Optimal Surgical Outcome of Minimally Invasive Partial Nephrectomy (MIPN) Based on an Early Postoperative Estimated Glomerular Filtration Rate (eGFR).

PURPOSE OF REVIEW: To compare laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) performed in two European tertiary centers using the classic optimal surgical definition - "MIC" - and a new optimal surgical definition: the "Novel TRIFECTA" (NT) concept. We sought to strengthen the PN evidence and to test the NT's performance. RECENT FINDINGS: The study population comprehended 505 cases of localized kidney cancer from two tertiary centers between 2012 and 2019. The NT achievement was higher in the RAPN group when compared to LPN (70.5 vs. 87.4%; p = 0.004), while no differences were found when considering the MIC criteria. Also, a similar high-grade complications rate (Clavien-Dindo > III) and operative time (105 min vs. 100 min; p = NS) were found. In the multivariable regression, the RAPN approach was a predictor of NT achievement (OR 2.45; p = 0.008). NT achievement was higher in the RAPN group, while similar results were found when evaluating the MIC criteria. The NT definition could be more sensitive to the individual-specific responses related to the PN.

The Role of the Low-Intensity Extracorporeal Shockwave Therapy on Penile Rehabilitation After Radical Prostatectomy: A Randomized Clinical Trial.

BACKGROUND: Erectile dysfunction (ED) after radical prostatectomy (RP) still represents a major issue. Considering the benefits recently described regarding the application of low-intensity extracorporeal shockwave therapy (LiESWT) in vasculogenic ED, questions arise about its role in the scenario of penile rehabilitation. AIM: To compare the early introduction of phosphodiesterase-5 inhibitor (PDE5i) with a combination therapy enrolling both early PDE5i use and LiESWT in patients submitted to RP. METHODS: This study is a randomized clinical trial, open-label, with 2 parallel arms and an allocation ratio of 1:1. The study was registered in ReBEC (ensaiosclinicos.gov.br) Trial: RBR-85HGCG. Both arms started tadalafil at a dose of 5 mg/day right after the removal of the transurethral catheter, and the experimental group received 2,400 shocks/session-week distributed on 4 different penile regions. The full treatment consisted of 19,200 impulses across 8 weeks. OUTCOMES: The primary clincal end point was ≥4-point difference favoring the experimental group considering the mean International Index of Erectile Function short form (IIEF-5) at last follow-up. Any statistical difference in the IIEF-5 score between the arms was stated as the primary statistical end point. RESULTS: Between September 25, 2017, and December 3, 2018, 92 men were enrolled in the study. At last follow-up, we assessed 77 patients, 41 in the control group and 36 in the intervention group. A difference between groups was detected when accessing the final median IIEF-5 score (12.0 vs 10.0; P = .006). However, the primary clinical endpoint considering a difference ≥4-point between the arms has not been reached. When performing an exploratory analysis comparing the proportion of those individuals with an IIEF-5 score ≥17, no difference between groups was noted (17.1% vs 22.2%; P = .57). CLINICAL IMPLICATIONS: So far, the benefits arising from LiESWT for penile rehabilitation after RP have been uncertain. STRENGTHS & LIMITATIONS: This is the first trial assessing the role of LiESWT on erectile function after RP. Our study protocol included only one session per week for the experimental group, raising a query if a more intensive application could achieve better results once a statistically significant difference was found between groups. We discontinue the PDE5i use at the last session, which may have interfered in the penile vascular rehabilitation, maybe compromising the results too. CONCLUSION: After therapy with 19,200 impulses therapy across 8 weeks, we found an improvement of the IIEF-5 score, but it was not enough to be considered clinically significant. More studies are warranted before any recommendation on this topic. Baccaglini W, Pazeto CL, Corrêa Barros EA, et al. The Role of the Low-Intensity Extracorporeal Shockwave Therapy on Penile Rehabilitation After Radical Prostatectomy: A Randomized Clinical Trial. J Sex Med 2020;17:688-694.

HRQOL related to urinary diversion in Radical Cystectomy: a systematic review of recent literature.

