RESUMO
Based on a review of recently published articles, we evaluated the current status of high-intensity focused ultrasound (HIFU) as a primary treatment option for localized prostate cancer and as a salvage therapy when radiation has failed. With mid- and long-term progression-free survival rates around 70%, negative postoperative prostate biopsies almost 90%, and an excellent morbidity profile, primary HIFU appears to be a valid alternative to active surveillance protocols in low-risk patients and standard therapies in patients with life expectancies of 10 or fewer years. Moreover, HIFU has a considerable potential for local-only recurrence after radiation failure. HIFU is a recent technology, and many improvements will undoubtedly expand its future indications and use for the management of prostate cancer.
Assuntos
Neoplasias da Próstata/terapia , Terapia por Ultrassom/métodos , Terapia por Ultrassom/tendências , Humanos , Masculino , Recidiva Local de Neoplasia/etiologia , Recidiva Local de Neoplasia/terapia , Resultado do Tratamento , Terapia por Ultrassom/efeitos adversos , Ultrassom Focalizado Transretal de Alta IntensidadeRESUMO
In some patients at risk of disease recurrence of renal cancers, maximum conservation of the kidney is possible through partial nephrectomy. However, bloodless surgery is difficult to achieve. The article describes an ultrasonic clamp, which optimises energy deposition and monitors lesion development with an echo-based technique. Using this novel apparatus, coagulation necroses have been obtained in vitro on substantial thicknesses (23 to 38 mm) over exposure durations ranging from 10 s to 130 s, and with acoustic intensities of less than 15 W/cm(2) per transducer. When used for coagulation purposes, two transducers situated on opposite arms of the clamp are driven, while for monitoring, only one is used. Lesions are monitored in real time by analysing the echo signal returned by the opposite arm of the clamp. The presence of a lesion is evaluated on the basis of energy changes and echo phase as a function of time. Both kidneys of two pigs (30 to 36 mm thick) were treated in vivo with the clamp, and the partial nephrectomies performed proved to be bloodless.
Assuntos
Nefrectomia/métodos , Terapia por Ultrassom/métodos , Animais , Eletrônica , Feminino , Técnicas Hemostáticas/instrumentação , Modelos Animais , Suínos , Transdutores , Terapia por Ultrassom/instrumentaçãoRESUMO
OBJECTIVES: We evaluated the efficacy of Microporous Polysaccharide Hemospheres (MPH) for parenchymal hemostasis during laparoscopic partial nephrectomy (LPN) in the porcine model. METHODS: Six female farm pigs underwent a transperitoneal right lower-pole LPN during occlusion of the renal hilum. Renal parenchyma was excised using cold Endoshears. MPH was applied to the defect and the hilar clamp released. Animals were kept alive for one week. Before sacrifice, left LPN was similarly performed using MPH. Study variables included blood loss, number of MPH applications, hilar clamp time, hemostasis time, perioperative complications, and abnormalities noted at sacrifice. RESULTS: Hemostasis was achieved in all kidneys solely by using MPH. The average excised specimen represented 5.6% (range, 3.6 to 8.5) of renal weight. Mean hilar clamp and hemostatic times were 12.8 minutes (range, 6 to 18) and 2 minutes (range, 1 to 3), respectively. Hemostasis occurred after one MPH application in 8 kidneys (67%). In 3 kidneys, additional MPH powder was required to treat minor residual bleeding. In the remaining kidney, a second standard MPH application was required for hemostasis. No operative complications were encountered. No hematomas or residual MPH was found at necropsy; however, small urinomas were found in 2 of 6 kidneys. CONCLUSIONS: In the experimental porcine model, this initial study suggests that MPH provides effective parenchymal hemostasis during laparoscopic resection of an exophytic kidney lesion.
