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PURPOSE: We aimed to report the morbidity profile of salvage radical prostatectomy (SRP) after radiotherapy failure and assess the impact of minimally invasive surgery (MIS) on postoperative complications and functional outcomes. MATERIALS AND METHODS: Between 1985 and 2019, a total of 293 patients underwent SRP; 232 underwent open SRP; and 61 underwent laparoscopic SRP with or without robotic assistance. Complications were recorded and classified into standardized categories per the Clavien-Dindo classification. RESULTS: Twenty-nine patients (10%) experienced grade 3 complications within 30 days, 22 (9.5%) after open and 7 (11%) after MIS (p = 0.6). Between 30 and 90 days after surgery, 7.3% of patients in the open group and 10% in the MIS group had grade 3 complications (p = 0.5). The most common complication was bladder neck contracture (BNC), representing 40% of the 30-90 day complications. Within one year of SRP, 81 patients (31%, 95% CI 25%, 37%) developed BNC; we saw non-significant lower rates in MIS (25 vs 32%; p = 0.4). Functional outcomes were poor after SRP and showed no difference between open and MIS groups for urinary continence (16 vs 18%, p = 0.7) and erectile function (7 vs 13%, p = 0.4). 5 year cancer-specific survival and overall survival was 95% and 88% for the entire cohort, respectively. CONCLUSIONS: Our outcomes suggest poor functional recovery after SRP, regardless of the operative approach. Currently there is no evidence favoring the use of open or MIS approach. Further studies are required to ensure comparable outcomes between these approaches.
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Prostatectomía , Terapia Recuperativa , Humanos , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos , Morbilidad , Próstata/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVE: To examine a set of proposed eligibility factors for hemi-ablative focal therapy in prostate cancer and to determine the likelihood of residual extensive disease. METHODS: We retrospectively analyzed data from 98 patients with unilateral prostate cancer on biopsy with detailed tumor maps from whole-mount slides and preoperative magnetic resonance imaging data. These patients met the focal therapy consensus meeting inclusion criteria (prostate-specific antigen <15 ng/mL, clinical stage T1c-T2a and Gleason score 3 + 3 or 3 + 4 on needle biopsy), and underwent radical prostatectomy between 2000 and 2014. Extensive disease was defined as having Gleason pattern 4/5 in bilateral lobes, any extraprostatic extension, seminal vesicle invasion or lymph node invasion. Both lobes of the prostate were scored on magnetic resonance imaging. Preoperative characteristics including biopsy and magnetic resonance imaging data were used to predict extensive disease. RESULTS: Among our cohort of 98 patients, 40% (95% CI 30-50%) had extensive disease. A total of 33% (95% CI 24-43%) had Gleason pattern 4/5 in both lobes with a median Gleason pattern 4/5 tumor volume in the biopsy negative lobe of 0.06 cm3 , 17 patients had pathological tumor stage ≥3 and one patient had lymph node invasion. CONCLUSIONS: An important number of patients meeting the focal therapy consensus meeting inclusion criteria can present extensive disease. Further studies using targeted biopsies might provide more accurate information about the selection of focal therapy candidates.
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Antígeno Prostático Específico , Neoplasias de la Próstata , Humanos , Masculino , Clasificación del Tumor , Estadificación de Neoplasias , Prostatectomía , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/cirugía , Estudios RetrospectivosRESUMEN
OBJECTIVE: To investigate the effectiveness of combination treatment of vascular targeted photodynamic therapy and anti-cytotoxic T-lymphocyte-associated antigen 4 immunotherapy in a mouse model of urothelial carcinoma. METHODS: We used C57BL/6 mice injected with murine bladder 49 cell line. Mice were randomly allocated into four treatment groups: vascular targeted photodynamic therapy only, anti-cytotoxic T-lymphocyte-associated antigen 4 only, combination therapy and control. We carried out three separate experiments that used distinct cohorts of mice: tumor growth and development of lung metastases monitored with bioluminescent imaging (n = 91); survival evaluated with Kaplan-Meier curves (n = 111); and tumor cell population studied with flow cytometry (n = 20). In a fourth experiment, we re-challenged tumors in previously treated mice and compared tumor growth with that of naïve mice. RESULTS: Combination therapy provided significant benefits over the other three treatment groups: prolonged survival (P < 0.0001), lower tumor signal (P < 0.0001) and decreased lung signal uptake (P ≤ 0.002). We also observed that mice previously treated with vascular targeted photodynamic therapy only or combination therapy did not present tumor growth after re-challenged tumors. CONCLUSIONS: Combination of vascular targeted photodynamic therapy with anti-cytotoxic T-lymphocyte-associated antigen 4 is an effective therapy in a urothelial carcinoma syngeneic mouse model. The present results suggest this therapy as a potential treatment option for both bladder and upper tract tumors in future clinical trials.
