RESUMO
PURPOSE: Although targeted biopsies (TBx) are associated with improved disease assessment, concerns have been raised regarding the risk of prostate cancer (PCa) overgrading due to more accurate biopsy core deployment in the index lesion. METHODS: We identified 1672 patients treated with radical prostatectomy (RP) with a positive mpMRI and ISUP ≥ 2 PCa detected via systematic biopsy (SBx) plus TBx. We compared downgrading rates at RP (ISUP 4-5, 3, and 2 at biopsy, to a lower ISUP) for PCa detected via SBx only (group 1), via TBx only (group 2), and eventually for PCa detected with the same ISUP 2-5 at both SBx and TBx (group 3), using multivariable logistic regression models (MVA). RESULTS: Overall, 12 vs 14 vs 6% (n = 176 vs 227 vs 96) downgrading rates were recorded in group 1 vs group 2 vs group 3, respectively (p < 0.001). At MVA, group 2 was more likely to be downgraded (OR 1.26, p = 0.04), as compared to group 1. Conversely, group 3 was less likely to be downgraded at RP (OR 0.42, p < 0.001). CONCLUSIONS: Downgrading rates are highest when PCa is present in TBx only and, especially when the highest grade PCa is diagnosed by TBx cores only. Conversely, downgrading rates are lowest when PCa is identified with the same ISUP through both SBx and TBx. The presence of clinically significant disease at SBx + TBx may indicate a more reliable assessment of the disease at the time of biopsy potentially reducing the risk of downgrading at final pathology.
Assuntos
Imageamento por Ressonância Magnética Multiparamétrica , Neoplasias da Próstata , Humanos , Neoplasias da Próstata/patologia , Neoplasias da Próstata/cirurgia , Masculino , Pessoa de Meia-Idade , Idoso , Biópsia Guiada por Imagem/métodos , Gradação de Tumores , Prostatectomia/métodos , Estudos Retrospectivos , Medição de Risco , Próstata/patologia , Biópsia/métodosRESUMO
BACKGROUND: Differences have often been reported in the outcomes of bladder cancer (BC) patients according to gender. OBJECTIVE: This study aims to provide data on patients undergoing radical cystectomy (RC) in a high-volume tertiary urologic center and to assess whether gender discrepancies do exist in terms of surgical options and clinical outcomes. MATERIALS AND METHODS: Consecutive BC patients treated between 2016 and 2020 at a single center (Careggi University Hospital, Florence, Italy) were included in the study. The impact of gender on disease stage at diagnosis, overall survival (OS), and type of surgery was analyzed. RESULTS: The study series comprised 447 patients (85 females and 362 males). At a median follow-up of 28.3 months (IQR: 33.5), OS was 52.6% and cancer-specific survival was 67.6%. Significant differences in OS emerged for age, acute myocardial infarction (AMI), Charlson Comorbidity Index (CCI), pT, and pN. OS rates were higher in patients undergoing robot-assisted surgery and in those receiving open orthotopic neobladder (ONB) (p = 0.0001). No statistically significant differences were found between male and female patients regarding surgical offer in any age group, surgical time, early postoperative complications, pathologic stage, and OS. CONCLUSIONS: After adjustment for pathologic tumor stage and treatment modalities, female and male patients showed similar oncologic outcomes. Further studies should be undertaken to evaluate functional results in women subjected to RC.
Assuntos
Procedimentos Cirúrgicos Robóticos , Estruturas Criadas Cirurgicamente , Neoplasias da Bexiga Urinária , Humanos , Feminino , Masculino , Cistectomia/métodos , Resultado do Tratamento , Neoplasias da Bexiga Urinária/cirurgia , Neoplasias da Bexiga Urinária/patologia , Bexiga Urinária/cirurgia , Estruturas Criadas Cirurgicamente/patologia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodosRESUMO
PURPOSE: Benign Prostatic Hyperplasia (BPH) is a result of prostate inflammation, frequently occurring in metabolic syndrome (MetS). Low testosterone is common in MetS. A randomized clinical trial was designed to evaluate if 24 weeks of testosterone therapy (TTh) in BPH men with MetS and low testosterone improve urinary symptoms and prostate inflammation. METHODS: One-hundred-twenty men with MetS waitlisted for BPH surgery were enrolled. They were categorized into normal testosterone (TT ≥ 12 nmol/L and cFT ≥ 225 pmol/L; n = 48) and testosterone deficient (TD) (TT < 12 nmol/L and/or cFT < 225 pmol/L; n = 72) then randomized to testosterone gel 2% (5 g/daily) or placebo for 24 weeks. At baseline and follow-up, questionnaires for urinary symptoms and trans-rectal ultrasound were performed. Prostate tissue was collected for molecular and histopathological analyses. RESULTS: No differences in the improvement of urinary symptoms were found between TTh and placebo (OR [95% CI] 0.96 [0.39; 2.37]). In TD + TTh, increase in prostate but not adenoma volume was observed (2.64 mL [0.07; 5.20] and 1.82 mL [- 0.46; 0.41], respectively). Ultrasound markers of inflammation were improved. In a subset of 61 men, a hyper-expression of several pro-inflammatory genes was found in TD + placebo when compared with normal testosterone. TTh was able to counteract this effect. For 80 men, the inflammatory infiltrate was higher in TD + placebo than in normal testosterone (0.8 points [0.2; 1.4]) and TD + TTh men (0.9 points [0.2; 1.5]). CONCLUSIONS: Twenty-four weeks of TTh in TD men with BPH and MetS improves ultrasound, molecular and histological proxies of prostate inflammation. This does not result in symptom improvement.