Assuntos
Hemostase Endoscópica/instrumentação , Nefrectomia , Polissacarídeos/administração & dosagem , Animais , Perda Sanguínea Cirúrgica/prevenção & controle , Feminino , Nefrectomia/métodos , Assistência Perioperatória/métodos , Pós , Suínos , Fatores de TempoRESUMO
OBJECTIVE: To evaluate the haemostatic property of a high intensity focused ultrasound (HIFU) applicator in lower pole partial nephrectomy in a porcine model. MATERIALS AND METHODS: An applicator with a flat HIFU transducer operating at a frequency of 3.78 MHz was designed. Nine female pigs weighing between 35 and 39 kg were used. The kidneys of 5 pigs were used to characterize basic lesions, study haemostatic efficacy and measure the temperature rise in treated tissues. The following 4 pigs were treated by HIFU prior to bilateral lower pole partial nephrectomy. Treatment consisted of circumferential juxtaposition of basic lesions in the lower pole with vascular clamping. Haemostatic efficacy was evaluated immediately and 30 minutes after lower pole resection. RESULTS: A 50-second ultrasound pulse with an intensity of 26 W/cm2 induced a full thickness lesion of the kidney, between 22 and 36 mm. Lesions were reproducible. The temperature rise observed in treated tissues was 62 +/- 12, 59 +/- 9 and 58 +/- 11 degrees C at distances of 15, 20 and 25 mm from the transducer, respectively. All lower pole partial nephrectomies were exsanguinated, except for one case (12.5%), in which a central renal artery was not controlled. CONCLUSIONS: Our HIFU applicator is an excellent haemostatic tool ensuring effective coagulation of the renal parenchyma, allowing dry lower pole partial nephrectomy. Improvement of the ergonomics of this applicator and adaptation to laparoscopy are currently under investigation.
Assuntos
Técnicas Hemostáticas , Nefrectomia/métodos , Terapia por Ultrassom , Animais , Feminino , SuínosRESUMO
Partial nephrectomy has recently become the reference treatment for localized renal cancer, less than 40 mm in diameter, in adults. The development of laparoscopy remains limited by the difficulties of haemostasis in these indications. "Minimally invasive techniques" have therefore been developed in this context, in order to achieve two objectives: parenchyma sparing and low morbidity. Various approaches, using cryotherapy, radiofrequency, microwaves or high intensity focused ultrasound, are under investigation. The preliminary clinical results appear to be promising, but the efficacy endpoints of these treatments still need to be evaluated, as well as the survival results based on longer term follow-up. However, if the good initial results are confirmed, these techniques could constitute, in the future, an alternative to surgery for the management of renal cancers less than 40 mm in diameter The objective of this article is to review these various techniques, to summarize the studies published in the literature and to discuss the preliminary oncological results.
Assuntos
Neoplasias Renais/terapia , Ablação por Cateter , Criocirurgia , Humanos , Neoplasias Renais/patologia , Micro-Ondas/uso terapêutico , Terapia por UltrassomRESUMO
Radiotherapy alone or in combination with other modalities is used in the treatment of a large number of pelvic tumours of urological or gynaecological origin. Despite constant progress in this field, medium-term and long-term complications remain frequent and often require difficult long-term management. Radiation cystitis is one of the most frequent complications and directly concerns urologists. Among the various treatment options for haemorrhagic cystitis, hyperbaric oxygen therapy appears to give good short-term and medium-term results. It is currently reserved for cases refractory to the standard treatments for radiation cystitis.
Assuntos
Cistite/terapia , Hemorragia/terapia , Oxigenoterapia Hiperbárica , Lesões por Radiação/terapia , Cistite/etiologia , Hemorragia/etiologia , Humanos , Lesões por Radiação/complicaçõesRESUMO
Idiopathic spontaneous renal artery dissection (SRAD) is a rare disease and must be taken into account in the differential diagnosis of low back pain. It may be due to various aetiologies, secondary to degenerative or traumatic diseases, or it may be idiopathic. Intravenous urography is usually normal. Abdominal CT usually visualizes the renal infarction and selective arteriography confirms the diagnosis of renal artery dissection. Medical treatment and surveillance provide effective management of the disease. However, surgical management may be proposed either immediately or secondarily. SRAD usually has a favourable course, but, in the longer term, may be complicated by organic renal failure and renovascular hypertension.
Assuntos
Dissecção Aórtica/complicações , Infarto/etiologia , Rim/irrigação sanguínea , Artéria Renal , Adulto , Humanos , MasculinoRESUMO
Hypospadias is a frequent malformation and its treatment is not devoid of complications, particularly fistulas. The authors describe the department's surgical technique (modified Duplay technique). Urethroplasty is no longer performed by simple approximation of the urethral plate without dissection. The inferior surface of corpora cavernosa is exposed as far as the lateral border and as far as the summit in the glans, allowing tension-free suture of urethral tissues with a lengthening effect of this intermediate plane. This completes correction of chordee and especially "bucket-handle" glans and protects the reconstructed urethra and proximal urethra. The risk of fistula is therefore reduced (2 cases out of 51). This technical modification can be used to treat all forms of distal hypospadias (glanular, glanulo-preputial, and anterior penile). It has also been used for several cases of more severe hypospadias. These good results must be confirmed in a larger series of patients.
