary incontinence assessed by the Pad Test and Daily Pad Used, before treatment (T0), after four weeks (T1) and after eight weeks of treatment (T2). Data analysis was performed using a longitudinal model of Generalized Estimating Equations, significance level of 0.05. Results: The control group showed greater urinary loss compared to the intervention group at T1 (p = 0.006) and at T2 (p < 0.001). Both groups showed improvement in the level of urinary incontinence over time, but the improvement was greater in the intervention group (p < 0.001). Conclusion: Acupuncture associated with pelvic floor muscle training was effective in reducing urinary incontinence in prostatectomized men. Brazilian Registry of Clinical Trials:RBR-3jm5y2

RESUMEN Objetivo: evaluar la efectividad de la acupuntura asociada al entrenamiento muscular de piso pélvico para el control de la incontinencia urinaria post-prostatectomía radical. Método: ensayo clínico aleatorizado paralelo, del tipo abierto. El grupo intervención (n = 33) fue sometido a ocho sesiones de acupuntura sistémica asociada al entrenamiento muscular de piso pélvico y el grupo control (n = 31) solamente al entrenamiento muscular de piso pélvico. La variable desfecho fue incontinencia urinaria evaluada por el Pad Test y Daily Pad Used, antes del tratamiento (T0), después de cuatro semanas (T1) y después de ocho semanas de tratamiento (T2). El análisis de datos fue realizado por modelo longitudinal de Ecuaciones de Estimaciones Generalizadas, nivel de significancia de 0,05. Resultados: el grupo control presentó mayor pérdida urinaria en comparación al grupo intervención en T1 (p = 0,006) y en T2 (p < 0,001). Ambos grupos presentaron mejor nivel de incontinencia urinaria a lo largo del tiempo, sin embargo la mejora fue mayor en el grupo intervención (p < 0,001). Conclusión: la acupuntura asociada al entrenamiento muscular de piso pélvico fue efectiva para la reducción de la incontinencia urinaria en hombres prostatectomizados. Registro Brasileño de Ensayos Clínicos:RBR-3jm5y2

RESUMO Objetivo: Avaliar a efetividade da acupuntura associada ao treinamento muscular do assoalho pélvico para o controle da incontinência urinária pós-prostatectomia radical. Método: Ensaio clínico aleatorizado paralelo, do tipo aberto. O grupo intervenção (n = 33) foi submetido a oito sessões de acupuntura sistêmica associada ao treinamento muscular do assoalho pélvico e o grupo controle (n = 31) somente ao treinamento muscular do assoalho pélvico. A variável desfecho foi incontinência urinária avaliada pelo Pad Test e Daily Pad Used, antes do tratamento (T0), após quatro semanas (T1) e após oito semanas de tratamento (T2).A análise de dados foi realizada por modelo longitudinal de Equações de Estimações Generalizadas, nível de significância de 0,05. Resultados: O grupo controle apresentou maior perda urinária em comparação ao grupo intervenção em T1 (p = 0,006) e em T2 (p < 0,001). Ambos os grupos apresentaram melhora no nível de incontinência urinária ao longo do tempo, porém a melhora foi maior no grupo intervenção (p < 0,001). Conclusão A acupuntura associada ao treinamento muscular do assoalho pélvico foi efetiva para a redução da incontinência urinária em homens prostatectomizados. Registro Brasileiro de Ensaios Clínicos:RBR-3jm5y2

¿Cómo mejorar la función eréctil post-prostatectomía radical? / How to improve erectile function after radical prostatectomy?

La prostatectomía radical (PR) es uno de los pilares en el manejo del cáncer próstata. Esta cirugía constituye un reto para el urólogo, quien debe encontrar un balance entre el riesgo de extensión extraprostática y el grado de preservación del tejido neural. A pesar del avance en técnicas quirúrgicas, la incontinencia urinaria y disfunción eréctil (DE) post-prostatectomía continúan impactando considerablemente la calidad de vida de los pacientes. Por lo anterior, un abordaje transdisciplinario desde el momento del diagnóstico es esencial para mejorar los desenlaces funcionales y oncológicos.