Assuntos
Sintomas do Trato Urinário Inferior , Síndrome Metabólica , Hiperplasia Prostática , Prostatite , Biomarcadores , Humanos , Inflamação/tratamento farmacológico , Sintomas do Trato Urinário Inferior/tratamento farmacológico , Sintomas do Trato Urinário Inferior/etiologia , Masculino , Síndrome Metabólica/tratamento farmacológico , Hiperplasia Prostática/tratamento farmacológico , Hiperplasia Prostática/metabolismo , Testosterona/uso terapêuticoRESUMO
STUDY QUESTION: How is the semen quality of sexually active men following recovery from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection? SUMMARY ANSWER: Twenty-five percent of the men with recent SARS-Cov-2 infections and proven healing were oligo-crypto-azoospermic, despite the absence of virus RNA in semen. WHAT IS KNOWN ALREADY: The presence of SARS-CoV-2 in human semen and its role in virus contagion and semen quality after recovery from coronavirus disease 2019 (COVID-19) is still unclear. So far, studies evaluating semen quality and the occurrence of SARS-CoV-2 in semen of infected or proven recovered men are scarce and included a limited number of participants. STUDY DESIGN, SIZE, DURATION: A prospective cross-sectional study on 43 sexually active men who were known to have recovered from SARS-CoV2 was performed. Four biological fluid samples, namely saliva, pre-ejaculation urine, semen, and post-ejaculation urine, were tested for the SARS-CoV-2 genome. Female partners were retested if any specimen was found to be SARS-CoV-2 positive. Routine semen analysis and quantification of semen leukocytes and interleukin-8 (IL-8) levels were performed. PARTICIPANTS/MATERIALS, SETTING, METHODS: Questionnaires including International Index of Erectile Function and Male Sexual Health Questionnaire Short Form were administered to all subjects. The occurrence of virus RNA was evaluated in all the biological fluids collected by RT-PCR. Semen parameters were evaluated according to the World Health Organization manual edition V. Semen IL-8 levels were evaluated by a two-step ELISA method. MAIN RESULTS AND THE ROLE OF CHANCE: After recovery from COVID-19, 25% of the men studied were oligo-crypto-azoospermic. Of the 11 men with semen impairment, 8 were azoospermic and 3 were oligospermic. A total of 33 patients (76.7%) showed pathological levels of IL-8 in semen. Oligo-crypto-azoospermia was significantly related to COVID-19 severity (P < 0.001). Three patients (7%) tested positive for at least one sample (one saliva; one pre-ejaculation urine; one semen and one post-ejaculation urine), so the next day new nasopharyngeal swabs were collected. The results from these three patients and their partners were all negative for SARS-CoV-2. LIMITATIONS, REASONS FOR CAUTION: Although crypto-azoospermia was found in a high percentage of men who had recovered from COVID-19, clearly exceeding the percentage found in the general population, the previous semen quality of these men was unknown nor is it known whether a recovery of testicular function was occurring. The low number of enrolled patients may limit the statistical power of study. WIDER IMPLICATIONS OF THE FINDINGS: SARS-CoV-2 can be detected in saliva, urine, and semen in a small percentage of men who recovered from COVID-19. One-quarter of men who recovered from COVID-19 demonstrated oligo-crypto-azoospermia indicating that an assessment of semen quality should be recommended for men of reproductive age who are affected by COVID-19. STUDY FUNDING/COMPETING INTEREST(S): None. TRIAL REGISTRATION NUMBER: N/A.
