"Non-metastatic, Castration-resistant Prostate Cancer: Diagnostic and Treatment Recommendations by an Expert Panel from Brazil".

INTRODUCTION: Non-metastatic, castration-resistant prostate cancer (nmCRPC) is an important clinical stage of prostate cancer, prior to morbidity and mortality from clinical metastases. In particular, the introduction of novel androgen-receptor signaling inhibitors (ARSi) has changed the therapeutic landscape in nmCRPC. Given recent developments in this field, we update our recommendations for the management of nmCRPC. METHODS: A panel of 51 invited medical oncologists and urologists convened in May of 2021 with the aim of discussing and providing recommendations regarding the most relevant issues concerning staging methods, antineoplastic therapy, osteoclast-targeted therapy, and patient follow-up in nmCRPC. Panel members considered the available evidence and their practical experience to address the 73 multiple-choice questions presented. RESULTS: Key recommendations and findings include the reliance on prostate-specific antigen doubling time for treatment decisions, the absence of a clear preference between conventional and novel (i.e., positron-emission tomography-based) imaging techniques, the increasing role of ARSis in various settings, the general view that ARSis have similar efficacy. Panelists highlighted the slight preference for darolutamide, when safety is of greater concern, and a continued need to develop high-level evidence to guide the intensity of follow-up in this subset of prostate cancer. DISCUSSION: Despite the limitations associated with a consensus panel, the topics addressed are relevant in current practice, and the recommendations can help practicing clinicians to provide state-of-the-art treatment to patients with nmCRPC in Brazil and other countries with similar healthcare settings.

Wünderlich Syndrome in Renal Transplant Recipients: A Case Report and Literature Review.

BACKGROUND: Wünderlich syndrome, or spontaneous atraumatic renal hemorrhage, is a clinical entity rarely described in the native kidney of patients who have undergone renal transplant. Although its manifestation is quite similar in reported cases, it may present few symptoms, from bleeding of unidentified etiology to dramatic pictures associated with hypovolemic shock. There are few reports of spontaneous hemorrhage of a native kidney after kidney transplantation. CASE REPORT: We present a 38-year-old male patient who developed hemorrhage of a ruptured native kidney after a late renal transplantation. We analyze what has been reported in the literature and highlight the possibility of this complication after kidney transplantation. Imaging exams and surgical specimen demonstrated the presence of ruptured angiomyolipoma in the patient's native right kidney. The postoperative period was not complicated, with a benign clinical evolution. CONCLUSION: Although rare in patients who have undergone renal transplant, it is justified to suggest Wünderlich syndrome in the presence of acute flank pain, abdominal tenderness, and signs of internal bleeding (Lenk's triad), with unexplained hemoglobin drop.

Rate of spontaneous voiding recovery after acute urinary retention due to bed rest in the hospital setting in a non-urological population clinical study of the relationship between lower limbs and bladder function

Abstract Objectives To understand the clinical relationship between lower limbs functions and the recovery of spontaneous voiding after an acute urinary retention (AUR) in older patients admitted to hospitals for non-urological causes using clinical parameters. Materials and Methods 56 adult patients (32 men; mean age: 77.9 ± 8.3 and 24 women; mean age 82.1 ± 4.6) with AUR were prospectively followed with validated Physical Performance Mobility Exam (PPME) instrument to evaluate the relationship between the recovery of mobility capacity and spontaneous voiding. After a short period of permanent bladder drainage patients started CIC along evaluation by PPME during hospitalization and at 7, 15, 30 60, 90, and 180 days of discharge. Mann-Whitney U, chi-square test and ANOVA tests were used. Results All patients were hospitalized for at least 15 days (Median 26.3 ± 4.1 days). Progressive improvement on mobility scale measured by PPME was observed after leaving ICU and along the initial 7 days of hospitalization but with a deterioration if hospitalization extends beyond 15 days (p<0.03). Prolonged hospital stay impairs mobility in all domains (p<0.05) except step-up and transfer skills (p<0.02) although a recovery rate on spontaneous voiding persistented. Restoration of spontaneous voiding was accompanied by improvement on mobility scale (p<0.02). Recovery of spontaneous voiding was markedly observed after discharging the hospital. All patients recovered spontaneous voiding until 6 months of follow-up. Conclusions Recovery to spontaneous voiding after acute urinary retention in the hospital setting may be anticipated by evaluation of lower limbs function measured by validated instruments.

