Mesentery-Sparing Technique: a New Intracorporeal Approach for Urinary Diversion in Robot-Assisted Radical Cystectomy.

BACKGROUND: Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is associated with significant morbidity and mortality. We present an alternative technique that preserves the complete mesenteric vascularization during the isolation of the intestinal segment used in ICUD, including distal vessels. This approach aims to minimize the risk of ischemia in both the ileal anastomosis and the isolated loop at the diversion site. METHODS: This cohort study included 31 patients, both male and female, who underwent RARC with ICUD from February 2018 to November 2023, performed by a single surgeon. Intraoperative and postoperative complications data were retrieved for analysis, employing our proposed mesentery-sparing technique in all cases. The primary endpoint was the incidence of intraoperative and postoperative complications directly attributable to the mesentery-sparing approach in ICUD. Secondary endpoints included other postoperative variables not directly related to mesentery preservation, such as the incidence of postoperative ileus requiring parenteral nutrition and the duration of hospitalization. RESULTS: None of the patients experienced intraoperative or postoperative complications directly related to mesentery-sparing, such as intestinal fistulae or internal hernias. The median duration of hospitalization was 6 days, and postoperative ileus necessitating total parenteral nutrition occurred in 19% of the patients. Minor complications (Clavien-Dindo grades I-II) accounted for 27.6% of the cases and major complications (grades III-V) accounted for 20.6%. CONCLUSION: The mesentery-sparing technique outlined herein offers an alternative method for preserving the vascularization of intestinal segments and reducing the risk of intestinal complications in ICUD during RARC.

Ergonomic risk assessment of surgeon's position during radical prostatectomy: Laparoscopic versus robotic approach.

BACKGROUND AND OBJECTIVES: Radical prostatectomy (RP) is a definitive surgical therapy for localized prostate cancer. Evidence suggests that the poor ergonomics of surgeons during RP may lead to work-related musculoskeletal disorders and loss of productivity. Since each surgery modality has its physical demands, we compared the ergonomic risk between laparoscopic (LRP) and robotic-assisted (RARP) radical prostatectomy. METHODS: The study assessed the posture of 10 urological surgeons during LRP and RARP surgeries with the Rapid Entire Body Assessment (REBA) scale. RESULTS: We found that the RARP approach resulted in lower REBA scores over the LRP procedure. CONCLUSIONS: Robotic surgery improves body posture for the urological surgeon like in other medical specialties. However, the surgeons display harmful postures in both surgeries.

Patient's safety and satisfaction on same day discharge after robotic and laparoscopic radical prostatectomy versus discharge after 24 or 48 h: a longitudinal randomized prospective study.

BACKGROUND: There is a tendency of prompted global health systems to reduce the length of hospital stay without compromising patient safety or satisfaction. We evaluated the safety and viability of early discharge in patients undergoing minimally invasive radical prostatectomy (MIRP), as well as patient satisfaction with this strategy. METHODS: This longitudinal prospective study included 72 patients who underwent MIRP for prostate cancer. Three groups were performed according to the day of hospital discharge following surgery: same day (G1), first day after (G2), and second day after (G3). Satisfaction, adverse events, and readmission were analyzed for each group. Associations between clinicopathologic variables and same-day discharge were analyzed by comparing data between G1 patients who did and did not achieve same-day discharge. RESULTS: 16.7% of patients were not discharged according to randomization (10 randomized to G1). 80% of G1 patients who did not achieve same-day discharge had Gleason scores of 3 + 4 or 4 + 3, which were observed in 35.7% of patients discharged on the same day (P < 0.05). Average prostate weight was significantly lower in patients who achieved same-day discharge than in those who did not (P < 0.01). Univariable logistic regression points to Gleason scores of 3 + 4 or 4 + 3 as the main factors associated with unsuccessful same-day discharge (P < 0.05). There were no significant differences in satisfaction scores. CONCLUSIONS: Same-day discharge was both safe and feasible and does not appear to affect satisfaction in a subset of patients with prostate cancer. Surgeons should consider the Gleason score when determining whether same-day discharge is appropriate.