Assuntos
COVID-19 , SARS-CoV-2 , Estudos Transversais , Feminino , Humanos , Masculino , Estudos Prospectivos , RNA Viral , Sêmen , Análise do SêmenRESUMO
PURPOSE: The COVID-19 outbreak has substantially altered residents' training activities. While several new virtual learning programs have been recently implemented, the perspective of urology trainees regarding their usefulness still needs to be investigated. METHODS: A cross-sectional, 30-item, web-based Survey was conducted through Twitter from April 4th, 2020 to April 18th, 2020, aiming to evaluate the urology residents' perspective on smart learning (SL) modalities (pre-recorded videos, webinars, podcasts, and social media [SoMe]), and contents (frontal lessons, clinical case discussions, updates on Guidelines and on clinical trials, surgical videos, Journal Clubs, and seminars on leadership and non-technical skills). RESULTS: Overall, 501 urology residents from 58 countries completed the survey. Of these, 78.4, 78.2, 56.9 and 51.9% of them considered pre-recorded videos, interactive webinars, podcasts and SoMe highly useful modalities of smart learning, respectively. The contents considered as highly useful by the greatest proportion of residents were updates on guidelines (84.8%) and surgical videos (81.0%). In addition, 58.9 and 56.5% of responders deemed seminars on leadership and on non-technical skills highly useful smart learning contents. The three preferred combinations of smart learning modality and content were: pre-recorded surgical videos, interactive webinars on clinical cases, and pre-recorded videos on guidelines. CONCLUSION: Our study provides the first global «big picture¼ of the smart learning modalities and contents that should be prioritized to optimize virtual Urology education. While this survey was conducted during the COVID-19 outbreak, our findings might have even more impact in the future.
Assuntos
COVID-19/epidemiologia , Educação a Distância/métodos , Internato e Residência , Pandemias/estatística & dados numéricos , SARS-CoV-2 , Urologia/educação , Adulto , Estudos Transversais , Feminino , Cirurgia Geral/educação , Humanos , Internacionalidade , Internato e Residência/estatística & dados numéricos , Masculino , Inquéritos e Questionários/estatística & dados numéricos , Urologia/estatística & dados numéricos , Webcasts como AssuntoAssuntos
COVID-19/epidemiologia , Transplante de Rim/estatística & dados numéricos , Pandemias , SARS-CoV-2 , Doadores de Tecidos/estatística & dados numéricos , Academias e Institutos , Adulto , Morte Encefálica , Estudos de Viabilidade , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Obtenção de Tecidos e Órgãos/estatística & dados numéricosRESUMO
PURPOSE OF REVIEW: Aim of our systematic review is to evaluate and summarize the efficacy and safety of tadalafil alone or in combination with tamsulosin for the management of lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH) and erectile dysfunction (ED). RECENT FINDINGS: Daily tadalafil, in particular 5 mg, according to retrieved studies, appears to be both safe and effective in treating LUTS/BPH and ED, compared with placebo or tamsulosin. The combination of daily tadalafil 5 mg and tamsulosin 0.4 mg allows a better improvement of LUTS compared with both the monotherapies, even if with an increased, but acceptable and tolerated, adverse events rate. After discontinuation of tamsulosin or tadalafil in patients previously treated with their combination, the improvement of LUTS retains significance compared with baseline. Tadalafil 5 mg should be considered a primary treatment option for patients with LUTS/BPH and ED. Evidence highlight an excellent tolerability, safety, and effectiveness profile, both alone or in combination with tamsulosin 0.4 mg. A better efficacy on LUTS relief has been observed for combination therapy, preserving also sexual function. The further switch to monotherapy allows to preserve LUTS relief, but tadalafil only is able to retain ED improvement. Our results support the evidence for a more and more tailored and modular LUTS treatment.
