Estrogen therapy in patients with prostate cancer: a contemporary systematic review.

PURPOSE: To evaluate the effectiveness and harms of DES in treating prostate cancer compared to other forms of androgen deprivation therapy (orchiectomy, LHRH agonists, and anti-androgens). METHODS: We included clinical trials comparing DES with other forms of ADT (bicalutamide, flutamide, LHRH agonists, or orchiectomy) in PCa treatment. The primary outcomes were overall survival, cancer-specific survival, and progression-free survival, and secondary outcomes were cardiovascular effects. We searched in MEDLINE, EMBASE, Central, and Lilacs from inception to nowadays and saturated information for unpublished data in other sources. We performed a qualitative analysis of all included studies. It was not possible to perform meta-analysis due to low-quality trials and high heterogeneity. RESULTS: Overall, 1700 references were scanned and 14 prospective randomized trials with a total of 3986 patients were included in the final analysis. Although trials showed DES as similarly effective to another forms of ADT, evidences about cardiovascular toxicity in out of date high doses have discouraged its use. In doses of 1 mg, DES has been used as secondary line PCa treatment with safety. CONCLUSIONS: DES might be similarly effective to other forms of ADT on advanced PCa patients, with potential important roles. Intriguingly, the burden of severe cardiovascular toxicity is mainly related to old-fashioned doses of 5.0 and 3.0 mg. Modern PCa hormonal knowledge warrants stout high-quality prospective randomized trials in the low-dose 1 mg DES scenario.

Long-Term Results of Anderson-Hynes Pyeloplasty in Children: How Long Follow-Up Is Necessary?

PURPOSE: After a successful pyeloplasty at 3 to 6 months, the question remains whether children need a long follow-up. METHODS: The medical charts of patients with long-term follow-up (> 5 years), who underwent dismembered pyeloplasty for uretero-pelvic junction obstruction (UPJO) from May 1998 to May 2007, excluding those with bilateral UPJO, solitary kidney, associated vesicoureteral reflux or other abnormalities, and inconclusive renogram due to poor renal function, were retrospectively reviewed. Ultrasonography, differential renal function (DRF, DMSA), and renal drainage on diuretic renography (diethylene-triamine-pentaacetate technetium-99 or DTPA-Tc99) were performed at 3 and 6 months every year. RESULTS: Complete data were available for 28 consecutive patients (28 renal unities) with 2 months to 12 years (mean age, 2.4 years) at surgery, of whom 21 (75%) were boys, 17 diagnosed prenatally (61%) and 18 unities (64.3%) were left, with median follow-up of 10.7 years. Images were graded according to the Society for Fetal Urology grading system: Grade III in 11 (49%) and grade IV in 17 (61%). All cases presented > 10% DRF (DMSA) and obstructed DTPA-Tc99. The T1/2 (the half-time of drainage) less than 20 minutes at 3 months was found in 21 cases (75%) and less than 25 minutes in 7 cases (25%). Renal function and patency were maintained during follow-up for all units with 8% maximum fluctuation of DRF. One index case (3.6%) of renal function deterioration presented DRF fluctuation > 8% at 3 months (from 23 to 32%) and progressive hydronephrosis and indeterminate DTPA at 6 months. CONCLUSIONS: Satisfactory diuretic renogram at 3 to 6 months after pyeloplasty with maintained renal function and stable hydronephrosis suggests no need for further follow-up and indicates no functional loss with time. More than 8% DRF fluctuation might be a significant cutoff for further intervention aiming nephron preservation.

PSA-nadir at 1 year as a sound contemporary prognostic factor for low-dose-rate iodine-125 seeds brachytherapy.