Assuntos
Hipospadia/cirurgia , Pênis/cirurgia , Uretra/cirurgia , Criança , Pré-Escolar , Humanos , Lactente , Masculino , Resultado do TratamentoRESUMO
INTRODUCTION: Neuroendocrine cancer of the prostate (NECP) is a rare entity. Screening for this tumour, although not systematic, may have therapeutic implications. The authors retrospectively evaluated 6 cases of NECP observed in the department between September 1998 and May 2002. MATERIAL AND METHODS: The diagnosis was based on immunohistochemical analysis of biopsy fragments with the presence of marked neuroendocrine differentiation (minimum 50%). Positive staining for anti-Neuron-Specific Enolase (NSE) and anti-Chromogranin A antibodies was observed in 5 and 6 cases, respectively, while anti-PSA antibody labelling was always negative. RESULTS: NECP represented 2.1% of all prostate cancers diagnosed in the department over the same period. Digital rectal examination was abnormal in every case with a median PSA of 9.75 ng/ml (range: 0.25-19.6). Three patients presented metastatic disease at the time of the diagnosis. Four of the 6 patients were urgently admitted to hospital because of acute clinical features. Paroxysmal abdominal pain occurred during the course of the disease in every case with a median of 52 days (range: 22-198) and was initially present in 2 cases. Chemotherapy was performed in 3 cases and palliative therapy was administered in the other cases. A survival difference was observed for patients treated by chemotherapy (13 months versus 4.7). The median survival was 9 months and 14 days. Death occurred in a context of rapid alteration of the general state and renal function. CONCLUSION: NECP has a poor prognosis. Clinical and complementary features guide the diagnosis, which can be confirmed by immunohistochemical analysis, allowing early management based on chemotherapy.
Assuntos
Tumores Neuroendócrinos/diagnóstico , Neoplasias da Próstata/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Humanos , Masculino , Pessoa de Meia-Idade , Tumores Neuroendócrinos/terapia , Neoplasias da Próstata/terapia , Estudos RetrospectivosRESUMO
PURPOSE: To evaluate pre-operative prognostic risk factors to predict oncologic outcome of Salvage High-Intensity Focused Ultrasound (S-HIFU) for radiorecurrent prostate cancer (PCa). METHODS AND MATERIALS: A total of 290 men with biopsy-confirmed locally radiorecurrent PCa, underwent S-HIFU. D'Amico risk group before external beam radiotherapy (EBRT), Prostate Specific Antigen (PSA), estimated Gleason score prior HIFU and post HIFU biopsies were analyzed for predictive utility of local cancer control, cancer-specific, metastasis free, and progression free survival rates (PFSR). RESULTS: Local cancer control with negative biopsy results was obtained in 81% of the 208 patients who underwent post-S-HIFU biopsies. Median PSA nadir was 0.14 ng/ml and 127 patients did not require androgen deprivation therapy (ADT). The mean follow up was 48 months for cancer-specific survival rates. The cancer-specific and metastasis-free survival rates at 7 years were 80% and 79.6% respectively. The PFSR was significantly influenced by: the pre-HIFU PSA level (hazard ratio (HR): 1.09, 95% CI 1.04-1.13), a Gleason score ≥8 versus ≤6 (HR: 1.17, 95% CI 1.03-1.3), and a previous ADT (HR: 1.28, 95% CI 1.09-1.46). The rates of recto-urethral fistula (0.4%) and grade II/III incontinence (19.5%) indicate significant reduction in serious side effects with use of dedicated post-radiation acoustic parameters compared with standard parameters. CONCLUSION: S-HIFU is an effective curative option for radiorecurrent PCa with acceptable morbidity for localized radiorecurrent PCa, but should be initiated early following EBRT failure. Use of prognostic risk factors can optimize patient selection.