INTRODUCTION: The health-related QoL is a patient-centered evaluation covering several aspects. This evaluation seems to be particularly important in patients submitted to radical cystectomy (RC) and urinary diversion with ileal conduit (IC) or a neobladder (NB). OBJECTIVE: Review all recent data comparing QoL outcomes after radical cystectomy with NB and IC diversions. EVIDENCE ACQUISITION: A systematic search in PubMed/Medline, Embase, and Cochrane databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement in December 2018. All articles published from January 01, 2012 to December 31, 2018, were included. A study was considered relevant if it compared QoL outcomes using validated questionnaires (EORTC QLQ C30, FACT-G, FACT-BL, FACT-VCI, and BCI). EVIDENCE SYNTHESIS: In 11 included studies, a total of 1389 participants were accounted (730 NB and 659 IC cases). The studies were conducted in 8 different countries, two were prospective, and none was randomized. There were two studies favoring results with a neobladder, 3 with incontinent diversion and 6 with no differences. The EORTC-QLQ-C30 was the most used instrument (5 studies) followed by FACT VCI and BCI (3 studies each). Given the heterogeneity of data and lack of prospective studies, a meta-analysis was not performed. CONCLUSION: No superiority of one urinary diversion was characterized. It seems that the choice must be individualized with an extensive preoperative orientation of the patient and their relatives. That will probably infl uence how the patient accepts the new condition.

Robot-assisted Simple Prostatectomy with Tunnel-Shaped Trigonization (RASP-TST) - A Novel Technique.

To describe a technical modifi cation for robotic-assisted simple prostatectomy (RASP) using three-steps reconstructive technique to achieve a 360 trigonization of the bladder mucosa. Through fi ve-trocars transperitoneal access, we perform a longitudinal incision of the bladder wall and prostate capsule. Our technique of RASP is very similar to the standard operative technique described during laparoscopic and robotic removal of adenoma, however, for reconstruction, we propose the Tunnel-Shaped Trigonization (TST). The fi rst step is the advancement of a bladder mucosa fl ap until the posterior part of the prostatic urethra. The second step, a running suture between the advanced mucosa and the prostatic capsule is done bilaterally. At this point, the prostate capsule should be totally isolated from the rest of the urinary tract. Finally, the third step is closing both sides of the capsule and bladder mucosa anteriorly identical to a tunnel conformation. Hiding the prostatic capsule optimizes the patient recovery since hematuria is the most related factor for hospital stay length. This pilot-case has shown satisfactory results without the need for continuous bladder irrigation. The prostate volume in the TRUS was 130 cm3 and the preoperative International Prostate Symptom score was 24. He was discharged at second postoperative day and no late complications were detected. In conclusion, the TST-RASP seems to be a safe and feasible modifi cation of the RASP. We hope that the application of the TST can lead us to lower rates of blood loss, transfusion and postoperative complications in comparison to the standard technique.

Idiosyncratic reaction after injection of polyacrylate - polyalcohol copolymer.

CONTEXT: Polyacrylate-polyalcohol copolymer is a synthetic product, non-biodegradable, with low rate of therapeutic failure and lower incidence of reactions at the site of injection, when compared to biodegradable agents. We report an unprecedent, exuberant and persistent inflammatory reaction following injection of that substance. PATIENT: A 17 years-old patient with vesico-ureteral reflux and complete pyelocaliceal right duplication was submitted to treatment with polyacrylate-polyalcohol copolymer (STING technique). In the seventh day of post-operatory, she presented intense dysuria and hypogastric pain, without laboratory exams alterations; a symptomatic treatment was started. After two months, the symptoms persisted and an ultrasound detected thickening of bladder wall close to the uretero-vesical junction. After that exam, a cystostopic biopsy showed epithelial hyperplasia with increased edema of lamina propria, suggesting an adverse reaction to the polymer. After four months, there was complete remission, but the reflux persisted with the same grade. HYPOTHESIS: This is an unprecedent reaction following injection of this copolymer. The presence of characteristics such as absence of infection, temporal relation between treatment and beginning of symptoms, and detection of epithelial hyperplasia at the local of injection reinforce the hypothesis of association of the substance and adverse reaction. In that patient, important complains motivated early investigation of urinary tract, that confirmed those aspects. Maybe if that reaction had occurred in patients with lower capacity of expression (such as in infants) it would be unnoticed.

A Safe teaching protocol of LRP (laparoscopic radical prostatectomy).