OBJECTIVES: To identify predictors of outcomes in patients with localized prostate cancer treated with iodine-125 brachytherapy in a longitudinal uncontrolled study. METHODS: Between 2000 and 2011, 560 histologically confirmed patients were treated with brachytherapy of whom 305 with ≥24-month follow-up and localized tumor were evaluated after exclusion of those locally advanced and under androgen ablation. RESULTS: Patients' mean age was 63.93 years (44-88), mean pretreatment prostate-specific antigen (PSA) was 6.34 ng/mL (0.67-33.09), overall median follow-up was 75.35 months (24-158.37), biochemical recurrence occurred in 17 patients (5.57 %), cancer-specific survival was 100 %, and overall survival was 98.03 %. At multivariate analyses, only PSA-nadir at 1 year and age were related to disease-free survival: To each unit of PSA-nadir, the risk increases 87.3 %-OR 1.87 (p < 0.001; 95 % CI 1.31-2.67), and risk was 4.7 times higher for those under 50 years (vs. >70)-OR 4.69 (p = 0.04; 95 % CI 1.39-18.47). Best cutoff for PSA-nadir at one year was 0.285 (AUC = 0.78; p < 0.001; 95 % CI 0.68-0.89). Kaplan-Meier analysis confirmed PSA-nadir (p < 0.001) as prognostic, while D'Amico's classification failed (p = 0.24). No grade 3 or 4 complication was reported, and only 31.4 % of patients had grade 2 urinary or rectal toxicity. PSA bounce ≥0.4 ng/mL occurred in 18.4 % with no impact on biochemical recurrence. CONCLUSIONS: Half (50.49 %) of patients in the scenario of localized prostate cancer treated with iodine-125 brachytherapy reach PSA-nadir at 1 year <0.285, recognized as a key independent prognostic factor.

Higher prostate weight is inversely associated with Gleason score upgrading in radical prostatectomy specimens.

Background. Protective factors against Gleason upgrading and its impact on outcomes after surgery warrant better definition. Patients and Methods. Consecutive 343 patients were categorized at biopsy (BGS) and prostatectomy (PGS) as Gleason score, ≤6, 7, and ≥8; 94 patients (27.4%) had PSA recurrence, mean followup 80.2 months (median 99). Independent predictors of Gleason upgrading (logistic regression) and disease-free survival (DFS) (Kaplan-Meier, log-rank) were determined. Results. Gleason discordance was 45.7% (37.32% upgrading and 8.45% downgrading). Upgrading risk decreased by 2.4% for each 1 g of prostate weight increment, while it increased by 10.2% for every 1 ng/mL of PSA, 72.0% for every 0.1 unity of PSA density and was 21 times higher for those with BGS 7. Gleason upgrading showed increased clinical stage (P = 0.019), higher tumor extent (P = 0.009), extraprostatic extension (P = 0.04), positive surgical margins (P < 0.001), seminal vesicle invasion (P = 0.003), less "insignificant" tumors (P < 0.001), and also worse DFS, χ (2) = 4.28, df = 1, P = 0.039. However, when setting the final Gleason score (BGS ≤6 to PGS 7 versus BGS 7 to PGS 7), avoiding allocation bias, DFS impact is not confirmed, χ (2) = 0.40, df = 1, P = 0.530.Conclusions. Gleason upgrading is substantial and confers worse outcomes. Prostate weight is inversely related to upgrading and its protective effect warrants further evaluation.

The interpretation of the figure of the prophet Jonah by Michelangelo on the ceiling of the Sistine Chapel: anatomical urological vision.

PURPOSE: A detailed analysis in the iconography and pictorial appearance of the scene of the "Prophet Jonah" painted by the artist Michelangelo Buonarroti (1475-1564) on the ceiling of the Sistine Chapel between the years 1508 and 1512. MATERIALS AND METHODS: Literature review on the Italian Renaissance period and the life of Michelangelo Buonarroti and analysis of historical aspects of the evolution of studies of human anatomy in this period and the works of the artist. RESULTS: A comparative analysis of the representation of the figure of the fish on the left thigh of "Jonah " with a cross section of penis shows a curious similarity. The pictorial and iconographic analysis reveals an intensity of light on the pubic area and the position of the prophet with the legs spread apart and left hand placed on this region. A tube-shaped cloth covers the region and the angel at the side seems to be looking at this anatomical region of "Jonah". In fact, sets of iconographic and pictorial relate to the deciphered code. CONCLUSIONS: This description helps to confirm the relationship of the Renaissance art with the human anatomy; science has been much studied in this period. The design of a cross section of the penis is revealed with the two cavernous bodies with the septum between them and the spongy body. Considering the circumstances in which Michelangelo had painted, subjectivity was fundamental due to religious motivations added to the vigorous implications of a limited scientific knowledge typical of that era.