Role of salvage lymph node dissection in patients previously treated for prostate cancer: systematic review.

Prostate cancer is the most common invasive cancer in men. Radical prostatectomy (RP) is a definitive treatment option, but biochemical recurrence can reach 40%. Salvage lymphadenectomy is a relatively recent approach to oligometasis and has been rapidly diffused primarily due to improvement in imaging diagnosis and results showing possibly promising therapy. A systematic literature review was performed in March 2020, according to the PRISMA statement. We excluded studies with patients with suspicion or confirmation of visceral and / or bone metastases. A total of 27 articles were included in the study. All studies evaluated were single arm, and there were no randomized studies in the literature. A total of 1,714 patients received salvage lymphadenectomy after previous treatment for localized prostate cancer. RP was the most used initial therapeutic approach, and relapses were based on PET / CT diagnosis, with Coline-11C being the most widely used radiopharmaceutical. Biochemical response rates ranged from 0% to 80%. The 5 years - Free Survival Biochemical recurrence was analyzed in 16 studies with rates of 0% up to 56.1%. The articles do not present high levels of evidence to draw strong conclusions. However, even if significant rates of biochemical recurrence are not evident in all studies, therapy directed to lymph node metastases may present good oncological results and postpone the onset of systemic therapy. The long-term impact in overall survival and quality of life, as well as the best strategies for case selection remains to be determined.

Laparoscopic partial nephrectomy without clamping the renal pedicle.

INTRODUCTION: Renal cell carcinoma (RCC) accounts for about 2-3% of all malignancies in adults and 90-95% of renal neoplasms. Curative treatment is eminently surgical, the first reports describing the laparoscopic partial nephrectomy (LPN) date from the beginning of the 1990s since then LPN has been consolidated as a safe and reproducible procedure. In order to improve the results of the LPN in relation to the postoperative renal function, while retaining the benefits of minimally invasive surgery, some surgeons began to implement the technique of laparoscopic partial nephrectomy without renal pedicle clamping (LPNWRPC) in selected cases. OBJECTIVE: To compare the perioperative, oncological and functional results of patients submitted to LPN with renal pedicle clamping (LPNRPC) and LPNWRPC in the hospitals linked to our institution. MATERIAL AND METHOD: All patients' charts were submitted to LPN from January 2000 to January 2016. Data were collected and analyzed retrospectively, patients were divided into two groups: LPNRPC (RPC group) and LPNWRPC (WRPC group). RESULTS: Data from 177 patients submitted to LPN for renal neoplasms were collected, 88 patients (49.7%) in the RPC group and 89 (50.3%) in the WRPC group. Surgical margins were positive in 2.56% of patients in the RPC group and 3.70% in the WRPC group. There was no significant difference despite the technique applied. Clavien 3 or 4 postoperative complications occurred in five cases (5.68%) in the RPC group and three cases in the WRPC group (3.7%), with no significant difference between the groups. Patients in the RPC group developed higher levels of creatinine in the postoperative period (creatinine 1.01 ± 0.16 preoperative vs. 1.12 ± 0.18 postoperatively, p = 0.031) and worsened filtration rate (EGFR) (preoperative 79.18 ± 16.28 × 74.43 ± 21.06 post-operative, p = 0.017). DISCUSSION: Our casuistry agrees with the results of previous studies with regard to major bleeding in patients submitted to LPNWRPC when compared to those submitted to LPNWRPC. However, although bleeding and surgical time were higher in the WRPC group, there was no impact on patients' postoperative evolution regarding both the need for transfusion of blood products and serious complications. In the high-complexity tumors, the mean warm ischemia time (WIT) in the RPC group was higher, this was probably responsible for a better response in the WRPC group evolving patients with lower creatinine levels and better postoperative glomerular filtration rates. CONCLUSION: LPNWRPC has been shown to be equally effective, safe, feasible, with low blood transfusion rates and postoperative complications comparable to LPNRPC, and has similar oncological results. Main impact factor in long-term renal dysfunction is WIT, which can be completely eliminated with the use of LPNWRPC.