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Antígeno CTLA-4/antagonistas & inhibidores , Carcinoma de Células Transicionales/terapia , Neoplasias Pulmonares/tratamiento farmacológico , Fotoquimioterapia/métodos , Neoplasias de la Vejiga Urinaria/terapia , Animales , Antígeno CTLA-4/inmunología , Carcinoma de Células Transicionales/irrigación sanguínea , Carcinoma de Células Transicionales/inmunología , Carcinoma de Células Transicionales/secundario , Línea Celular Tumoral/trasplante , Modelos Animales de Enfermedad , Humanos , Mediciones Luminiscentes , Pulmón/irrigación sanguínea , Pulmón/diagnóstico por imagen , Pulmón/efectos de los fármacos , Pulmón/efectos de la radiación , Neoplasias Pulmonares/irrigación sanguínea , Neoplasias Pulmonares/inmunología , Neoplasias Pulmonares/secundario , Masculino , Ratones , Ratones Endogámicos C57BL , Vejiga Urinaria/irrigación sanguínea , Vejiga Urinaria/efectos de los fármacos , Vejiga Urinaria/inmunología , Vejiga Urinaria/efectos de la radiación , Neoplasias de la Vejiga Urinaria/irrigación sanguínea , Neoplasias de la Vejiga Urinaria/inmunología , Neoplasias de la Vejiga Urinaria/patologíaRESUMEN
BACKGROUND: A growing number of men undergo repeat biopsies prior to radical prostatectomy for prostate cancer. However, the long-term impact of repeat biopsies on functional outcomes in this patient population remains unelucidated. Thus, we compared functional outcomes between patients who underwent single biopsy versus repeat biopsies before radical prostatectomy. METHODS: From 1996 to 2015, 1015 consecutive patients underwent radical prostatectomy, and subsequently had urinary continence and erectile function assessed for >2 years follow-up. One-fourth of patients (275; 27%) had ≥2 biopsies before prostatectomy. Logistic regression models tested whether repeat biopsy before prostatectomy predicted continence or erectile function recovery. RESULTS: For the overall cohort, continence rates were 84%, 92%, 96%, and 98% at 3, 6, 12, and 24 months, respectively. Repeat biopsy before prostatectomy was associated with lower continence rate at 3 months compared to single biopsy (P = 0.03); however, no significant differences were observed at 6, 12, or 24 months. In multivariable analyses adjusting for age, body mass index and diabetes/cardiovascular disease/smoking, the association between repeat biopsy and lower likelihood of continence at 3 months remained (odds ratio 0.67, 95% confidence interval 0.47-0.97; P = 0.03). Overall erectile function recovery rates were 16%, 33%, 51%, and 55% at 3, 6, 12, and 24 months, respectively. No difference in erectile function recovery rates was seen at any time point for single biopsy versus repeat biopsy. In multivariable analyses, repeat biopsy was not predictive of erectile function recovery at any time point. CONCLUSIONS: Repeat biopsy before radical prostatectomy impairs early continence after surgery. However, erectile function recovery and mid-term to long-term continence are not affected. These data support the current trend towards active surveillance and delayed local treatment in patients with low- to intermediate-risk prostate cancer.