One hundred cases of sui treatment that failed: a prospective observational study on the behavior of patients after surgical failure

Objectives Determine what happens to patients after unsuccessful SUI operations and to explore the reasons why these patients change doctors. Materials and Methods One hundred consecutive failed patients treated for SUI were interviewed about the exams requested after persistence of the incontinence as well as the reasons they abandoned their primary doctors through a structured questionnaire. Results Among the patients with cases of anterior colporrhaphy, bladder suspensions or slings, 34.3%, 13.7% and 8.3%, respectively, were not offered any further type of investigative procedures to clarify the failure. Urodynamic evaluations were recommended in 75% of failed slings, and 66.6% of the patients proceeded with these tests. In contrast, only 31% of patients with bladder suspensions and 40% of patients with anterior colporrhaphy were recommended for urodynamic investigations, and only 44.4% and 28.5% of them, respectively, proceeded with the option. Patients´ delusions were reinforced by the doctors’ attitude toward the investigations. Vacuous justifications and the lack of intention to seek improvement were the driving forces causing the patients to change doctors. Conclusion Unsuccessful patients are evaluated in a non-protocol form. Difficulty in clarifying the reasons for surgical failure and the disruption of the doctor-patient relationship are the main reasons why patients abandon them. .

Slings may not fail as frequently as believed for stress urinary incontinence: the misinterpretation of postoperative voiding dysfunction as failure based on patient report.

OBJECTIVE: : Sling operations may obstruct the urethra, promoting voiding dysfunction and secondary urine leakage that are incorrectly attributed to surgical failure. METHODS: : We prospectively evaluated the evolution of urinary symptoms in the postoperative follow-up of 108 polypropylene sling cases. Patients presented for follow-up at 1, 3, 6, 12, 18, 24, 36, and 48 months for review of individual urinary symptoms. Statistical analysis used Fisher exact test. RESULTS: : On the 30th postoperative day, 100% of the cases were cured of stress urinary incontinence, although frequency (62.9%), urgency (29.6%), urge-incontinence (23.1%), nocturia (28.6%), incomplete voiding sensation (11.1%), and poor stream (11.1%) persisted. At 3 months, 16.6% reported frequency, 38% complained of urgency, and 29.6% were troubled by nocturia. True urinary leakage under stress was resolved in 100% of cases by the first visit and did not show any further decrease when specifically questioned. Pad usage decreased after 3 months but did not completely disappear after 48 months. A total of 94.4% of the cases achieved total continence and clinical satisfaction after 4 years of follow-up, in parallel with the steady disappearance of voiding dysfunction observed in the early postoperative period. CONCLUSIONS: : Voiding dysfunction after sling procedures is frequent but transitory. As symptoms improve or disappear, patients tend to miss their follow-up. In this study, 94.4% of the cases had complete dryness and satisfaction with the operation.

Pubo-fascial versus vaginal sling operation for the treatment of stress urinary incontinence: a prospective study.

AIMS: To compare the long-term results of stress urinary incontinence (SUI) treatment involving the fascial or vaginal sling operations. MATERIAL AND METHODS: Two-hundred-thirty-two women were consecutively submitted to fascial or vaginal sling operations due to urodynamic proven SUI. The fascial group had a median age of 47.3 years with a parity of 2.2 and 1.8 surgeries/patient, while the vaginal group demonstrated a median age of 48.5 years with a median parity of 3.1 and 2.2 anterior surgeries/patient. The results were subjectively classified as cured--no further pads, greatly improved--very rare dribbling, improved--eventual dribbling necessitating one pad, no cure--with no urine loss change and worse. The number of pads/day, the presence of urgency or urge-incontinence episodes were all measured. Statistical analysis using Fisher's exact test was employed. RESULTS: The patients were followed up for an average time of 70.3 and 44.9 months, in the fascial and vaginal sling group respectively. Subjective clinical success rate was 93.7% for the fascial sling group and 79.8% for the vaginal one, however, the stratification of the results favored the fascial sling group mostly with 74.4% (94 cases) of the cases with total urinary control and no voiding dysfunctions. Only two cases (1.6%) in this group classified themselves as worsened. On the other hand, the vaginal sling subset revealed cure with total clinical satisfaction and no urinary complaint in 61.5% (62 females) (P > 0.05). Thirteen cases (12.5%) reported recurrence of the urine loss under stress and these constituted the failure group. The average number of pads diminished from 3.3 (+/- 0.8) to 0.2 (+/- 0.2) and from 3.2 (+/- 0.7) to 0.6 (+/- 0.5) after the surgery, for the fascial and vaginal sling operations respectively. Return to daily activities occurred after 9.3 days (+/- 1.2, max: 33, min: 2) for the fascial slings and 5.3 days (+/- 0.2, max: 17, min: 2) in the vaginal group. Surgical complications were compared between the groups. Time to urethral voiding varied according to expertise, demonstrating a diminishing tendency after the initial 20 cases. Female obstruction was observed in 11.1% of the fascial slings and 8.6% after vaginal approach, but none in the vaginal group required urethrolysis. Looking individually, the FS group migrated to the worse results while the VWS group started to lose the efficiency after 6 months. CONCLUSIONS: Sling operations are a safe and efficacious option to treat SUI, however, the results can vary according to the technique employed. Shorter efficacy and fewer complications are observed in vaginal wall sling operations, while durable results, but with a higher rate of voiding dysfunctions compromising the long-term clinical satisfaction may be observed after excessive urethral suspensions, as in fascial sling suspension.