Assuntos
Recidiva Local de Neoplasia/terapia , Neoplasias da Próstata/terapia , Terapia de Salvação , Ultrassom Focalizado Transretal de Alta Intensidade , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Recidiva Local de Neoplasia/mortalidade , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/mortalidade , Neoplasias da Próstata/patologia , Taxa de SobrevidaRESUMO
BACKGROUND: Local occurrence of prostate cancer (PCa) after external beam radiation (EBRT) may benefit from definitive local therapy. OBJECTIVE: To evaluate the safety and efficacy of salvage high-intensity focal ultrasound (HIFU) in local PCa recurrence after EBRT and to determine prognostic factors for optimal patient selection. DESIGN, SETTING, AND PARTICIPANTS: Between 1995 and 2006, patients with a local PCa recurrence after EBRT were retrospectively included. INTERVENTION: All patients received salvage HIFU with the Ablatherm device. MEASUREMENTS: Prognostic factors (pre-EBRT risk group, androgen-deprivation [AD] use, pre-HIFU prostate-specific antigen [PSA], Gleason score and positive biopsy percentage) were studied in univariate and multivariate analyses. Progression was defined as positive biopsy and/or last PSA > nadir + 2 ng/ml and/or adjuvant therapy introduction. All complications were recorded. RESULTS AND LIMITATIONS: Some 194 HIFU sessions for 167 patients were performed. Local cancer control was achieved with negative biopsy results in 122 (73%) patients. The median PSA nadir was 0.19 ng/ml. The mean follow-up period was 18.1 mo (range: 3-121 mo). Seventy-four patients required no hormone therapy. The actuarial 5-yr overall survival rate was 84%. The actuarial 3-yr progression-free survival rate was significantly lower in three circumstances: (1) worsening of the pre-EBRT stage with 53%, 42%, and 25% for low-, intermediate-, and high-risk patients, respectively, (2) increase in the pre-HIFU PSA, and (3) use of AD during PCa management. In multivariate analyses, the risk ratio for intermediate- and high-risk patients were 1.32 and 1.96, respectively. The risk ratio was 2.8 if patients had received AD. No rectal complications were observed. Urinary incontinence accounted for 49.5% of the urinary sphincter implantations required in 11% of patients. This is a retrospective study in which the role of the PSA doubling time and the time until recurrence was not evaluated. CONCLUSIONS: Salvage HIFU is a curative treatment option for local relapse after EBRT with acceptable morbidity. Careful patient selection is imperative depending upon the aforementioned prognostic factors.
Assuntos
Recidiva Local de Neoplasia/terapia , Neoplasias da Próstata/terapia , Terapia de Salvação/métodos , Terapia por Ultrassom , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias da Próstata/radioterapia , Estudos Retrospectivos , Fatores de Tempo , Falha de Tratamento , Resultado do TratamentoRESUMO
The objective of this study was to retrospectively evaluate the results of radiofrequency ablation (RFA) of renal tumors with an impedance-based system using an expandable multitined electrode. Twenty-two patients (30 tumors) were treated with RFA over a 7-year period, percutaneously (16 tumors) or intraoperatively (14 tumors). Follow-up imaging was performed at 1-3, 6, and 12 months and yearly thereafter. Twenty-seven of 30 tumors (19/22 patients) showed no residual tumor on the first imaging control. Two residual tumors were successfully ablated by a second RFA procedure. Our mean follow-up period was 35 months (range, 3-84 months). Two tumors that had been completely ablated based on imaging criteria recurred 11 and 48 months after RFA. One was treated by partial nephrectomy. The other one was not treated because the patient developed bone metastases. One patient had nephrectomy because of an RFA-induced ureteropelvic junction stricture. Nine patients (11 sessions) had a pyeloperfusion of cooled saline during RFA. None developed symptomatic complications, even though in three patients the ablation zone extended to the closest calyx (3-5 mm from the tumor). We conclude that RFA of renal tumors is promising, but serious complications to the collecting system must be taken into consideration. Prophylactic per-procedural cooling of the collecting system is feasible but needs further assessment.
Assuntos
Carcinoma de Células Renais/cirurgia , Ablação por Cateter/instrumentação , Complicações Intraoperatórias/prevenção & controle , Neoplasias Renais/cirurgia , Pelve Renal , Perfusão/métodos , Adulto , Idoso , Carcinoma de Células Renais/mortalidade , Carcinoma de Células Renais/patologia , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Eletrodos , Desenho de Equipamento , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Hipotermia Induzida/métodos , Neoplasias Renais/mortalidade , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estadiamento de Neoplasias , Projetos Piloto , Probabilidade , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: The growing interest in high-intensity focused ultrasound (HIFU) is mainly due to its potential applications as a minimally invasive therapy. HIFU has been assessed for its role in the treatment of localized prostate cancer in patients who otherwise would not have benefited from surgery and in local recurrences after radiation failure. METHODS: Relevant information on HIFU treatment was identified through a MEDLINE search using specified terms. Papers that presented original outcomes were included in the present review. RESULTS: High biochemical efficacy, excellent tumor local control and favorable mid-term oncological data with a low morbidity rate have been proven in many series of patients. CONCLUSIONS: Although HIFU is a recent and emerging technology, it has been well studied and developed to a point that HIFU will undoubtedly be an effective alternative to radiation therapy.