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Biopsia/efectos adversos , Disfunción Eréctil/etiología , Próstata/patología , Prostatectomía/efectos adversos , Neoplasias de la Próstata/cirugía , Incontinencia Urinaria/etnología , Anciano , Estudios de Cohortes , Humanos , Masculino , Persona de Mediana Edad , Próstata/cirugía , Neoplasias de la Próstata/patología , Recuperación de la Función , Reoperación/efectos adversosRESUMEN
PURPOSE: We tested the latest update in the prostate cancer staging system by assessing the prognostic association of pT2 subclassification with the probability of survival related outcomes in patients who underwent radical prostatectomy. MATERIALS AND METHODS: We retrospectively analyzed the records of a total of 15,305 patients who underwent radical prostatectomy at 2 referral centers between 1985 and 2016, and had pT2 disease at the final pathological evaluation. Descriptive statistics were used to compare baseline data stratified by pT2 substages (pT2a/b vs pT2c). Cox regression models were adjusted for institution analyzed differences in the rate of biochemical recurrence, metastasis, cancer specific death and overall mortality. Multivariable Cox regression models were used to evaluate the predictive value of pT2 subclassification for survival, including the linear predictor from the Stephenson nomogram. RESULTS: Prostate specific antigen levels and Gleason score differed significantly between the pT2 substages (each p <0.0001). At a median followup of 6.0 years (IQR 3.3-10.1) 2,083 patients had biochemical recurrence, 161 had metastases, 43 had died of prostate cancer and 1,032 had died of another cause. On univariate analysis the pT2 subclassification was significantly associated with biochemical recurrence (p = 0.001) and distant metastasis (p = 0.033) but not with cancer specific death (p = 0.6) or overall mortality (p = 0.3). Multivariable analysis showed no evidence of a significant association between the pT2 subclassification and biochemical recurrence (p = 0.4) or distant metastasis (p = 0.6). Multivariable analysis of cancer specific death and overall mortality was omitted due to lack of significance on univariate analysis. CONCLUSIONS: Subclassification of pT2 prostate cancer is not a prognostic indicator of survival related outcomes after radical prostatectomy. Our results validate the elimination of pT2 substages in the updated staging system.
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Recurrencia Local de Neoplasia/diagnóstico , Próstata/patología , Prostatectomía , Neoplasias de la Próstata/cirugía , Anciano , Supervivencia sin Enfermedad , Humanos , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Recurrencia Local de Neoplasia/sangre , Estadificación de Neoplasias , Valor Predictivo de las Pruebas , Pronóstico , Próstata/cirugía , Antígeno Prostático Específico , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/mortalidad , Neoplasias de la Próstata/patología , Estudios RetrospectivosRESUMEN
PURPOSE: To assess the association between obstructive sleep apnea (OSA) and Fuhrman grade in patients with clear cell renal cell carcinoma (ccRCC). As secondary endpoints, we studied its association with tumor size, metastasis-free survival (MFS) and cancer-specific survival (CSS). METHODS: We reviewed the databases of two tertiary care centers, identifying 2579 patients who underwent partial or radical nephrectomy for ccRCC between 1991 and 2014. Descriptive statistics were used to compare pathologic variables between patients with and without OSA. Linear and logistic regression models were used to assess the association of OSA with Fuhrman grade and tumor size. A Cox proportional hazards model was used to determine OSA association with MFS and CSS. A pathway analysis was performed on a cohort with available gene expression data. RESULTS: In total, 172 patients (7 %) had self-reported OSA at diagnosis. More patients with OSA had high Fuhrman grade compared to those without OSA [51 vs. 38 %; 13 % risk difference; 95 % confidence interval (CI), 5-20 %; p = 0.003]. On multivariable analysis, the association remained significant (OR 1.41; 95 % CI 1.00-1.99; p = 0.048). OSA was not associated with tumor size (p > 0.5), MFS (p = 0.5) or CSS (p = 0.4). A trend toward vascular endothelial growth factor pathway enrichment was seen in OSA patients (p = 0.08). CONCLUSIONS: OSA is associated with high Fuhrman grade in patients undergoing surgery for ccRCC. Pending validation of this novel finding in further prospective studies, it could help shape future research to better understand etiological mechanisms associated.