Assuntos
Disfunção Erétil/tratamento farmacológico , Sintomas do Trato Urinário Inferior/tratamento farmacológico , Hiperplasia Prostática/tratamento farmacológico , Tadalafila/uso terapêutico , Tansulosina/uso terapêutico , Agentes Urológicos/uso terapêutico , Terapia Combinada , Disfunção Erétil/etiologia , Humanos , Sintomas do Trato Urinário Inferior/etiologia , Masculino , Hiperplasia Prostática/complicações , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do TratamentoAssuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Pacientes Ambulatoriais/psicologia , Satisfação do Paciente/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Telemedicina , Urologia/estatística & dados numéricos , Fatores Etários , Idoso , COVID-19 , Escolaridade , Humanos , Itália/epidemiologia , Pandemias , Relações Médico-Paciente , SARS-CoV-2 , Inquéritos e Questionários/estatística & dados numéricosRESUMO
BACKGROUND: Nowadays, serodiscordant couples (SDCs) with human immunodeficiency virus (HIV) or hepatitis C virus (HCV)-infected men have the chance to conceive safely, giving birth with a minimum risk of cross-infection. OBJECTIVE: To assess the impact of male HIV and HCV infection on the assisted reproductive technologies (ART) outcomes in SDCs, with HIV or HCV seropositive men and negative partners. MATERIALS AND METHODS: Of 153 couples: 24 in Group 1 (HIV-seropositive men), 60 in Group 2 (HCV-seropositive men) and 69 in Group 3 (controls). Sperm-washing procedure was performed using a three-step system. Fresh ICSI cycles were carried out in HIV SDCs, HCV SDCs and controls. Seminal parameters, fertilization rate (FR), cleavage rate (CR), pregnancy rate per cycle (PR/C), miscarriage rate, implantation rate (IR) and live birth rate were evaluated. RESULTS: All the seropositive men have undetectable viral loads at the time of insemination, and both partners were free from co-morbid infections. The median number of embryos transferred was 2.0 (IQR 1.0-3.0), with no differences among groups. FR was significantly reduced in HIV and HCV SDCs compared to the controls (66%, 61% and 75%, respectively; p < 0.01). CR was similar between groups (p = 0.3). IR was 12.1%, 11.1% and 14.1%, respectively, in the three groups (p = 0.30). PR/C was 21.7%, 17.6% and 20.2% in HIV, HCV and controls, respectively. Live birth rate per cycle was 17.4%, 15.7% and 15.9%, respectively. There were no significant differences in clinical pregnancies per cycle, as well as miscarriages and live births (p = 0.30; 0.30; 0.60, respectively). CONCLUSIONS: The sperm-washing technique with ICSI may generate a promising way to improve pregnancy outcomes and to reduce the risk of viral transmission in these couples. In this setting, we can correctly counsel HIV- and HCV-infected men of SDCs with regard to the likelihood of father their own biological child.
Assuntos
Infecções por HIV/prevenção & controle , Infecções por HIV/transmissão , Hepatite C/prevenção & controle , Hepatite C/transmissão , Técnicas de Reprodução Assistida , Espermatozoides/virologia , Adulto , Estudos de Casos e Controles , Feminino , HIV/isolamento & purificação , Soropositividade para HIV , Hepacivirus/isolamento & purificação , Humanos , Masculino , Pessoa de Meia-Idade , Gravidez , Taxa de Gravidez , Qualidade de Vida , Risco , Carga Viral , Adulto JovemRESUMO
Leukocyte infiltration plays an active role in controlling tumor development. In the early stages of carcinogenesis, T cells counteract tumor growth. However, in advanced stages, cancer cells and infiltrating stromal components interfere with the immune control and instruct immune cells to support, rather than counteract, tumor malignancy, via cell-cell contact or soluble mediators. In particular, metabolites are emerging as active players in driving immunosuppression. Here we demonstrate that in a prostate cancer model lactate released by glycolytic cancer-associated fibroblasts (CAFs) acts on CD4+ T cells, shaping T-cell polarization. In particular, CAFs exposure (i) reduces the percentage of the antitumoral Th1 subset, inducing a lactate-dependent, SIRT1-mediated deacetylation/degradation of T-bet transcription factor; (ii) increases Treg cells, driving naive T cells polarization, through a lactate-based NF-kB activation and FoxP3 expression. In turn, this metabolic-based CAF-immunomodulated environment exerts a pro-invasive effect on prostate cancer cells, by activating a previously unexplored miR21/TLR8 axis that sustains cancer malignancy.
Assuntos
Linfócitos T CD4-Positivos/patologia , Ácido Láctico/metabolismo , MicroRNAs/metabolismo , Receptor 8 Toll-Like/metabolismo , Microambiente Tumoral/imunologia , Acetilação , Linfócitos T CD4-Positivos/imunologia , Linfócitos T CD4-Positivos/metabolismo , Fibroblastos Associados a Câncer/metabolismo , Fibroblastos Associados a Câncer/patologia , Fatores de Transcrição Forkhead/metabolismo , Humanos , Tolerância Imunológica , Masculino , NF-kappa B/metabolismo , Neoplasias da Próstata/imunologia , Neoplasias da Próstata/metabolismo , Neoplasias da Próstata/patologia , Sirtuína 1/metabolismo , Linfócitos T Reguladores/imunologia , Linfócitos T Reguladores/patologia , Células Th1/imunologia , Células Th1/metabolismo , Células Th1/patologia , Receptor 8 Toll-Like/genética , Receptor 8 Toll-Like/imunologiaRESUMO
Azoospermia can be diagnosed in about 10%-15% of the infertile male population. To overcome the problem of failure to produce spermatozoa in the ejaculate in patients with nonobstructive azoospermia (NOA), testicular sperm extraction (TESE) may be performed to find the focal area of spermatogenesis. A 47-year-old man with NOA presented for treatment of secondary couple infertility. The patient underwent a first TESE 7 years earlier with cryopreservation, and an intracytoplasmic sperm injection-embryo transfer ended in a term pregnancy. He reported a history of repeated testicular traumas. At the present time, a complete medical workup was carried out, including clinical history, general and genital physical examination, scrotal and transrectal ultrasounds. Hormone measurements showed follicle-stimulating hormone level of 42.7 IU/L, luteinising hormone of 11.4 IU/L, total testosterone of 2.6 ng/ml and right and left testicular volume, respectively, of 4 and 3.9 ml. He underwent a second TESE, with successful sperm retrieval and cryopreservation. The histological pattern was hypospermatogenesis. In cases of extreme testicular impairment, although in the presence of very high follicle-stimulating hormone value and small testicular volume, estimating poor sperm recovery potential, the integration of clinical and anamnestic data, could help the surgeon to practise the more appropriate method of treatment.