Prostate cancer screening among elderly men in Brazil: should we diagnose or not?

PURPOSE: Prostate cancer screening in the elderly is controversial. The Brazilian government and the National Cancer Institute (INCA) do not recommend systematic screening. Our purpose was to assess prevalence and aggressiveness of prostate cancer in men aged 70 years and above, on the first Latin American database to date. MATERIALS AND METHODS: Cross-sectional study (n=17,571) from 231 municipalities, visited by Mobile Cancer Prevention Units of a prostate-specific antigen (PSA) based opportunistic screening program, between 2004 and 2007. The criteria for biopsy were: PSA>4.0ng/ml, or PSA 2.5-4.0ng/ml with free/total PSA ratio ≤15%, or suspicious digital rectal examination findings. The screened men were stratified in two age groups (45-69 years, and ≥70 years). These groups were compared regarding prostate cancer prevalence and aggressiveness criteria (PSA, Gleason score from biopsy and TNM staging). RESULTS: The prevalence of prostate cancer found was 3.7%. When compared to men aged 45-69 years, individuals aged 70 years and above presented cancer prevalence about three times higher (prevalence ratio 2.9, p<0.01), and greater likelihood to present PSA level above 10.0ng/ml at diagnosis (odds ratio 2.63, p<0.01). The group of elderly men also presented prevalence of histologically aggressive disease (Gleason 8-10) 3.6 times higher (p<0.01), and 5-fold greater prevalence of metastases (PR 4.95, p<0.05). CONCLUSIONS: Prostate cancer screening in men aged over 70 may be relevant in Brazil, considering the absence of systematic screening, higher prevalence and higher probability of high-risk disease found in this age range of the population studied.

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.

External validation of nomogram to predict inguinal lymph node metastasis in patients with penile cancer and clinically negative lymph nodes.

INTRODUCTION: Penile cancer (PC) occurs less frequently in Europe and in the United States than in South America and parts of Africa. Lymph node (LN) involvement is the most important prognostic factor, and inguinal LN (ILN) dissection can be curative; however, ILN dissection has high morbidity. A nomogram was previously developed based on clinicopathological features of PC to predict ILN metastases. Our objective was to conduct an external validation of the previously developed nomogram based on our population. MATERIALS AND METHODS: We included men with cN0 ILNs who underwent ILN dissection for penile carcinoma between 2000 and 2014. We performed external validation of the nomogram considering three different external validation methods: k-fold, leave-oneout, and bootstrap. We also analyzed prognostic variables. Performance was quantified in terms of calibration and discrimination (receiver operator characteristic curve). A logistic regression model for positive ILNs was developed based on clinicopathological features of PC. RESULTS: We analyzed 65 men who underwent ILN dissection (cN0). The mean age was 56.8 years. Of 65 men, 24 (36.9%) presented with positive LNs. A median 21 ILNs were removed. Considering the three different methods used, we concluded that the previously developed nomogram was not suitable for our sample. CONCLUSIONS: In our study, the previously developed nomogram that was applied to our population had low accuracy and low precision for correctly identifying patients with PC who have positive ILNs.

Time between diagnosis and surgical treatment on pathological and clinical outcomes in prostate cancer: does it matter?