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Carcinoma de Células Renales/epidemiología , Neoplasias Renales/epidemiología , Apnea Obstructiva del Sueño/epidemiología , Anciano , Carcinoma de Células Renales/mortalidad , Carcinoma de Células Renales/patología , Carcinoma de Células Renales/cirugía , Estudios de Cohortes , Comorbilidad , Bases de Datos Factuales , Supervivencia sin Enfermedad , Femenino , Humanos , Neoplasias Renales/mortalidad , Neoplasias Renales/patología , Neoplasias Renales/cirugía , Modelos Lineales , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Clasificación del Tumor , Nefrectomía , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Transducción de Señal/genética , Apnea Obstructiva del Sueño/genética , Transcriptoma , Carga Tumoral , Factor A de Crecimiento Endotelial Vascular/genéticaRESUMEN
OBJECTIVES: Based on imaging features, nephrometry scoring systems have been conceived to create a standardized and reproducible way to characterize renal tumor anatomy. However, less is known about which of these individual measures are important with regard to clinically relevant perioperative outcomes such as ischemia time (IT), estimated blood loss (EBL), length of hospital stay (LOS), and change in estimated glomerular filtration rate (eGFR) after robotic partial nephrectomy (PN). We aimed to assess the utility of the RENAL and PADUA scores, their subscales, and C-index for predicting these outcomes. MATERIALS AND METHODS: We analyzed imaging studies from 283 patients who underwent robotic PN between 2008 and 2014 to assign nephrometry scores (NS): PADUA, RENAL and C-index. Univariate linear regression was used to assess whether the NS or any of their subscales were associated with EBL or IT. Multivariable linear regression and linear regression models were created to assess LOS and eGFR. RESULTS: The three NS were significantly associated with EBL, IT, LOS, and eGFR at 12 months after surgery. All subscales with the exception of anterior/posterior were significantly associated with EBL and IT. Collecting system, renal rim location, renal sinus, exophytic/endophytic, and nearness to collecting system were significant predictors for LOS. Only renal rim location, renal sinus invasion and polar location were significantly associated with eGFR at 12 months. CONCLUSIONS: Tumor size and depth are important characteristics for predicting robotic PN outcomes and thus could be used individually as a simplified way to report tumors features for research and patient counseling purposes.
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Tasa de Filtración Glomerular/fisiología , Neoplasias Renales/cirugía , Nefrectomía/métodos , Procedimientos Quirúrgicos Robotizados , Pérdida de Sangre Quirúrgica , Femenino , Humanos , Isquemia/etiología , Isquemia/fisiopatología , Neoplasias Renales/fisiopatología , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios Retrospectivos , Resultado del Tratamiento , Carga TumoralRESUMEN
PURPOSE: To report survival outcomes of patients treated surgically for sarcomatoid-variant renal cell carcinomas (sRCC) and to assess whether the underlying histologic subtype is an independent predictor of outcome. METHODS: One hundred and fifty-one patients underwent surgery at a referral center between 1991 and 2014 and had sRCC in final pathology. Kaplan-Meier curves for metastasis-free survival and cancer-specific survival (CSS) were calculated, and the log-rank test assessed differences between clear cell sRCC and nonclear cell sRCC. Cox regression models were generated to test the prognostic value of histologic subtype. RESULTS: Of 151 patients, 120 (79 %) had clear cell sRCC and 31 (21 %) had nonclear cell sRCC. Ninety-eight (65 %) patients had M0/Mx disease at presentation. Among those M0/Mx patients, metastasis-free survival probabilities were 49 % at 2 years [95 % confidence interval (CI) 38-60] and 39 % at 5 years (95 % CI 28-50), while CSS probabilities were 50 % at 2 years (95 % CI 41-58) and 32 % at 5 years (95 % CI 24-41). There was no significant difference in metastasis-free survival between clear cell and nonclear cell sRCC (p = 0.8). However, patients with nonclear cell sRCC had significantly lower CSS than patients with clear cell sRCC (p = 0.035). In multivariable analyses, nonclear cell sRCC conferred a higher risk of cancer-specific death compared with clear cell sRCC (HR 2.30, 95 % CI 1.38-3.82, p = 0.001). CONCLUSIONS: In a cohort of patients treated surgically, the underlying histologic subtype of sRCC had an impact on CSS. These results present valuable information for individual counseling and patient selection in clinical trials.