Radical prostatectomy (RP) is one of the mainstays in the management of prostate cancer. This surgery constitutes a challenge for the urologist, who must find a balance between the risk of extraprostatic extension and the degree of preservation of neural tissue. Despite advances in surgical techniques, post-prostatectomy urinary incontinence and erectile dysfunction (ED) continue to significantly impact the quality of life of patients. Therefore, a transdisciplinary approach from the time of diagnosis is essential to improve functional and oncologic outcomes.

Biochemical Relapse in Low-risk Prostate Cancer Treated with Radical Prostatectomy and Bilateral Pelvic Lymphadenectomy / Recaída bioquímica en cáncer de próstata de bajo riesgo tratado con prostatectomía radical y linfadenectomía pélvica bilateral

Introduction For low-risk prostate cancer (PCa), curative treatment with radical prostatectomy (RP) can be performed, reporting a biochemical relapse-free survival rate (bRFS) at 5 and 7 years of 90.1% and 88.3%, respectively. Prostatic specific antigen (PSA), pathological stage (pT), and positive margins (R1) are significant predictors of biochemical relapse (BR). Even though pelvic lymphadenectomy is not recommended during RP, in the literature, it is performed in 34% of these patients, finding 0.37% of positive lymph nodes (N1). In this study, we aim to evaluate the 10-year bRFS in patients with low-risk PCa who underwent RP and extended pelvic lymph node dissection (ePLND). Methodology All low-risk patients who underwent RP plus bilateral ePLND at the National Cancer Institute of Colombia between 2006 and 2019 were reviewed. Biochemical relapse was defined as 2 consecutive increasing levels of PSA > 0.2 ng/mL. A descriptive analysis was performed using the STATA 15 software (Stata Corp., College Station, TX, USA), and the Kaplan-Meier curves and uni and multivariate Cox proportional hazard models were used for the survival outcome analysis. The related regression coefficients were used for the hazard ratio (HR), and, for all comparisons, a two-sided p-value ˂ 0.05 was used to define statistical significance. Results Two hundred and two patients met the study criteria. The 10-year bRFS for the general population was 82.5%, statistically related to stage pT3 (p = 0.047), higher Gleason grade group (GG) (p ≤ 0.001), and R1 (p ≤ 0.001), but not with N1. A total of 3.9% of the patients had N1; of these, 75% had R1, 25% GG2, and 37% GG3. Among the N0 (non-lymph node metástasis in prostate cáncer) patients, 31% of the patients had R1, 41% GG2, and 13% GG3. Conclusions Our bRFS was 82.5% in low-risk patients who underwent RP and ePLND. With higher pT, GG, and presence of R1, the probability of BR increased. Those with pN1 (pathologicaly confirmed positive lymph nodes) were not associated with bRFS, with a pN1 detection rate of 3.9%. Details: In low-risk PCa, curative treatment with RP can be performed, reporting a bRFS rate at 5 and 7 years of 90.1% and 88.3%, respectively. Despite the fact that pelvic lymphadenectomy is not recommended during RP in clinical guidelines, in the literature, it is performed in 34% of these patients, finding 0.37% of N1. In this study, we report the 10-year bRFS in patients with low-risk PCa who underwent surgery.