Assuntos
Neoplasias da Próstata/diagnóstico por imagem , Resultado do Tratamento , Ultrassonografia/métodos , Humanos , Masculino , Neoplasias da Próstata/terapia , Ultrassonografia/efeitos adversos , Ultrassonografia/instrumentaçãoRESUMO
OBJECTIVES: To evaluate the efficacy and safety of the InVance bulbourethral sling in male stress urinary incontinence. MATERIALS AND METHODS: Between June 2003 and April 2005, the InVance bulbourethral sling was implanted into 50 patients with urinary incontinence after prostate surgery in 49 cases and pelvic trauma in 1 case. The patients were monitored and evaluated in a prospective manner (continence, tolerance, and satisfaction). The treatment was considered to be successful if the patient stopped wearing any kind of continence pad (patient cured) or only one pad per day (patient improved), with no de novo urinary disorders and without significant postvoid residual urine. Patient satisfaction with the procedure was assessed. RESULTS: After a median follow-up of 6 mo, 50% of patients were dry, 26% had improved, and 24% suffered treatment failure. The success rates for the patients with severe incontinence and those who had undergone radiation therapy were 50% and 25%, respectively. All patients who were dry or had improved were satisfied and presented no obstructive or irritative de novo urinary disorders. The overall success rate for the 51 procedures conducted was 74.5%. Six cases of transitory acute urine retention and six cases of persistent perineal pain were reported. Explantation was necessary because of suppuration of the sling in three patients and of a de novo irritative urinary disorder in one patient. No cases of pubic osteitis or urethral erosion were reported. CONCLUSIONS: The InVance bulbourethral sling procedure makes it possible to treat stress urinary incontinence after prostate surgery with satisfactory and lasting short-term results. Severe incontinence and a past history of pelvic radiation therapy seem to be factors contributing to the failure of this procedure.
Assuntos
Próteses e Implantes , Incontinência Urinária por Estresse/cirurgia , Idoso , Idoso de 80 Anos ou mais , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Urológicos Masculinos/métodosRESUMO
Free-floating intraperitoneal pelvic masses are exceedingly rare. These abnormalities, typically composed of organized fat necrosis, are most commonly thought to occur after spontaneous torsion and subsequent infarction of an appendix epiploica. Most of these loose bodies are incidentally discovered. Surgical removal is recommended because cross-sectional imaging typically cannot accurately make the diagnosis. Laparoscopy offers a minimally invasive tool to simultaneously inspect the abdominal cavity, assess the pelvic mass diagnosis, and treat the patient. We describe the case of a patient followed up for pudendal neuropathy in which organized fat necrosis was diagnosed and treated by laparoscopy.
Assuntos
Necrose Gordurosa/cirurgia , Laparoscopia , Neuralgia/complicações , Dor Pélvica/etiologia , Cavidade Peritoneal , Diagnóstico Diferencial , Necrose Gordurosa/diagnóstico , Necrose Gordurosa/diagnóstico por imagem , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios XRESUMO
PURPOSE: Microporous polysaccharide hemospheres (MPH, Medafor, Minneapolis, Minneapolis) are a novel hemostatic agent made from purified plant starch. MPH activates the clotting cascade and hyperconcentrates platelets and coagulation proteins, while enhancing a hemostatic plug. We evaluated the hemostatic efficacy of MPH compared with standard surgical technique in a porcine open partial nephrectomy model. MATERIALS AND METHODS: Standardized lower pole partial nephrectomy was consecutively performed in each kidney of 12 female pigs. Each pig was randomized to 2 groups, namely treatment with MPH application or control with the conventional surgical technique (oxidized cellulose with bolster sutures). The right kidney was harvested 1 half-hour after hemostasis was achieved and the left kidney was harvested after 7 days. RESULTS: Mean animal and resected renal tissue weight were comparable. Ischemic and hemostasis times were significantly decreased in the MPH treated group (2.67 and 4.67 minutes, respectively) vs the control group (8.33 and 7.75 minutes, respectively) (each p = 0.004). Blood loss was equivocal (0.88 gm in the treatment group vs 2.09 gm in the control group, p = 0.07). No hemostatic complications were noted in either group. No evidence of residual foreign material was found in the MPH group at 1 week. CONCLUSIONS: MPH provided rapid, effective and durable hemostasis in the porcine open partial nephrectomy model. Additional experimental and clinical evaluation is warranted to define the role of MPH assisted partial nephrectomy in humans.