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Carcinoma de Células Renales/diagnóstico , Neoplasias Renales/diagnóstico , Riñón/patología , Estadificación de Neoplasias/métodos , Nefrectomía/métodos , Sarcoma/diagnóstico , Anciano , Carcinoma de Células Renales/mortalidad , Carcinoma de Células Renales/cirugía , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Renales/mortalidad , Neoplasias Renales/cirugía , Masculino , Persona de Mediana Edad , New York/epidemiología , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Sarcoma/mortalidad , Sarcoma/cirugía , Tasa de Supervivencia/tendenciasRESUMEN
INTRODUCTION AND OBJECTIVE: Radical cystectomy (RC) with pelvic lymph node dissection is the standard treatment for muscle invasive bladder cancer and the oncologic outcomes following it are directly related to disease pathology and surgical technique. Therefore, we sought to analyze these features in a cohort from a Brazilian tertiary oncologic center and try to identify those who could negatively impact on the disease control. PATIENTS AND METHODS: We identified 128 patients submitted to radical cystectomy, for bladder cancer treatment, from January 2009 to July 2012 in one oncology tertiary referral public center (Mario Penna Institute, Belo Horizonte, Brazil). We retrospectively analyzed the findings obtained from their pathologic report and assessed the complications within 30 days of surgery. RESULTS: We showed similar pathologic and surgical findings compared to other large series from the literature, however our patients presented with a slightly higher rate of pT4 disease. Positive surgical margins were found in 2/128 patients (1.5%). The médium number of lymph nodes dissected were 15. Major complications (Clavien 3 to 5) within 30 days of cystectomy occurred in 33/128 (25.7%) patients. CONCLUSIONS: In the management of invasive bladder cancer, efforts should focus on proper disease diagnosis and staging, and, thereafter, correct treatment based on pathologic findings. Furthermore, extended LND should be performed in all patients with RC indication. A critical analysis of our complications in a future study will help us to identify and modify some of the factors associated with surgical morbidity.
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Carcinoma de Células Transicionales/patología , Carcinoma de Células Transicionales/cirugía , Cistectomía/métodos , Escisión del Ganglio Linfático/métodos , Neoplasias de la Vejiga Urinaria/patología , Neoplasias de la Vejiga Urinaria/cirugía , Adenocarcinoma/complicaciones , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Biopsia , Brasil , Carcinoma de Células Escamosas/complicaciones , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Carcinoma de Células Transicionales/complicaciones , Cistectomía/efectos adversos , Femenino , Humanos , Escisión del Ganglio Linfático/efectos adversos , Ganglios Linfáticos/cirugía , Masculino , Persona de Mediana Edad , Tempo Operativo , Pelvis , Complicaciones Posoperatorias , Pronóstico , Estudios Retrospectivos , Factores de Tiempo , Neoplasias de la Vejiga Urinaria/complicacionesRESUMEN
Locally advanced urothelial cancer has high recurrence and progression rates following surgical treatment. This highlights the need to develop neoadjuvant strategies that are both effective and well-tolerated. We hypothesized that neoadjuvant sub-ablative vascular-targeted photodynamic therapy (sbVTP), through its immunotherapeutic mechanism, would improve survival and reduce recurrence and progression in a murine model of urothelial cancer. After urothelial tumor implantation and 17 days before surgical resection, mice received neoadjuvant sbVTP (WST11; Tookad Soluble, Steba Biotech, France). Local and systemic response and survival served as measures of therapeutic efficacy, while immunohistochemistry and flow cytometry elucidated the immunotherapeutic mechanism. Data analysis included two-sided Kaplan-Meier, Mann-Whitney, and Fischer exact tests. Tumor volume was significantly smaller in sbVTP-treated animals than in controls (135 mm3 vs. 1222 mm3, P < 0.0001) on the day of surgery. Systemic progression was significantly lower in sbVTP-treated animals (l7% vs. 30%, P < 0.01). Both median progression-free survival and overall survival were significantly greater among animals that received sbVTP and surgery than among animals that received surgery alone (P < 0.05). Neoadjuvant-treated animals also demonstrated significantly lower local recurrence. Neoadjuvant sbVTP was associated with increased early antigen-presenting cells, and subsequent improvements in long-term memory and increases in effector and active T-cells in the spleen, lungs, and blood. In summary, neoadjuvant sbVTP delayed local and systemic progression, prolonged progression-free and overall survival, and reduced local recurrence, thereby demonstrating therapeutic efficacy through an immune-mediated response. These findings strongly support its evaluation in clinical trials.