Assuntos
Azoospermia/diagnóstico , Escroto/diagnóstico por imagem , Recuperação Espermática , Testículo/diagnóstico por imagem , Azoospermia/sangue , Azoospermia/terapia , Estradiol/sangue , Hormônio Foliculoestimulante/sangue , Humanos , Hormônio Luteinizante/sangue , Masculino , Pessoa de Meia-Idade , Prolactina/sangue , Testosterona/sangue , Resultado do Tratamento , UltrassonografiaRESUMO
BACKGROUND: Metabolic syndrome (MetS) and prostate cancer (PCa) are highly prevalent conditions worldwide. Current evidence suggests the emerging hypothesis that MetS could play a role in the development and progression of several neoplasms. The aims of this study are to evaluate the impact of MetS and MetS factors on PCa incidence, on the risk of high-grade PCa and to analyze the role of MetS and single MetS components on the development of aggressive PCa features. METHODS: A systematic literature search and analysis on PubMed, EMBASE, Cochrane and Academic One File databases until September 2015 was performed by 2 independent reviewers to evaluate the associations between MetS and PCa incidence, and between MetS and high-grade PCa incidence (bioptical Gleason Score⩾8, Prognostic Group 4-5 according to the novel prostate cancer grading system). Also the association between MetS and individual MetS components with pathological Gleason Score⩾8, extra-capsular extension, seminal vesicle invasion, positive surgical margins and biochemical recurrence (defined as two consecutive PSA values ⩾0.2 ng ml-1 after radical prostatectomy) was evaluated. RESULTS: 24 studies were selected including a total of 132 589 participants of whom 17.35% had MetS. There was a slight association between MetS and PCa incidence (odds ratio (OR)=1.17 (1.00-1.36), P=0.04) and between high-grade PCa and MetS (OR= 1.89 (1.50-2.38), P<0.0001) but the studies were statistically heterogeneous. No association was found between MetS components and PCa risk except for hypertension. MetS was significantly associated with pathologic Gleason Score⩾8 (OR= 1.77 (1.34-2.34); P<0.01), extra-capsular extension (OR=1.13 (1.09-1.18); P<0.01), seminal vesicle invasion (OR=1.09 (1.07-1.12); P<0.01), positive surgical margins (OR=1.67 (1.47-1.91); P<0.01) and biochemical recurrence (OR=1.67 (1.04-2.69); P<0.01). CONCLUSIONS: The presence of MetS is associated with worse oncologic outcomes in men with PCa, in particular with more aggressive tumor features, and biochemical recurrence.