INTRODUCTION: Prostate cancer (PC) most of the time presents with an indolent course. Thus, delays in treatment due to any causes might not affect long-term survival and may not affect cancer cure rates. PURPOSE: In this study, we evaluated the effect of delay-time between PC diagnosis and radical prostatectomy regarding oncological outcomes: Gleason score upgrade on surgical specimen, pathologic extracapsular extension (ECE) on surgical specimen, and postoperative biochemical recurrence (BCR) on follow-up. METHODS: We evaluated PC patients who underwent radical prostatectomy (RP) regarding clinical and pathological findings and theirs respective interval between diagnosis and surgical treatment measured in days and months. We used univariate and multivariate logistic regression to evaluate the impact of interval-time. RESULTS: A total of 908 PC patients underwent RP between 2006 and 2014. Mean age was 61.5 years, the mean time-to-surgery was 191 days (> 6 months) and 187 (20.5%) patients had BCR, with a mean follow-up of 44 months. According to our analysis, no statistically significant maximum cut-off time interval between diagnostic biopsy and surgery could be established (p = 0.215). Regardless of interval-time: ≤ 6 months (56.5%), 6-12 months (38.5%), and > 12 months (5.1%) after biopsy, we found no time interval correlated with poor oncological outcomes. This study has several limitations. It was retrospective and had a mean follow-up of 4 years. Additional follow-up is necessary to determine whether these findings will be maintained over time. CONCLUSIONS: We showed that the time between diagnosis and surgical treatment did not affect the oncological outcomes in our study.

Robotic surgery in public hospitals of Latin-America: a castle of sand?

INTRODUCTION: There is no information about the evolution of robotic programs in public hospitals of Latin-America. OBJECTIVE: To describe the current status and functioning of robotic programs in Latin-American public hospitals since their beginning to date. METHODS: We conducted a survey among leading urologists working at public hospitals of Latin-America who had acquired the Da Vinci laparoscopic-assisted robotic system. Questions included: date the program started, its utilization by other services, number and kind of surgeries, surgery paying system, surgery related deaths, occurrence and reasons of robotic program interruptions and its use for training purposes. Medians and 25-75 centiles (IQR) were estimated. RESULTS: Since 2009, there are ten public hospitals of four Latin-American countries that acquired the Da Vinci robotic system. The median number of months robotic programs has been functioning without considering transitory interruption: 43 (IQR 35, 55). Median number of urologic and total surgeries performed: 140 (IQR 94, 168) and 336 (IQR 292, 621), respectively. The corresponding median number of urologic and total surgeries performed per month: 3 (IQR 2, 5) and 8 (IQR 5, 11). Median number of total surgeries performed per year per institution was 94 (IQR 68,123). The median proportion of urologic cases was 40% (IQR 31, 48), ranging from 24 to 66%. Five of ten institutions had their urology programs transitory or definitively closed due to the high burden costs. CONCLUSION: Adoption and development of robotic surgery in some public hospitals of Latin-America have been hindered by high costs.

Neovagina construction and continent cutaneous urinary reservoir using a previous orthotopic ileal neobladder.

Standard radical cystectomy (RC) in women involves removal of the distal ureters, bladder, proximal urethra, uterus, ovaries, and adjacent vagina. Furthermore, pelvic organ-preserving RC to treat selected women has become an accepted technique and may confer better postoperative sexual and urinary functions than standard RC, avoiding complications such as incontinence, prolapse, neobladder-vaginal fistula (NVF), and sexual dysfunction, without compromising oncological outcome. This article reports a different surgical approach: a patient who underwent a cutaneous continent reservoir and neovagina construction using a previous ileal orthotopic neobladder after RC. Patient presented no complications and she has no evidence of recurrent disease and is sexually active, with a satisfactory continent reservoir. This case is the first report of this procedure that was able to treat concomitant dyspareunia caused by short vagina and neobladder-vaginal fistula. In conclusion, standard radical cystectomy with no vaginal preservation can have a negative impact on quality of life. In the present case, we successfully treated neobladder fistula and short vagina by transforming a previous ileal orthotopic neobladder into two parts: a continent reservoir and a neovagina. However, to establish the best approach in such patients, more cases with long-term follow-up are needed.

Synchronous abdominal tumors: is combined laparoscopic surgery in a single approach a safe option?