PURPOSE: The LRP has a steep learning curve to obtain proficiency during which patient safety may be compromised. We present an adapted modular training system which purpose to optimize the learning curve and perform a safe surgery. MATERIALS AND METHODS: A retrospective analysis of the LRP safe learning protocol applied during a fellowship program over eight years (2008-2015). The surgery was divided in 12 steps and 5 levels of difficulty. A maximum time interval was stipulated in 240 minutes. After an adaptation, the fellows had 120 minutes to perform all the corresponding modules to its accumulated skill. The participants gradually and safely pass through the steps and difficulty levels. Surgeries performed by fellows were analyzed as a single group and compared to a prior series performed by tutor. RESULTS: In eight years, 250 LRP were performed (25 per apprentice) during fellowship program and 150 procedures after completion. The baseline characteristics were comparable. Most cases operated were of intermediate risk. Mean operative time was longer in the fellow group when compared to the tutor (150 min). Mean estimated blood loss were similar among the groups. Functional and oncological outcomes were better in the Tutor´s group. No conversion to open surgery was performed. CONCLUSIONS: The LRP safe learning protocol proved to be an effective method to optimize the learning curve and perform safe surgery. However, the tutor's functional and oncological results were better, showing that this is a procedure with a steep learning curve and proficiency demands more than 25 cases.

PSA kinetics before 40 years of age.

PURPOSE: The baseline PSA has been proposed as a possible marker for prostate cancer. The PSA determination before 40 years seems interesting because it not suffers yet the drawbacks related to more advanced ages. Considering the scarcity of data on this topic, an analysis of PSA kinetics in this period seems interesting. MATERIALS AND METHODS: A retrospective assay in a database of a private diagnostic center was performed from 2003 to 2016. All subjects with a PSA before 40 years were included. RESULTS: 92995 patients performed PSA between the ages of 21 - 39. The mean value ranged from 0.66 ng / mL (at age 22) to 0.76 ng / mL (at age 39) and the overall mean was 0.73 ng / mL. As for outliers, 3783 individuals presented a baseline PSA > 1.6 ng / mL (p95). A linear regression model showed that each year there is a PSA increase of 0.0055 ng / mL (ß = 0.0055; r² = 0.0020; p < 0.001). A plateau in PSA between 23 and 32 years was found and there were only minimal variations among the ages regardless of the evaluated percentile. CONCLUSION: It was demonstrated that PSA kinetics before 40 years is a very slow and progressive phenomenon regardless of the assessed percentile. Considering our results, it could be suggested that any PSA performed in this period could represent the baseline value without significant distortions.

Alternative approach of a Fibroepithelial polyp.

A 41-year-old male presented at Emergency Department (ED) with right flank pain associated with hematuria for 3 days. Patient had a previous history of nephrolithiasis. The physical examination and blood tests were normal. Urine analyses showed haematuria > 1.000.000/µL. After clinical evaluation, a computer tomography (CT) showed right ureteral dilata¬tion caused by a 5 mm proximal stone and a distal intraluminal mass of 8 cm in length. In this setting, an ureteroscopic biopsy was performed and revealed a large polypoid lesion histologically suggestive of fibroepithelial polyp. Due to technical difficulties (intraluminal mass length and technical issue for the passage of guidewire) and after discussing all available minimally invasive options, we opted for a laparoscopic approach. Instead of ureterectomy of the affected segment of the ureter, as classically performed, we proceeded with an ureterotomy, blunt dissection of the tumor and ureterolithotomy, with complete removal of the mass. This approach did not require ureteral anastomosis and the ureteral dilatation facilitated its primary closure. No complications occurred, even after 3 years of follow-up.

Premature ejaculation prevalence among young men who have sex with men: a cross-sectional study with internet users in the metropolitan region of São Paulo, Brazil.