Introducción En el cáncer de próstata (CaP) de bajo riesgo se puede realizar un tratamiento curativo mediante prostatectomía radical (PR), con una tasa de supervivencia libre de recaída bioquímica (SLRb) a 5 y 7 años del 90,1% y el 88,3%, respectivamente. El antígeno prostático específico (PSA), el estadio patológico (pT) y los márgenes positivos (R1) son predictores significativos de recaída bioquímica (BR). Aunque la linfadenectomía pélvica no está recomendada durante la PR, en la literatura se realiza en el 34% de estos pacientes, encontrándose un 0,37% de ganglios linfáticos positivos (N1). En este estudio, nuestro objetivo es evaluar la SLB a 10 años en pacientes con CaP de bajo riesgo sometidos a PR y disección ganglionar pélvica extendida (DGLPe). Metodología Se revisaron todos los pacientes de bajo riesgo sometidos a PR más ePLND bilateral en el Instituto Nacional de Cancerología de Colombia entre 2006 y 2019. La recaída bioquímica se definió como 2 niveles crecientes consecutivos de PSA > 0,2 ng/mL. Se realizó un análisis descriptivo utilizando el software STATA 15 (Stata Corp., College Station, TX, USA), y se utilizaron las curvas de Kaplan-Meier y los modelos uni y multivariados de riesgos proporcionales de Cox para el análisis de resultados de supervivencia. Los coeficientes de regresión relacionados se utilizaron para la hazard ratio (HR), y, para todas las comparaciones, se utilizó un valor p de dos caras ˂ 0,05 para definir la significación estadística. Resultados Doscientos dos pacientes cumplieron los criterios del estudio. La bRFS a 10 años para la población general fue del 82,5%, estadísticamente relacionada con el estadio pT3 (p = 0,047), mayor grupo de grado Gleason (GG) (p ≤ 0,001), y R1 (p ≤ 0,001), pero no con N1. Un total del 3,9% de los pacientes tenían N1; de ellos, el 75% tenían R1, el 25% GG2, y el 37% GG3. Entre los pacientes N0 (metástasis no ganglionar en el cáncer de próstata), el 31% de los pacientes tenían R1, el 41% GG2 y el 13% GG3. Conclusiones Nuestra SSEb fue del 82,5% en los pacientes de bajo riesgo que se sometieron a RP y ePLND. A mayor pT, GG y presencia de R1, mayor probabilidad de RB. Aquellos con pN1 (ganglios linfáticos patológicamente confirmados como positivos) no se asociaron con la SSEb, con una tasa de detección de pN1 del 3,9%. Detalles: En el CaP de bajo riesgo se puede realizar tratamiento curativo con PR, reportando una tasa de SSEb a 5 y 7 años de 90,1% y 88,3%, respectivamente. A pesar de que la linfadenectomía pélvica no está recomendada durante la PR en las guías clínicas, en la literatura se realiza en el 34% de estos pacientes, encontrando un 0,37% de N1. En este estudio, reportamos la SLB a 10 años en pacientes con CaP de bajo riesgo sometidos a cirugía.

Aumento da Incidência de Recidiva Bioquímica após Prostatectomia Radical em um Centro de Formação em Urologia Oncológica no Brasil: Doenças mais Avançadas estão sendo submetidas à Cirurgia? / Increase of the Incidence of Biochemical Recurrence after Radical Prostatectomy in an Uro-Oncology Training Center in Brazil: Are More Advanced Diseases undergoing Surgery? / Aumento de la Incidencia de Recurrentes Bioquímicos Después de Prostatectomía Radical en un Centro de Capacitación en Urología Oncológica en Brasil: ¿Enfermedades más Avanzadas están siendo sometidas a Cirugía?

Introdução: O câncer de próstata é a neoplasia maligna mais incidente em homens, representando 29% dos diagnósticos da doença no Brasil, segundo o Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Esse câncer é suspeito em alterações do toque retal e/ ou do nível sérico do antígeno prostático específico (PSA) total, sendo o diagnóstico definitivo feito por estudo histopatológico. Objetivo: Verificar a associação entre parâmetros clínicos e anatomopatológicos após prostatectomia radical com recidiva bioquímica ao longo do seguimento. Método: Estudo retrospectivo observacional dos parâmetros clínicos (idade, PSA inicial, toque retal, classificação histopatológica da International Society of Urological Pathology (ISUP), escala de D'Amico e estádio clínico) e anatomopatológicos (grau ISUP da peça cirúrgica, margens cirúrgicas, extensão extracapsular tumoral e presença de linfonodos acometidos), de 177 pacientes submetidos à prostatectomia radical em serviço de uro-oncologia de junho/2010-maio/2018. Resultados: A recidiva bioquímica ocorreu em 44,1% dos casos no tempo de seguimento médio de 34,9 meses. A análise univariada demonstrou PSA inicial >9 ng/mL, toque retal alterado, classificação patológica ISUP 4 e 5, risco D'Amico alto e estágio clínico TNM T3 como fatores diretamente associados à recidiva bioquímica. As margens cirúrgicas foram positivas em 46,3%; em 47,7%, identificou-se extensão extraprostática tumoral. Linfonodos positivos em 10,9% e vesículas seminais comprometidas ocorreram em 21,8%. Conclusão: Fatores clínico-patológicos podem ser preditores de recidiva bioquímica. Nesses casos, foi identificado padrão clínico pré-tratamento supostamente mais agressivo em comparação à literatura em geral. Além disso, deve-se considerar a curva de aprendizado dos cirurgiões em formação no serviço, o que pode resultar em maiores taxas de margens cirúrgicas positivas