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Terapia Neoadyuvante , Neoplasias Experimentales/terapia , Fotoquimioterapia , Neoplasias de la Vejiga Urinaria/terapia , Animales , Masculino , RatonesRESUMEN
BACKGROUND: Indications for partial nephrectomy (PN) have expanded to include larger tumors. Compared with radical nephrectomy (RN), PN reduces the risk of chronic kidney disease but is associated with higher morbidity. OBJECTIVE: To explore whether the benefit of PN (preservation of estimated glomerular filtration rate [eGFR] ≥60ml/min/1.73m2 1yr postoperatively) over RN is offset by higher morbidity for cT2-cT3a tumors. DESIGN, SETTING, AND PARTICIPANTS: A total of 1921 patients with renal cortical tumors who underwent nephrectomy between 2000 and 2012 were analyzed, with 297 having clinical stage T2 or higher disease. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariable logistic regression models adjusted for age, tumor size, and comorbidities were used to calculate the risk of complications within 90d and the risk of low eGFR across a range of tumor sizes. Models were created separately for RN and PN, and the difference between risk estimates was calculated. RESULTS AND LIMITATIONS: For tumors with diameters between 7 and 12cm, the risk of eGFR downgrade associated with RN was higher than the risk of complications associated with PN. The magnitude of the risk of eGFR downgrade was similar to the magnitude of complications risk across all tumor sizes. Our analysis was performed at a single institution, and used only tumor size to compare the risk and benefits of surgery. CONCLUSIONS: Our study suggests that PN is associated with higher eGFR preservation than RN for cT2 or greater renal tumors. The magnitude of this advantage offsets the higher morbidity observed with PN. PATIENT SUMMARY: When treating a large kidney tumor, it is difficult to decide whether it is better to remove the whole kidney or remove just the tumor. The second option improves postoperative renal function but is more complex. We tried to find whether there is a tumor size at which one technique should be used over the other.
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Neoplasias Renales/cirugía , Nefrectomía/métodos , Complicaciones Posoperatorias/epidemiología , Anciano , Femenino , Tasa de Filtración Glomerular , Humanos , Riñón/fisiología , Neoplasias Renales/patología , Masculino , Persona de Mediana Edad , Morbilidad , Estadificación de Neoplasias , Estudios Prospectivos , Medición de RiesgoRESUMEN
The "super-active surveillance" concept denotes any active surveillance optimization that allows longer surveillance periods, with the main intention of avoiding overtreatment, by safely eliminating or postponing radical treatment. Super-active surveillance might add to the oncological control with minimal functional impact and similar quality of life compared to active surveillance, which has proved to be safe in well-selected patients. Vascular targeted photodynamic therapy has pioneering shown to significantly reduce the upgrade on subsequent biopsies, resulting in fewer cases converted to radical therapy, and any energy source can be applied to the super-active surveillance concept allowing more men to consider a tissue-preserving therapy for prostate cancer.