Background: There are only a few studies about the prevalence and correlates of premature ejaculation (PE) among men who have sex with men (MSM). Aim: (1) To estimate PE prevalence according to 3 assessment methods: self-reported time from penetration to ejaculation (ejaculation latency time [ELT]); Premature Ejaculation Diagnostic Tool (PEDT); and a direct question about the self-perception of ejaculation as being normal, too early (premature), or retarded. (2) To assess the agreement of the 3 assessment methods and identify factors associated with PE according to each method and their combination. Methods: We evaluated data from 226 MSM who participated in a cross-sectional study about sexual behavior among men living in the metropolitan region of São Paulo, Brazil. They responded anonymously to an online survey between May 2019 and March 2020. We calculated the agreement of the 3 assessment methods and their association with other characteristics using logistic regression models. Outcomes: Outcomes included the prevalence of PE according to the assessment methods and the association measures (PE vs sociodemographic characteristics and sexual behavior). Results: The prevalence of PE among MSM was 21.2% (95% CI, 16.1%-27.1%) according to the PEDT, 17.3% (95% CI, 12.6%-22.8%) per self-report, and 6.2% (95% CI, 3.4%-10.2%) by estimated ELT ≤2 minutes. The agreement among the 3 assessments was fair (kappa, 0.31; 95% CI, 0.25-0.37; P < .001). Association with PE varied by assessment method: obesity and shorter time for ejaculation with anal sex vs masturbation were associated with PE according to the PEDT and ELT but not self-evaluation. Perception about ideal time to ejaculate ≤5 minutes increased the chance of PE based on ELT. Higher chances of self-reported PE were associated with trying to hold back ejaculation, and lower chances were associated with higher frequencies of masturbation. Clinical Implications: Combining tools to investigate PE allows the identification of characteristics associated with this condition and may result in improvement in the care of MSM. Strengths and Limitations: This anonymous online survey provided the privacy necessary for participants to respond freely about sensitive questions, with a low risk of social adequacy bias. However, as it was a secondary analysis of a larger study, it could not evaluate comorbidities (eg, erectile dysfunction, prostatitis, depression) and the use of condoms. Conclusion: The prevalence of PE among MSM is high and varies according to the instrument used for the assessment, and the agreement among the 3 assessments was only fair.

Spermatic cord torsion: a retrospective analysis.

OBJECTIVE: To evaluate the time interval and possible delay in transportation to referral units for the treatment of testicular torsion. METHODS: We retrospectively analyzed all cases of spermatic cord torsion surgically treated at a university hospital between January 2018 to December 2021. We evaluated the time intervals, including pain onset until the first presentation (D1), interhospital transference time (D2), pain onset until urological evaluation in a tertiary service (D3), urological evaluation until surgery (D4), and time from pain onset to surgical treatment (D5). We analyzed demographic and surgical data, orchiectomy rates, and time intervals (D1-D5). Torsions presented to the first medical presentation within 6h were considered early for testicular preservation. RESULTS: Of the 116 medical records evaluated, 87 had complete data for the time interval analysis (D1 to D5) and were considered the total sample. Thirty-three had D1 ≤6h, 53 had D1 ≤24h (includes patients in the D1 ≤6h subgroup), and 34 had D1 >24h. The median time intervals of the total samples and subgroups D1 ≤6h, D1 ≤24h, and D1 >24h were D1 = 16h 42min, 2h 43min, 4h 14min and 72h, D2 = 4h 41min, 3h 39min, 3h 44min and 9h 59min; D3 = 24h, 6h 40min, 7h and 96h; D4 = 2h 20min, 1h 43min, 1h 52min and 3h 44min; D5 = 24h 42min, 8h 03min, 9h 26min and 99h 10min, respectively. Orchiectomy rates of the total sample, subgroups D1 ≤6h, D1 ≤24h, and D1 >24h were 56.32%, 24.24% (p<0.01), 32.08% (p<0.01), and 91.18% (p<0.01), respectively. CONCLUSION: Late arrival at the emergency department or a long interhospital transference time determined a large number of patients who underwent orchiectomy. Thus, public health measures and preventive strategies can be developed based on the data from this study aiming to reduce this avoidable outcome.

Premature Ejaculation Among Internet Users Living in the Metropolitan Region of São Paulo, Brazil: A Cross-Sectional Comparison Between the Premature Ejaculation Diagnostic Tool (PEDT) and Patient-Reported Latency Time and Perception.