A randomized and prospective study on the value of antibiotic prophylaxis administration in transurethral resection of the prostate

CONTEXTO: A profilaxia antibiótica nas ressecções transuretrais da próstata é uma prática regular e freqüente na clínica urológica. No entanto, seu efeito profilático e bactericida protetor pode ser contestado se procedimentos assépticos são utilizados na realização da cirurgia, sobretudo em pacientes com urina estéril. No caso de infecção urinária, a identificação dos germes para escolha do antibiótico adequado pode ser necessária. OBJETIVO: Verificar a eficácia da antibioticoprofilaxia em pacientes com urina estéril submetidos a ressecção transuretral de próstata. TIPO DE ESTUDO: Prospectivo num centro de referência de tratamento urológico, aberto. LOCAL: Hospital de referência terciária. PARTICIPANTES: 124 pacientes. VARIÁVEIS ESTUDADAS: 124 pacientes consecutivos foram randomicamente divididos em dois grupos para receber ou não antibioticoterapia profilática na ressecção transuretral de próstata. Cultura do meato uretral, urina, líquido irrigante e anti-séptico, além dos fragmentos de próstata ressecados foram analisados quanto a sensibilidade a antibióticos, escolhidos a critério do cirurgião, e determinada a partir de antibiograma com as cepas bacterianas identificadas nos sítios mencionados. RESULTADOS: Não se encontrou diferença estatisticamente significante na evolução clínica de ambos os grupos. Aqueles que receberam antibioticoprofilaxia apresentaram menor freqüência de cultura urinária positiva do que aqueles que não receberam profilaxia. No entanto, na observação da evolução clínica de ambos os grupos, o uso de antibiótico não mostrou qualquer benefício no que concerne à ocorrência de febre, positividade das culturas obtidas dos fragmentos de próstata ressecados ou episódios de bacteremia. 68 casos (57,1%) apresentaram cultura positiva do tecido prostático. Entretanto, não houve correlação entre a bactéria identificada a partir do tecido prostático e de outros locais, tais como meato, urina, líquido irrigante ou anti-séptico utilizado. Somente em seis casos foi encontrada a mesma bactéria no tecido prostático e na urina pós-operatória. Apenas em 15 casos (25%) do grupo antibiótico observou-se a sensibilidade esperada da bactéria identificada ao antibiótico utilizado...

Qualidade de vida relacionada à saúde em paciente transplantado renal / Health-related quality of life in renal transplant patients