BACKGROUND AND PURPOSE: Recent advances in cancer treatment have resulted in better prognosis with impact on patient's survival, allowing an increase in incidence of a second primary neoplasm. The development of minimally invasive surgery has provided similar outcomes in comparison to open surgery with potentially less morbidity. Consequently, this technique has been used as a safe option to simultaneously treat synchronous abdominal malignancies during a single operating room visit. The objective of this study is to describe the experience of two tertiary cancer hospitals in Brazil, in the minimally invasive treatment of synchronous abdominal neoplasms and to evaluate its feasibility and peri-operative results. MATERIALS AND METHODS: We retrospectively reviewed the data from patients who were submitted to combined laparoscopic procedures performed in two tertiary hospitals in Brazil from May 2009 to February 2015. RESULTS: A total of 12 patients (9 males and 3 females) with a mean age of 58.83 years (range: 33 to 76 years) underwent combined laparoscopic surgeries for the treatment of at least one urological disease. The total average duration of surgery was 339.8 minutes (range: 210 to 480 min). The average amount of intraoperative bleeding was 276.6mL (range: 70 to 550mL) and length of hospitalization was 5.08 days (range: 3 to 10 days). Two patients suffered minor complications regarding Clavien system during the immediate postoperative period. CONCLUSIONS: Combined laparoscopic surgery for the treatment of synchronous tumors is feasible, viable and safe. In our study, there was a low risk of postoperative morbidity.

Pelvic floor muscle training and electrical stimulation as rehabilitation after radical prostatectomy: a randomized controlled trial.

[Purpose] To investigate the effect of electrical stimulation and pelvic floor muscle training on muscle strength, urinary incontinence and erectile function in men with prostate cancer treated by radical prostatectomy. [Subjects and Methods] One hundred twenty-three males were randomized into 3 groups 1 month after RP: (G1, n=40) control; (G2, n=41) guideline: patients were instructed to perform three types of home exercises to strengthen the pelvic floor and (G3, n=42) electrical stimulation: patients in this group were also instructed to perform exercises as group G2, and also received anal electro-stimulation therapy, twice a week for 7 weeks. The primary outcome assessment was based on the measurement of the recovery of pelvic floor muscle strength between groups. Secondary outcomes were: 1 hour Pad Test, ICIQ-SF, IIEF-5 and IPSS. Data were obtained preoperatively and at 1, 3 and 6 months after surgery. [Results] There was no significant difference in the demographic data among groups. Greater urinary leakage and pelvic floor muscle weakness in the first month compared to pre treatment improved after 3 and 6 months postoperative, without difference among groups. [Conclusion] The muscle strength recovery occurs independently of the therapy employed. Pelvic floor exercises or electrical stimulation also did not have an impact on the recovery of urinary continence and erectile function in our study.

Incremental value of MRI for preoperative penile cancer staging.

PURPOSE: To evaluate the incremental value of magnetic resonance imaging (MRI), compared to clinical examination, for penile cancer (PC) local staging. MATERIALS AND METHODS: Twenty-five consecutive patients with histologically proven PC were evaluated prospectively. MRI staging was performed on 1.5 and 3.0T scanners using high-resolution T2 -weighted and postcontrast T1 -weighted images. Two blinded observers interpreted MR images. Clinical local staging was performed by experienced urologists. The pathology report was used as the standard of reference. RESULTS: The interobserver agreement for MRI staging, using a kappa test for T-staging was moderate, 0.52 (95% confidence interval [CI] = 0.24-0.78), P = 0.001, although a high correlation for N-staging, 0.72 (95% CI = 0.42-1.00), P = 0.001, was detected. Clinical staging was correct in 52.0% (13/25) of patients. After pathological staging, five (20.0%) lesions were upstaged and seven (28.0%) lesions were downstaged compared to clinical examination. MRI accurately defined T-staging in 18/25 lesions (72.0%). After pathologic staging, five (20.0%) were upstaged and two downstaged (8.0%), compared to MRI. Fifteen patients were submitted to inguinal and pelvic lymphadenectomy and considered for comparison of accuracy of nodal staging by physical examination and MRI. Clinical staging accurately staged 7/15 patients (46.7%). After histopathologic analysis, six cases had nodal staging upgraded and two cases were downgraded. MRI correctly staged 13/15 (86.7%). Using a chi-square for comparison, differences in proportion of corrected staging between clinical examination and MRI were not significant for T-staging (P = 0.14), but were significant for nodal staging (P = 0.02). CONCLUSION: According to our results, MRI improves local staging of PC patients, particularly for those with limited physical examination. LEVEL OF EVIDENCE: 1 J. Magn. Reson. Imaging 2017;45:118-124.