BACKGROUND: Premature ejaculation (PE) prevalence can vary according to different definitions, assessment methods and populational demographics and culture. AIMS: To investigate the differences between men classified as having "probable PE" (PEDT≥11), "possible PE" (PEDT = 9 or 10) or "no PE" (PEDT≤8) according to the Premature Ejaculation Diagnostic Tool (PEDT) criteria in regard to sociodemographic characteristics, and sexual and relational behavior. To assess the agreement of prevalence of PE according to 3 assessment methods: (i) the ejaculation latency time (ELT) according to the participant's memory; (ii) PEDT and (iii) a direct question about the self-perception of ejaculation as being normal, too early (premature) or retarded. METHODS: In this web-based cross-sectional study, men aged ≥ 18 years living in the metropolitan region of São Paulo, Brazil, responded anonymously to an online survey. We used multinomial regression to estimate the association between PE according PEDT criteria and other features and the kappa coefficient to estimate agreement between the assessment methods. OUTCOMES: Association between PEDT-PE, sociodemographic characteristics and sexual and relational behaviors; agreement between PEDT, ELT and self-perception of PE. RESULTS: Obesity, trying to hold back ejaculation, short or nonexistent foreplay and age <30 years were associated with PEDT ≥11. Men who considered that latency was shorter for oral, anal and vaginal sex than for masturbation were more likely to have probable PE according to PEDT. Possible PE (PEDT scores 9/10) was associated with trying to hold back ejaculation and considering time for ejaculation shorter for vaginal sex. There was fair agreement between assessments (kappa 0.39; CI:0.28 -0.42; P < .001). CONCLUSION: PE prevalence varies according to instruments and cut-offs used, with fair agreement between them. This finding shows that the methods evaluate different aspects of the EP syndrome and they must be combined to allow the discrimination between the different types of PE and treatments. Clinical approaches should consider the sexual behavior and relationship of the patient and their distress. dos Reis M de MF, Barros EAC, Monteiro L, et al. Premature Ejaculation Among Internet Users Living in the Metropolitan Region of São Paulo, Brazil: A Cross-Sectional Comparison Between the Premature Ejaculation Diagnostic Tool (PEDT) and Patient-Reported Latency Time and Perception. Sex Med 2022;10:100463.

Radiotherapy-related toxicity for localized prostate cancer: meta-analysis comparing conventional or moderately hypofractionated vs. ultrahypofractionated protocols.

BACKGROUND: To compare toxicities in relation to standard radiation treatments [conventional fractionation RT (CRT) and moderate hypofractionated RT (MRT)] with ultrahypofractionated RT (URT) in the treatment of patients with localized PCa. METHODS: A searched was performed in Medline, Embase, Cochrane CENTRAL, and LILACS to January 2020 for studies comparing URT to CRT and/or MRT in relation to genitourinary (GU) and gastrointestinal (GI) toxicity in the treatment of patients with localized PCa. URT, MRT and CRT were defined as protocols delivering a daily dose of ≥5 Gy, 2.4-4.9 Gy, and <2.4 Gy per fractions regardless total dose, respectively. RESULTS: Eight studies with 2929 patients with localized PCa were included in the analysis. These eight studies did not find any difference between URT and MRT/CRT groups in relation to acute GU toxicity (21.0% × 23.8%, RD -0.04; 95% CI -0.13, 0.06; p = 0.46; I2 = 89%) and acute GI toxicity (4.9% × 6.9%, RD -0.03; 95% CI -0.07, 0.01; p = 0.21; I2 = 79%). Six studies did not find any difference between URT and MRT/CRT groups in relation to late GU toxicity (3.9% × 4.7%, RD -0.01; 95% CI -0.03, 0.00; p = 0.16; I2 = 19%) and late GI toxicity (2.1% × 3.5%, RD -0.01; 95% CI -0.03, 0.00; p = 0.05; I2 = 22%). CONCLUSION: The present study suggests that acute GU/GI and late GU/GI toxicity are similar between URT and standard protocols. More studies with longer follow-ups directed to oncology outcomes are warranted before any recommendation on this topic.

Prostate cancer awareness in the city of São Paulo.