Introduction: Prostate cancer is the most common cancer in men representing 29% of diagnoses of the disease in Brazil according to the National Cancer Institute José Alencar Gomes da Silva (INCA). If digital rectal examination presents alterations and/or altered serum level of prostate-specific antigen (PSA) total is detected, there is suspicion of prostate cancer, but the definitive diagnosis occurs only with histopathological study. Objective: To correlate clinical and pathological parameters after radical prostatectomy with biochemical recurrence during follow-up. Method: Retrospective observational study of clinical parameters (age, initial PSA, digital rectal examination, histopathological classification of the International Society of Urological Pathology (ISUP), D'Amico scale and clinical stage) and pathological (ISUP degree of the surgical specimen, surgical margins, extracapsular tumor extension and presence of positive lymph nodes) of 177 patients who underwent radical prostatectomy in an uro-oncology service from June 2010 to May 2018. Results: Biochemical recurrence occurred in 44.1% of the cases within a mean follow-up time of 34.9 months. Univariate analysis showed that baseline PSA>9 ng/mL, altered rectal examination, pathological ISUP classification 4 and 5, high D'Amico risk, and clinical TNM stage T3 are risk factors for biochemical recurrence. Surgical margins were positive in 46.3%, and in 47.7% extracapsular extension was identified. Positive lymph nodes were detected in 10.9% and positive seminal vesicles occurred in 21.8%. Conclusion: Clinical and pathological factors can be predictors of biochemical recurrence. In these cases, it was identified a more aggressive clinical pattern than the literature in general. In addition, it should be considered the learning curve of surgeons in training at the service, which can result in higher rates of positive surgical margins

Introducción: El cáncer de próstata es lo más incidente en hombres representando 29% de los diagnósticos de enfermedades en Brasil según Instituto Nacional del Cáncer José Alencar Gomes da Silva (INCA), se sospecha en tacto rectal y/o en el nivel de análisis del antígeno prostático específico (PSA) total alterado, y el diagnóstico definitivo se realiza mediante el estudio histopatológico. Objetivo: Correlacionar los parámetros clínicos y patológicos después de la prostatectomía radical con la recurrencia bioquímica a lo largo del seguimiento. Método: Estudio observacional retrospectivo de parámetros clínicos (edad, PSA inicial, tacto rectal, clasificación histopatológica de la International Society of Urological Pathology (ISUP), escala D'Amico y estadio clínico) y patológicos (grado ISUP de la muestra quirúrgica, márgenes quirúrgicos, extensión capsular tumoral extra y ganglios linfáticos positivos) de 177 pacientes sometidos a prostatectomía radical en servicio de uro-oncología de junio/2010-mayo/2018. Resultados: La recurrencia bioquímica ocurrió en el 44,1% de los casos en un tiempo de seguimiento promedio de 34,9 meses. El análisis univariado demostró que el PSA inicial >9 ng/mL, alteración del tacto rectal, clasificación patológica ISUP 4 y 5, alto riesgo de D'Amico y estadificación TNM clínico T3 como factores de riesgo para recurrencia bioquímica. Los márgenes quirúrgicos fueron positivos en el 46,3%, y en el 47,7% se identificó una extensión extra capsular adicional. Los ganglios linfáticos positivos fueron detectados en 10,9% y las vesículas seminales positivas ocurrieron en el 21,8%. Conclusión: Los factores clínicos y patológicos pueden ser predictores de recurrencia bioquímica. En estos casos, fue identificado un patrón más agresivo que la literatura en general. Además, se debe considerar la curva de aprendizaje de los cirujanos en formación en el servicio, lo que puede resultar en mayores tasas de márgenes quirúrgicos positivos

The male sling for stress urinary incontinence: tips and tricks for success

ABSTRACT Urethral slings are a good treatment option for mild male stress urinary incontinence. There are many different sling options, but herein our group describes our techniques with the Advance® and Virtue® slings. More important than technique, we strongly think that patient selection is paramount to sling success. We only offer slings to patients who have low 24 hour pad weights, high Valsalva leak point pressure, and no history of pelvic radiation. Still, like with any surgery, we recommend that the surgeons implant the device that they are most comfortable with along with their chosen techniques.