Introdução :Diálise e transplante renal são as opções atuais para o tratamento de pacientes com insuficiência renal crônica avançada. Embora a taxa de sobrevida seja usada para avaliar o sucesso destas terapias, a importância da percepção do paciente quanto sua qualidade de vida relacionada (QDV) à saúde é bem reconhecida. Objetivo : Avaliar a QDV de pacientes transplantados renais, comparados a uma população mantida em programa de hemodiálise e a pessoas normais. Métodos: Foram estudados 72 pacientes com boa evolução após transplante renal, utilizando o instrumento genérico SF-36 (Medical Outcome Survey - Short-Form 36, Rand Corp, EUA), auto-aplicado, traduzido e validado para o português. Este instrumento avalia a QDV relacionada à saúde abordando seus oito conceitos: capacidade funcional (CF), aspectos físicos (AF), dor física (DF), estado geral de saúde (SG), vitalidade (VT), limitações sociais (AS), limitações emocionais (AE) e aspectos mentais (AM). Como controle, foram comparados os resultados obtidos nos pacientes transplantados renais com uma população sadia (58 pessoas) e outra composta de pacientes mantidos em hemodiálise (43 pacientes). Resultados :Os pacientes transplantados tinham idade média de 40,8± 12,1 anos (var.: 1 7 a 66 anos), sendo 37 masculinos, transplantados há 33,6±26,7 meses (var.: 1 a 133 m), todos com creatinina sérica inferior a 2,0 mgldi e em uso de imunosupressores. Seis eram diabéticos. Os questionários foram respondidos pelos pacientes sem interferência da equipe de saúde, não havendo relato de dificuldades e com somente oito dos 2.592 quesitos deixados sem respostas (0,3 por cento). Conclusão : Conclui-se que o instrumento SF-36 foi de fácil apliacção, com excelente retorno de respostas. Os pacientes transplantados ernais apresentaram escores do SF-36 superiores aos de urêmicos em hemodiálise e masi próximos aos de indivíduos sadios, demonstrando que o transplante renal alcançou seu objetivo de melhorar a reabilitação física , emntal e social dos pacientes.

Lymphocele: a possible relationship with acute cellular rejection in kidney transplantation

CONTEXT: The incidence of lymphocele after renal transplantation varies between 0.6 and 18 percent of cases, and many factors have been associated to its etiology. Cellular rejection of the kidney allograft has been described as a possible causal factor of lymphocele. OBJECTIVE: To analyze the possible relationship between lymphocele and acute cellular rejection. DESIGN: A retrospective study. SETTING: A referral hospital center. SAMPLE: 170 patients submitted to kidney transplantation from March 1992 to January 1997. A standard technique for renal transplantation was used. RESULTS: Of the 19 patients that developed lymphocele, 16 presented at least one episode of acute cell rejection (84 percent), and were treated with methylprednisolone. The relation between lymphocele and rejection was statistically significant (p = 0.04). Treatment of lymphocele consisted of peritoneal marsupialization in 3 patients (15.3 percent), percutaneous drainage in 7 (36.8 percent), laparascopic marsupialization in 2 (10.5 percent), and conservative treatment in 7 patients (36.8percent. Evolution was favorable in 15 patients (78.9 percent), 1 patient (5.3 percent) died due to a cause unrelated to lymphocele, and 3 (15.8 percent) lost the graft due to immunological factors. The average follow-up period was 24.5 months. CONCLUSION: The high incidence of acute cell rejection in patients with lymphocele suggests a possible causal relationship between both conditions

Extrofia de bexiga: reconstruçäo vesical ou derivaçäo primária? Resultados do Pouch Sigmóide-Reto (Mainz Pouch II) / Bladder exstrophy: reconstruction of the bladder neck or primary diversion? Results of the sigma-rectum pouch (Mains Pouch II)

Os autores discutem as opçöes para o tratamento cirúrgico da extrofia da bexiga, confrontando os procedimentos de reconstruçäo vesical com a derivaçäo urinária primária. Apresentam a seguir resumidamente a técnica operatória do pouch sigmóide-reto (Mainz Pouch II) e os resultados de 17 pacientes com extrofia de bexiga submetidos a esta cirurgia. Ausência de complicaçöes perioperatórias e índices de continência de 92,8 por cento foram obtidos como resultados

Analise de sobrevida de 487 pacientes com transplantes renais / Survival analysis of 487 patients with kidney transplantation