Assuntos
Síndrome Metabólica/patologia , Recidiva Local de Neoplasia/patologia , Neoplasias da Próstata/patologia , Progressão da Doença , Humanos , Masculino , Síndrome Metabólica/complicações , Síndrome Metabólica/epidemiologia , Prognóstico , Próstata/patologia , Neoplasias da Próstata/epidemiologia , Neoplasias da Próstata/etiologia , Neoplasias da Próstata/metabolismo , Fatores de RiscoRESUMO
INTRODUCTION AND OBJECTIVES: To analyze postoperative complications and to assess for significant predictive factors during partial nephrectomy (PN) using a large multicenter dataset. METHODS: Patients who underwent PN for clinical T1 renal tumors at 19 urological Italian centers (Registry of Conservative Renal Surgery [RECORd] project) were evaluated between 2009 and 2012. Anthropometric data, comorbidities and perioperative outcomes were analyzed. Complications were divided as intra- and postoperative, medical and surgical, as appropriate. The severity of postoperative complications was graded according to the modified Clavien classification system. Patients who experienced intraoperative complications were excluded from the analyses for the potential confounding effect in the evaluation of predicting factors for postoperative complications. RESULTS: Overall, 979 patients were analyzed: open, laparoscopic and robot-assisted (available since 2011) surgical approaches were used in 522 (56.4%), 286 (30.9%) and 117 (12.6%) cases, respectively. Surgical postoperative complications were reported in 121 (13.1%) cases (32 (3.5%) were Clavien 3), medical were reported in 52 (5.6%) cases (3 (0.3%) were Clavien 3). No Clavien 4 complications were reported. At multivariable analysis, ECOG score ≥1 (OR 1.98; p = 0.002), lower preoperative hemoglobin (OR 0.71; p < 0.0001) and open surgical approach (2.91; p = 0.02) were significant predictive factors of overall surgical postoperative complications, ECOG score ≥1 (OR 1.93; p = 0.04) and surgical approach (p = 0.05) were significant predictive factors of Clavien 3 either surgical or medical postoperative complications. CONCLUSIONS: Comorbidities and surgical approach should be considered in preoperative evaluation of patients undergoing PN, as they resulted to play a significant role in the occurrence of postoperative complications.
Assuntos
Injúria Renal Aguda/epidemiologia , Carcinoma de Células Renais/cirurgia , Obstrução Intestinal/epidemiologia , Neoplasias Renais/cirurgia , Nefrectomia/métodos , Pneumotórax/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Fístula Urinária/epidemiologia , Idoso , Arritmias Cardíacas/epidemiologia , Transfusão de Sangue , Carcinoma de Células Renais/patologia , Comorbidade , Embolização Terapêutica , Feminino , Hemoglobinas/metabolismo , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Humanos , Itália/epidemiologia , Neoplasias Renais/patologia , Laparoscopia/métodos , Laparotomia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Isquemia Miocárdica/epidemiologia , Estadiamento de Neoplasias , Pneumonia/epidemiologia , Hemorragia Pós-Operatória/epidemiologia , Hemorragia Pós-Operatória/terapia , Período Pré-Operatório , Estudos Prospectivos , Reoperação , Síndrome do Desconforto Respiratório/epidemiologia , Fatores de Risco , Índice de Gravidade de DoençaRESUMO
PURPOSE: To report a clinical experience of stereotactic body radiation therapy (SBRT) for isolated recurrence in the prostatic bed from prostate cancer. MATERIALS AND METHODS: Between November 2011 and November 2013, 16 patients were treated with SBRT for a macroscopic isolated recurrence of prostate cancer in the prostatic bed. All patients were initially treated with radical prostatectomy, and half of them also received radiotherapy. Two schedules of SBRT were used: 30 Gy in 5 fractions in previously irradiated patients, 35 Gy in five fractions in radiotherapy-naïve patients. RESULTS: At a median follow-up of 10 months (range 2-21 months), a significant biochemical response was found in all but one patient. At imaging evaluation, no local progression was noted: 10 patients showed partial response while four stable disease. At the moment of analysis, all 16 patients were alive. Seven of them experienced distant relapse, while nine maintained biochemical control, with no further therapy. Median time to relapse was 9.3 months (range 3-15.2 months). The treatment was well tolerated: One patient experienced G2 acute genitourinary and gastrointestinal toxicity. CONCLUSIONS: Our experience shows that SBRT with CyberKnife for isolated nodal relapse is a safe and well-tolerated treatment.
Assuntos
Estadiamento de Neoplasias , Próstata/diagnóstico por imagem , Neoplasias da Próstata/radioterapia , Radiocirurgia/métodos , Idoso , Biomarcadores Tumorais/sangue , Intervalo Livre de Doença , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/radioterapia , Tomografia por Emissão de Pósitrons , Próstata/efeitos da radiação , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Neoplasias da Próstata/diagnóstico , Estudos Retrospectivos , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
AIM: To assess the role of simple enucleation (SE) for the treatment of highly complex renal tumors. METHODS: Overall, 96 Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification score 10 to 13 renal tumors were treated with SE at our institution. All conventional perioperative variables, surgical, functional and oncological results were gathered in a prospectively maintained database. Survival curves were generated using a Kaplan-Meier method. Univariate analysis assessed the outcome differences. RESULTS: Mean (± 1s.d.) clinical tumor diameter was 4.8 (± 1.6 cm). 70.8% of patients had ≥ cT1b stage. The PADUA score was recorded as 10, 11, 12 and 13 in 57.3%, 29.2%, 11.5%, and 2.1% of tumors respectively. Overall, 76 patients were treated with an open approach and 20 robotically. Mean warm ischemia time (WIT) was 19.2 min, and WIT greater than 25 min occurred in 14.6% of cases. Positive surgical margin (PSM) rate was 3.6% and trifecta was achieved in 64.3% of patients. Postoperative surgical complications occurred in 24% of patients, with 14.6% Clavien-Dindo grade 1-2, 8.3% grade 3, and 1% grade 4. Five-year cancer specific survival (CSS), recurrent free survival (RFS), and overall survival (OS) rates resulted 96.1%, 90.8% and 88.0%, respectively. Overall, 4.2% of patients experienced progressive disease. At follow-up, the mean decrease of eGFR from preoperative value was 13.9 ml/min. This was not significantly correlated with PADUA score (p = 0.69). The surgical approach was neither a predictor of Trifecta outcome, nor of postoperative complications, WIT > 25 min or PSM rate. CONCLUSIONS: SE is an effective treatment for highly-complex renal tumors, with a potential key role to widen the NSS (nephron sparing surgery) indications according to guidelines.