Laparoendoscopic single-site retroperitoneoscopic adrenalectomy: bilateral step-by-step technique.

BACKGROUND: Laparoscopic adrenalectomy is the gold standard surgical approach for small benign adrenal tumors [1]. Several surgical approaches were developed in order to overcome the difficulty to access the adrenal glands, located in the upper retroperitoneum space [2-4]. Laparoendoscopic single-site posterior retroperitoneoscopic adrenalectomy (LESS-PRA) is an emerging technique that reduced the multiple trocar-related trauma and improved cosmetic outcomes while minimizing postoperative morbidity [5-8]. The aim of this study was to describe our step-by-step technique for LESS-PRA and to compare our perioperative outcomes with the conventional 3-port lateral retroperitoneoscopic adrenalectomy (LRA). METHODS: A retrospective review was carried out from February 2008 to January 2016 that included 100 patients with adrenal tumors smaller than 4 cm. Study exclusion criteria were defined as tumor size greater than 4 cm, patients older than 80 years, and body mass index (BMI) greater than 40. A total of 20 patients underwent LESS-PRA and 80 patients underwent 3-port lateral retroperitoneoscopic laparoscopic adrenalectomy. Patient's demographic data and perioperative outcomes were compared and statistically analyzed. The cosmetic satisfaction was evaluated with a visual analog scale. RESULTS: Estimated blood loss was higher in LRA (100 vs. 50 ml; p = 0.35). Operative time was longer in LESS-PRA than LRA (100.0 vs. 60 min; p < 0.001). Analgesic time necessary for LRA was longer than LESS-PRA (40 vs. 24 h; p < 0.001). Cosmetic satisfaction score was higher in LESS-PRA (9.5 vs. 8.6; p = 0.03). There were no significant differences in perioperative complications and length of hospital stay. No conversion to conventional laparoscopic or open surgery was necessary. CONCLUSION: LESS-PRA presented comparable functional and perioperative outcomes to LRA for small adrenal tumors. Although LESS-PRA was associated with longer operative time, it provided inferior estimated blood loss, analgesic time, and improved cosmetic satisfaction.

LHRH analog therapy is associated with worse metabolic side effects than bilateral orchiectomy in prostate cancer.

PURPOSE: The morbidity associated with metabolic syndrome induced by androgen deprivation therapy (ADT) in prostate cancer (PCa) has not been widely studied. There are no studies comparing surgical and pharmacological castration with regards to their metabolic side effects. The aim of this study was to compare both modalities. METHODS: A prospective observational study was conducted in men with PCa and with indications of any ADT. The participants were divided into two groups: (1) bilateral orchiectomy and (2) LHRH analogs. The metabolic profile was assessed before and during the period of ADT. Bioelectrical impedance analysis (BIA) and bone mineral density were measured before and after 6 months of treatment. The data were analyzed using the Chi-squared test, Student's t test, Bonferroni's test, and ANOVA. RESULTS: We enrolled 102 men for analysis, of whom 46 (54.9 %) had been subjected to bilateral orchiectomy and 56 (54.9 %) had been subjected to treatment with LHRH analogs. The basal metabolic profile, body mass index, and BIA were similar between the two groups. The oncologic control (PSA and testosterone) was also similar in both groups. In the intergroup comparison, insulin resistance (p = 0.044) and hemoglobin (p = 0.001) were worse in the group that used LHRH analogs, which was mainly diabetic patients (p = 0.007). CONCLUSION: This study showed that LHRH analogs had worse effects relative to insulin resistance, mainly in diabetic patients, and induced more anemia and bone demineralization compared to surgical castration. Further prospective, randomized, and comparative studies are needed for metabolic syndrome in ADT modalities.