O objetivo do presente trabalho foi analisar as perdas do enxerto, apos transplante renal em um grupo de 487 transplantes, sendo doador vivo relacionado 252 (51,46 por cento), doador cadaver 139 (28,5 por cento) e doador vivo nao relacionado 96 (19,7 por cento), feitos entre janeiro de 1986 a maio de 1990. Um total de 74 rins foi perdido nos primeiros tres meses pos transplante (15,19 por cento). Trinta e quatro casos por causa imunologica (45,9 por cento), 21 casos (28,3 por cento) por obito do paciente e 19 casos (25,7 por cento) por causa tecnica. Quanto ao doador a percentagem de perdas foi 9,52 por cento doador vivo relacionado, 24,46 por cento doador cadaver e 16,66 por cento doador vivo nao relacionado. Das 34 perdas por causas imunologicas, estas foram rejeicao de carater humoral 32 casos (rejeicao vascular aguda 11 casos, rejeicao humoral tardia 11 casos e rejeicao humoral imediata 9 casos), rejeicao celular aguda foi observada em um unico caso. Nenhum paciente faleceu por perda do enxerto por causa imunologica. A causa mais frequente dos 21 obitos foi sepsis (13 casos) e o foco mais comum foi pulmonar (5 casos). Quanto ao doador foi mais frequente no doador cadaver 10,07 por cento e somente 1,98 por cento no doador vivo relacionado e 2,08 por cento no doador vivo nao relacionado...

Cotrimazina no tratamento das infecçöes urinárias / Cotrimazine in the treatment of urinary tract infections

A associaçäo de 820 mg de sulfadiazina com 180 mg de trimetoprina foi utilizada, em dose única diária, em 20 pacientes portadores de infecçäo do trato urinário. A medicaçäo foi bem tolerada e näo se observou quaisquer tipos de reaçöes adversas que obrigassem a interrupçäo do tratamento. Os controles da funçäo hepática, renal e hematológica näo apresentaram variaçöes significativas. Quanto à eficácia do tratamento, os resultados obtidos foram: 80% excelentes, 15% bons e 5% regulares. Estes dados permitem concluir que a cotrimazina é uma excelente alternativa terapêutica para as infecçöes do trato urinário

Evaluación de los pacientes con tercer trasplante renal / Evaluation of patients with the third kidney transplantation

Se analiza la experiencia con 6 pacientes a los que se les efectuaron 3 injertos renales detallando las causas del fracaso de los anteriores, los aspectos quirúrgicos y su posterior evolución. Si bien la casuística es pequeña, queda demostrado que se trata de una conducta válida con evolución satisfactoria tanto desde el punto de vista clínico como quirúrgico

Implantaçäo ureterovesical invaginante no restabelecimento do trato urinário em homotransplante renal: experiência com 250 casos / Ureterovesical implantation with invagination in the repair of the urinary tract in homologous transplantation: experience with 250 cases

Em 250 homotransplantes renais a reconstruçäo do trato urinário foi realizada pela implantaçäo extra vesical com invaginaçäo da anastomose sob musculatura íntegra da bexiga. Nesta operaçäo a anastomose é realizada com fácil apresentaçäo o que permite suturas herméticas e, o posicionamento destas sob um túnel submucoso suturas diminui as possibilidades de deiscências e extravazamento de urina. Os índices de complicaçöes foram consideravelmente baixos: fístulas 1,2%, refluxo 0,8% e estenose 0,4%. Esta técnica, pela facilidade de realizaçäo, e pelos resultados obtidos nos parece ser uma boa alternativa no restabelecimento urinário do transplante renal

Estudo comparativo da pressäo arterial peniana e potência sexual em pacientes submetidos a transplante renal único ou múltiplo / Comparative study of penile arterial pressure and sexual potency in patients subjected to single or multiple renal transplantation

Foram estudados comparativamente 28 pacientes submetidos a transplante renal único (Grupo I - 16 pacientes) e múltiplo (Grupo II - 12 pacientes), utilizando-se respectivamente a artéria hipogástrica uni ou bilateralmente. Estes dois grupos foram analisados quanto a pressäo arterial peniana e potência sexual. Observou-se contrariando alguns dados de literatura näo haver variaçäo estatisticamente significante nos parâmetros estudados entre os pacientes do Grupo I e II

Pielovesicoanastomose no transplante renal / Pyelovesical anastomosis in renal transplantation

Relata-se um caso de correçäo de fístula urinária pós-transplante renal. A vesicopieloanastomose foi feita com técnica original em que o emprego da sonda de Guyon-Beniqué tornou a operaçäo mais simples e mais rápida

Cirurgia endourológica em rim transplantado / Endorological surgery in transplanted kidney

Os autores apresentam quatro casos de abordagem endourológica de rim enxertado. O método mostrou-se satisfatório em três casos e falhou em um caso. Descreveu-se a técnica e comentam-se os resultados desta nova via de acesso à via excretora de rins transplantados