Assuntos
Taxa de Filtração Glomerular , Neoplasias Renais/fisiopatologia , Neoplasias Renais/cirurgia , Nefrectomia/métodos , Néfrons , Tratamentos com Preservação do Órgão/métodos , Robótica , Adulto , Idoso , Carcinoma de Células Renais/fisiopatologia , Carcinoma de Células Renais/cirurgia , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Neoplasias Renais/mortalidade , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Nefrectomia/efeitos adversos , Período Perioperatório , Valor Preditivo dos Testes , Estudos Retrospectivos , Baço/lesões , Esplenectomia , Resultado do TratamentoRESUMO
Cyberknife is an emerging treatment for early stage prostate cancer. Between October 2012 and January 2014, 32 patients were treated in our institution. Prescribed dose was 35-36.25 Gy in five fractions. Biochemical response was observed in 22 patients. Four patients experienced G2 acute genitourinary toxicity and in two cases we recorded G3 acute GU toxicity. 5 patients experienced G2 acute proctitis. At last follow up visit, all patients were still alive. 29 remained free of disease at last follow up appointment, while three developed a biochemical recurrence. Our experience confirms the efficacy and safety of Cyberknife for localized prostate cancer.
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Neoplasias da Próstata/radioterapia , Neoplasias da Próstata/cirurgia , Radiocirurgia , Procedimentos Cirúrgicos Robóticos , Idoso , Idoso de 80 Anos ou mais , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Próstata/patologia , Próstata/cirurgia , Neoplasias da Próstata/patologia , Lesões por RadiaçãoRESUMO
INTRODUCTION: Nephron-sparing surgery (NSS) has become the standard of care for the surgical management of small and clinically localized renal cell carcinoma (RCC). The conservative management of those RCCs is increasing over time. Aim of this study was to report a snapshot of the clinical, perioperative and oncological results after NSS for RCC in Italy. MATERIAL AND METHODS: We evaluated all patients who underwent conservative surgical treatment for renal tumours between January 2009 and December 2012 at 19 urological Italian Centers (RECORd project). Perioperative, radiological and histopathological data were recorded. Surgical eras (2009 vs 2012 and year periods 2009-2010 vs 2011-2012) were compared. RESULTS: Globally, 983 patients were evaluated. More recently, patients undergoing NSS were found to be significantly younger (p = 0.05) than those surgically treated in the first study period, with a significantly higher rate of NSS with relative and imperative indication (p < 0.001). More recently, a higher percentage of procedures for cT1b or cT2 renal tumours was observed (p = 0.02). Utilization rate of open partial nephrectomy (OPN) constantly decreased during years, laparoscopic partial nephrectomy (LPN) remained almost constant while robot-assisted partial nephrectomy (RAPN) increased. The rate of clampless NSS constantly increased over time. The use of at least one haemostatic agent has been significantly more adopted in the most recent surgical era (p < 0.001). CONCLUSIONS: The utilization rate of NSS in Italy is increasing, even in elective and more complex cases. RAPN has been progressively adopted, as well as the intraoperative utilization of haemostatic agents and the rate of clampless procedures.