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In men who do not respond to initial radiation therapy, accurate knowledge of the site of cancer recurrence or persistence is necessary to understand treatment failure. We evaluated the pathologic characteristics of recurrent/persistent prostate cancer with tumor maps from the whole-mount slides of salvage radical prostatectomies performed between 2000 and 2014. Of 216 consecutive patients, detailed tumor maps were available for 77. Sixty-nine patients (90%) were found to have tumor in the apex, of which 46% occurred in the most apical 3mm. Fifty-three patients (69%) had tumors at a distance of ≤5mm from the urethra. Five patients had tumor directly involving the urethra, all of whom had urethral invasion at the apex. Seminal vesicle involvement was seen in 32 patients (42%), two of whom had tumor only in the seminal vesicles. Sixty-two patients (81%) had tumors in the distal apex, periurethral area, or seminal vesicles, that is, areas that are not routinely biopsied. Targeting these areas could improve the accuracy of biopsy when cancer recurrence is suspected. PATIENT SUMMARY: When recurrence is suspected, clinicians should include biopsy of the distal apex, areas surrounding the urethra, and seminal vesicles. This information will help tailor successful salvage treatments.
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Biopsia , Recurrencia Local de Neoplasia , Próstata , Neoplasias de la Próstata , Terapia Recuperativa/métodos , Anciano , Biopsia/métodos , Biopsia/normas , Exactitud de los Datos , Humanos , Masculino , Persona de Mediana Edad , Invasividad Neoplásica , Recurrencia Local de Neoplasia/diagnóstico por imagen , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/cirugía , Estadificación de Neoplasias , Próstata/diagnóstico por imagen , Próstata/patología , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/cirugía , Radioterapia/efectos adversos , Radioterapia/métodos , Reproducibilidad de los Resultados , Vesículas Seminales/patología , Uretra/patologíaRESUMEN
INTRODUCTION: Lymph node dissection (LND) performed during radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) remains controversial and difficult to evaluate. The aim of this study was to investigate whether removal of more lymph nodes during RNU is safe and improves oncologic outcomes. METHODS: We evaluated 422 patients who underwent RNU with concomitant LND for upper tract urothelial carcinoma between 1976 and 2015, assessing for an association between total nodes removed, recurrence-free survival, and cancer-specific survival using Cox proportional hazards models. We also investigated the relationship between nodal yield and perioperative metrics and intersurgeon variability using linear regression. RESULTS: In our cohort of 442 patients, 239 developed recurrences and 94 patients died of disease. Median follow-up among survivors was 3.7 years (interquartile range: 1.2, 7.4). The median nodal yield was 9 (interquartile range: 4, 16). Among patients with node-positive disease (pN1), we observed a significant improvement in recurrence-free survival (hazard ratio = 0.84 per 5 nodes removed, P = 0.039) and a nonsignificant improvement in cancer-specific survival with an increase in the nodal yield (hazard ratio = 0.90 per 5 nodes removed, P = 0.2). There was no evidence of an association between node yield and operative time, estimated blood loss, or 30-day complications on multivariable analysis. There was significant heterogeneity among surgeons regarding the extent of LND (P<0.0001). CONCLUSIONS: We found that a more extensive node dissection may improve oncologic outcomes in a subset of high-risk patients without significantly increasing operative time or serious complications. Additionally, we identified considerable intersurgeon heterogeneity regarding the extent of LND furthering the notion of surgeon variability as a nonstandardized factor.
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Carcinoma de Células Transicionales/cirugía , Ganglios Linfáticos/cirugía , Recurrencia Local de Neoplasia/prevención & control , Nefroureterectomía , Neoplasias Urológicas/cirugía , Anciano , Carcinoma de Células Transicionales/patología , Femenino , Estudios de Seguimiento , Humanos , Escisión del Ganglio Linfático , Ganglios Linfáticos/patología , Masculino , Persona de Mediana Edad , Pronóstico , Tasa de Supervivencia , Neoplasias Urológicas/patologíaRESUMEN
Testosterone synthesis and male fertility are the results of the perfect coordination of the hypothalamic-pituitary-gonadal axis. A negative feedback finely controls the secretion of hormones at the 3 levels. Congenital or acquired disturbance at any level leads to an impairment of reproductive function and the clinical syndrome of hypogonadism. In some cases, this condition is reversible. Once the diagnosis is made, testosterone replacement therapy is the standard therapy; however, novel therapies may improve spermatogenesis while elevating testosterone levels.