Videolaparoscopic prostatectomy in porcine model for training residents

ABSTRACT Introduction: Surgical training models prepare the resident for a more ethical surgical practice as well as providing a less steep learning curve. In urology, there are well-known models of pyeloplasty simulation, urethro-vesical anastomosis and nephrectomy, which have helped in the training of urology residents (1-3). Learning laparoscopic prostatectomy is a difficult surgery and requires advanced surgical skill from the surgeon (4), requires operate without a direct view of the surgical field in a two-dimensional space and with longer instruments (5). Laparoscopic prostatectomy step by step makes the surgeon's learning curve less difficult, lead to less intraoperative complications, such as blood loss, while also enabling shorter operative time and less positive surgical margins (6). The objective of surgical models is to simulate surgical procedures in a reliable way thus preparing the surgeon for his daily practice, surgical simulations in animal models have been described to compensate for inadequate clinical exposure (7). The canine model of prostate cancer has many similarities with humans. Despite trying to develop a model that is as credible as possible, there are ethical issues in several countries, such as Brazil, that do not allow the use of live dogs for scientific experimentation and there is a difficulty in not standardizing the animals used (8, 9). The swine surgical training model is widely known, accepted and used as a valuable tool in the teaching of new surgeons (10). The porcine video laparoscopic prostatectomy model allows the urologist in training to exercise the skills required in a real surgical situation, practicing them in a single session (10). We will present an experimental model in pigs for training urology residents in laparoscopic radical prostatectomy with current techniques (11-13). The limitations found are that the prostate has no limits as well defined as in humans, the urethra is long and coiled, the fat surrounding the pelvic organs is scarce and there is no postoperative follow-up for evaluating functionality after the procedure, as well as the effectiveness of the surgery with surgical margins. However, it is similar in surgical model presented, it is reproducible and can provide a realistic simulation environment to the beginner surgeon. Material and Methods: In this paper, according to the institutional protocol approved by the institutional ethics and research committee FMUSP n° 964/2017 and protocol was in accordance with current international regulations for the use of animals in Research: Reporting In Vivo Experiments (ARRIVE) guide. Ten male pigs weighing 20 to 22kg were used. The animals were anesthetized with a combination of Telazol (5mg/kg), Xylazine (1.5mg/kg), Cetamine (22mg/kg) and Atropine (0.04mg/kg) for orotracheal intubation followed by Isoflurane (2%). Animals were euthanized at the end of the procedure with a lethal dose of KCl (2mEq/kg). The trocar insertion points were marked using the epigastric vessels and umbilical region as reference points. Initially, urethral catheterization was performed using a hydrophilic Nitinol guidewire, followed by a perineal incision to dissect the tortuous urethra of the porcine model. A malleable urethral catheter 8Fr was inserted into their bladder. The animal was placed in the Trendelenburg position inserted and 12mm trocars were inserted in its umbilical region, utilizing 10mm in the surgeon's dominant hand, 5mm in his non-dominant hand of the surgeon, and 5mm in the first assistant's trocar. The surgeon replicates the steps performed in a laparoscopic radical prostatectomy in humans, including the bladder catheterization, dissection of the anterior bladder plane, the vesicular and prostatic dissection, the suture of the dorsal venous plexus, a prostatectomy, an urethral vesical anast omosis, as well as the waterproof test, even including the performing of surgical steps using current concepts of anterior urethral suspension as the reconstruction of the posterior plane of the rhabdosphincter. Results: All steps of surgery could be reproduced in all ten porcine cases. No significant bleeding was observed and the surgical time was gradually reduced fifty percent from case one to last cases. Conclusions: The porcine model allowed the surgeon to replicate all the steps usually performed in a laparoscopic radical prostatectomy. The junior surgeons are better prepared to such difficult surgery. However, further studies will be necessary to prove the impact of the animal model presented in urological clinical practice.