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Carcinoma de Células Renais/cirurgia , Neoplasias Renais/cirurgia , Nefrectomia/métodos , Néfrons , Tratamentos com Preservação do Órgão/métodos , Distribuição por Idade , Idoso , Carcinoma de Células Renais/patologia , Estudos de Coortes , Feminino , Humanos , Itália , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Nefrectomia/tendências , Duração da Cirurgia , Tratamentos com Preservação do Órgão/tendências , Estudos Prospectivos , Procedimentos Cirúrgicos Robóticos/tendências , Resultado do TratamentoRESUMO
We retrospectively analyzed the effects on the erectile function (EF) of no treatment (NT), and an oral therapy (OT; on-demand therapy (OD) or a regimented rehabilitation (RR) program with phosphodiesterase type 5 inhibitors (PDE5-Is)), in a cohort of 196 consecutive patients following nerve-sparing radical retropubic prostatectomy (NSRRP). Patients undergoing bilateral NSRRP (BP; n = 147) and unilateral NSRRP (UP; n = 49), chose between OT (PDE5-Is OD or RR program) and NT. Patients who chose OD therapy received PDE5-Is (100 mg sildenafil, 20 mg tadalafil and vardenafil), whereas patients who chose the RR program received 100 mg sildenafil or 20 mg vardenafil three times a week, or 20 mg tadalafil twice a week at bedtime. The t-test for unpaired data and Fisher test were used for univariate analyses, logistic regression multivariate analysis was used to test the accuracy of available variables to predict EF recovery after radical prostatectomy. Potency rates were significantly correlated with the surgical technique and with OT when compared to NT (P < 0.02), respectively 68.7% for BP (61% with no therapy and 71% with PDE5-Is) and 44% for UP (29% with no therapy and 51% with PDE5-Is), while no statistically significative differences were found between OD and rehabilitation protocols (72% with rehabilitation and 70% with OD therapy in BP, 52% with rehabilitation and 50% with OD therapy in UP; P = NS). Early OT with PDE5-Is (OD or RR program) was superior to NT in recovery of EF in NSRRP. Furthermore, an RR program with PDE5-Is did not appear to be superior to OD therapy.
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Disfunção Erétil/tratamento farmacológico , Inibidores da Fosfodiesterase 5/uso terapêutico , Prostatectomia/efeitos adversos , Adulto , Idoso , Carbolinas/administração & dosagem , Disfunção Erétil/etiologia , Humanos , Imidazóis/administração & dosagem , Masculino , Pessoa de Meia-Idade , Pênis/inervação , Piperazinas/administração & dosagem , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Purinas/administração & dosagem , Recuperação de Função Fisiológica , Estudos Retrospectivos , Citrato de Sildenafila , Sulfonamidas/administração & dosagem , Sulfonas/administração & dosagem , Tadalafila , Triazinas/administração & dosagem , Dicloridrato de VardenafilaRESUMO
External beam radiation therapy with conventional fractionation to a total dose of 76-80 Gy represents the most adopted treatment modality for prostate cancer. Dose escalation in this setting has been demonstrated to improve biochemical control with acceptable toxicity using contemporary radiotherapy techniques. Hypofractionated radiotherapy and stereotactic body radiation therapy have gained an increasing interest in recent years and they have the potential to become the standard of care even if long-term data about their efficacy and safety are not well established. Strong radiobiological basis supports the use of high dose for fraction in prostate cancer, due to the demonstrated exceptionally low values of α / ß . Clinical experiences with hypofractionated and stereotactic radiotherapy (with an adequate biologically equivalent dose) demonstrated good tolerance, a PSA control comparable to conventional fractionation, and the advantage of shorter time period of treatment. This paper reviews the radiobiological findings that have led to the increasing use of hypofractionation in the management of prostate cancer and briefly analyzes the clinical experience in this setting.
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Neoplasias da Próstata/radioterapia , Doses de Radiação , Radiocirurgia/métodos , Fracionamento da Dose de Radiação , Humanos , Masculino , Neoplasias da Próstata/patologiaRESUMO
Several studies have highlighted a strong association between benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS) and erectile dysfunction (ED), particularly in elderly men. Many epidemiological trials, such as in vitro and in vivo studies, have reported the emerging role of metabolic syndrome, including abdominal obesity, impaired glucose metabolism, hypertriglyceridemia, low high-density lipoprotein cholesterol, and hypertension, in the development and progression of urinary and sexual symptoms. Moreover, many authors have focused their studies on the identification of all the shared pathogenetic mechanisms of LUTS/BPH and ED, including alteration of cyclic guanosine monophosphate and RhoA-ROCK pathways or vascular and neurogenic dysfunction. All these are potential targets for proposed phosphodiesterase type 5 inhibitors (PDE5-Is). Therefore, several trials have recently been designed to evaluate the role of PDE5-Is alone or in combination with conventional treatment for BPH, such as α-adrenergic blockers, in men affected by LUTS/BPH, with or without ED. Different PDE5-Is are in clinical use worldwide and currently six of them are licensed for the oral treatment of ED. All these compounds differ in pharmacokinetic factors, with influence on drug action, and subsequently in the overall safety and efficacy profile.