OBJECTIVE: To evaluate awareness of prostate cancer in the population of the city of São Paulo. METHODS: A total of 392 adults were randomly interviewed on public spaces in the city of São Paulo, and answered a questionnaire that addressed demographic questions and specific knowledge about the prostate cancer. A score was used to assess awareness of cancer in general, and of prostate cancer, considering satisfactory knowledge a score of 6 points. RESULTS: The mean age was 36.9 years (standard deviation of ±12.6) and 58.2% of participants were male. No previous contact with information related to prostate cancer was reported by 45.5% of participants. For these cases, a greater proportion was observed among men aged over 50 years. As to the score, the mean was 3.7 (standard deviation of ±1.3), with a positive correlation among higher scores, higher income and education level. Less than 5% of participants believed they should only search for prostate cancer screening when symptomatic. Finally, among the less frequent responses to risk factors for prostate cancer, is "ethnic origin" (2.8%). CONCLUSION: Even though most participants did not have a satisfactory score, the level of awareness demonstrated in this study seems superior to that of other populational series. Hence it suggested the assessed population understood some essential concepts in prostate cancer, such as the importance of screening and the follow-up. The efforts made by the Sociedade Brasileira de Urologia on educational campaigns partially explain this. However, working in some concepts, like identifying risk factors for prostate cancer, might optimize screening outcomes.

Accuracy of MRI-guided Versus Systematic Prostate Biopsy in Patients Under Active Surveillance: A Systematic Review and Meta-analysis.

This meta-analysis focuses on the accuracy of upgrading to clinically significant prostate cancer (PCa) by multiparametric magnetic resonance imaging-targeted biopsy (MRI-TB) versus systematic biopsy (SB). We searched the Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and Literatura Latino Americana em Ciências da Saúde databases through January 2020 for comparative, retrospective/prospective, paired-cohort, and randomized clinical trials with paired comparisons. The population consisted of patients with low-risk PCa in active surveillance with at least 1 index lesion on imaging. We evaluated the quality of evidence by using the Quality Assessment of Diagnostic Accuracy Studies-2 score. Group comparisons considered the differences between the area under the curve summary receiver operating characteristic curve in a 2-tailed method. We also compared the positive predictive value of the best single method (MRI-TB or SB) and the referral study test (combined biopsy, a combination of MRI-TB and SB). The meta-analysis included 6 studies enrolling 741 patients. The pooled sensitivity for the 2 groups was 0.79 (95% confidence interval, 0.74-0.83; I2 = 75%) and 0.67 (95% confidence interval, 0.63-0.74; I2 = 55.4%), respectively. The area under the curve for the MRI-TB and SB groups were 0.99 and 0.92 (P < .001), respectively. The positive predictive value for the MRI-TB and combined biopsy groups were similar. The accumulated evidence suggests better results for MRI-TB compared with SB. Therefore, use of MRI-TB alone may be preferable in patients in active surveillance harboring low-risk PCa.

The influence of testosterone suppression on HER2 immunoexpression in prostatic neoplastic tissue.

During initial risk assessments, the metastatic potential of prostate cancer (PCa) may not be fully considered. The tumor's multicentric origin, which is associated with genetic mutations, may explain existing treatment limitations. Investigating human epidermal growth factor receptor 2 (HER2) expression in patients with different stages of PCa may therefore increase understanding of the mechanisms associated with the development of castration resistance. The present study examined the association between HER2 expression and the histologic features of PCa subjected to radical prostatectomy (RP) and evaluated the role of testosterone suppression in HER2 expression. In group 1, specimens from individuals who underwent RP without prior neoadjuvant androgen deprivation therapy (ADT) were included (n=42). In group 2 (PCa with ADT), specimens from individuals who underwent RP and received neoadjuvant cyproterone acetate during distinct periods (200 mg daily for 1-24 months) were included (n=150; cohort derived from a previous study). Immunohistochemical expression of HER2 was associated with prognostic factors such as perineural invasion, extra-prostatic disease, T stage, serum prostate-specific antigen (PSA), angiolymphatic invasion and surgical margins. Univariate regression analysis indicated that perineural invasion, PSA, International Society of Urological Pathology, angiolymphatic invasion, margin, T stage and neoadjuvant ADT was associated with HER2 expression. Ordinal regression analysis indicated a significant effect of neoadjuvant ADT alone on HER2 expression (P<0.001). In addition, regression analysis indicated a significant effect of neoadjuvant ADT alone on HER2 expression (odd ratio=0.01; 95% CI, 0.00, 0.02; P<0.001). HER2 was expressed in PCa samples but was not associated with known prognostic factors. The use of short-acting ADT and the consequent blockage of testosterone effect may suppress the expression of HER2 in PCa cells.