The interpretation of the figure of the prophet Jonah by Michelangelo on the ceiling of the sistine chapel: anatomical urological vision

PURPOSE:A detailed analysis in the iconography and pictorial appearance of the scene of the "Prophet Jonah" painted by the artist Michelangelo Buonarroti (1475-1564) on the ceiling of the Sistine Chapel between the years 1508 and 1512. MATERIALS AND METHODS:Literature review on the Italian Renaissance period and the life of Michelangelo Buonarroti and analysis of historical aspects of the evolution of studies of human anatomy in this period and the works of the artist. RESULTS:A comparative analysis of the representation of the figure of the fish on the left thigh of "Jonah" with a cross section of penis shows a curious similarity. The pictorial and iconographic analysis reveals an intensity of light on the pubic area and the position of the prophet with the legs spread apart and left hand placed on this region. A tube-shaped cloth covers the region and the angel at the side seems to be looking at this anatomical region of "Jonah". In fact, sets of iconographic and pictorial relate to the deciphered code. CONCLUSIONS: This description helps to confirm the relationship of the Renaissance art with the human anatomy; science has been much studied in this period. The design of a cross section of the penis is revealed with the two cavernous bodies with the septum between them and the spongy body. Considering the circumstances in which Michelangelo had painted, subjectivity was fundamental due to religious motivations added to the vigorous implications of a limited scientific knowledge typical of that era.

Bariatric surgery does not interfere with sperm quality--a preliminary long-term study.

PURPOSE: Positive impact of weight loss on sexual function and hormones has been demonstrated, and male fertility in this scenario is to be better defined. We evaluated the impact of lifestyle modifications and gastric bypass on sperm quality. METHODS: We prospectively studied 20 morbidly obese men during 24 months, randomized for intervention: lifestyle modifications (exercise and diet) for 4 months and subsequently gastric bypass (n = 10); and control: follow-up (n = 10). All patients underwent International Index of Erectile Function (IIEF-5) questionnaire, serum estradiol, prolactin (PRL), luteinizing and follicle-stimulating hormones (LH and FSH), free and total testosterones (FT and TT) and semen analysis at baseline (time 0), surgery 4 months later baseline (time 1) and final evaluation 24 months (time 2). RESULTS: Intervention group presented significant reduction in body mass index (BMI) at times 1 and 2, compared to control. There were no significant differences among sperm parameters between groups at times 0, 1, and 2 and among times 0, 1, and 2 in each group. Increases in IIEF-5 score (P = .0469), TT (P = .0349), and FSH (P = .0025) and reduction in PRL (P < .0001) were observed in the intervention group from times 0 to 2 and 1 to 2. Comparing groups at time 2, IIEF-5, TT, and FT increased significantly in the intervention group (P = .0224, P = .0043, and P = .0149, respectively). CONCLUSIONS: Surgery-induced massive weight loss does not interfere with sperm quality, while it increased the quality of sexual function, TT, FT and FSH and reduced PRL. Lifestyle modifications impacted merely the BMI. New studies are warranted, mostly considering birth rate as primary end point and including infertile men.

Is the minimally invasive treatment as good as transurethral resection for benign prostatic hyperplasia?

Despite the development of new technologies, transurethral resection of the prostate (TURP) is still considered the gold standard for surgical treatment of the benign prostate hyperplasia (BPH). In general, new minimally invasive treatments have not demonstrated better outcomes than TURP in evidence based medicine trials published to date, and should be reserved for patients who prefer to avoid surgery, who are unsuitable candidates for surgery or who no longer respond favorably to medication. TUMT and TUNA appears to be more effective than medical therapy but less effective than TURP. Both treatments can be given under topical anesthesia or local prostatic or perineal block. Efficacy of transurethral vaporization appears similar to TURP, but the studies are short-term and the glands operated on are relatively small. In patients with small prostates, the transurethral incision of the prostate can also be a good option, associated with less morbidity than TURP. Bipolar resection of the prostate is similar to TURP in effectiveness, but the data are inconclusive regarding blood loss, length of catheterization and hospital stay. Long-term comparative trials are needed to determine if the minimally invasive therapies are superior to standard TURP.