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Gónadas/fisiología , Sistema Hipotálamo-Hipofisario/fisiología , Testosterona/fisiología , Humanos , MasculinoRESUMEN
PURPOSE: Accurate identification of the source of a detectable serum prostate-specific antigen (PSA) in the postprostatectomy setting is a major challenge among the urologic community. The aim of this study was to assess positivity rates of imaging examinations performed in patients with early PSA rise after prostatectomy and to summarize the management strategies adopted in this clinical scenario. METHODS: Institutional Review Board-approved retrospective study of 142 postprostatectomy patients with PSA rise up to 1ng/ml who underwent evaluation with combination of multiparametric pelvic magnetic resonance imaging (MRI)±whole-body or bone MRI, bone scintigraphy, computed tomography (CT) chest-abdomen-pelvis, 18F-fludeoxyglucose-positron emission tomography (PET)/CT or 18F-sodium fluoride-PET/CT at a single tertiary cancer center. Imaging results were summarized per modality and compared with pathology findings. RESULTS: Pelvic MRI was positive in 15/142 (11%) patients (14 patients with local recurrence in the surgical bed and 1 patient with pelvic osseous metastases). Of these 15, 10 patients underwent additional imaging examinations; none revealed positive findings. Of the 127 patients with negative pelvic MRI, 54 (43%) underwent additional imaging examinations; only 1/54 had positive findings (false-positive T8 lesion on bone scintigraphy and FDG-PET/CT; biopsy was negative for cancer). Overall, 12/16 patients with positive imaging findings and 75/126 (60%) patients with negative imaging received treatment (radiation, hormones or chemotherapy). CONCLUSION: The conventional imaging identified sites of disease, almost always in the form of local recurrence, in a minority of patients with early PSA rise postprostatectomy.
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Adenocarcinoma/secundario , Antígeno Prostático Específico/sangre , Neoplasias de la Próstata/diagnóstico por imagen , Adenocarcinoma/sangre , Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/terapia , Anciano , Neoplasias Óseas/diagnóstico por imagen , Neoplasias Óseas/secundario , Terapia Combinada , Radioisótopos de Flúor , Fluorodesoxiglucosa F18 , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/diagnóstico por imagen , Tomografía Computarizada por Tomografía de Emisión de Positrones , Tomografía de Emisión de Positrones , Periodo Posoperatorio , Prostatectomía , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/cirugía , Neoplasias de la Próstata/terapia , Radiofármacos , Estudios Retrospectivos , Terapia Recuperativa , Fluoruro de Sodio , Nivel de AtenciónRESUMEN
OBJECTIVES: To analyze whether the histological subtype of renal cell carcinoma (RCC) affects survival after surgical resection in contemporary patients, and if so, whether prognostic significance differs according to the type of surgical resection or tumor stage. MATERIALS AND METHODS: From 2006 to 2014, 2,237 patients underwent surgical resection (25% radical nephrectomy and 75% partial nephrectomy [PN]) for nonmetastatic RCC at a tertiary referral center. Estimated survival function curves and Cox regression models evaluated the effect of histological subtype on recurrence-free survival (RFS) and overall survival (OS). Interaction analyses tested whether the effect of histological subtype depends on the type of surgical resection or tumor stage. RESULTS: Patients with RCC stage T2 or lower and those with low-grade conventional clear cell, papillary or chromophobe RCC of any stage had 5-year RFS probabilities>90%. Patients with clear cell papillary RCC stage T3 or greater had predicted 5-year RFS of 81%. However, 5-year OS probabilities were>94% for clear cell papillary RCC of any stage. High-grade conventional clear cell and papillary RCC stage T2 or lower, low-grade conventional clear cell and chromophobe RCC of any stage conferred 5-year OS probabilities of >93%. Unclassified RCC demonstrated the lowest OS probabilities at any stage. In multivariable analyses, histological subtype affected RFS (P<0.0001) and OS (P = 0.026) following surgical resection, with no differences in this association for radical nephrectomy vs. PN (RFS, P = 0.2; OS, P = 0.4), and across pathologic stages (RFS, P = 0.1; OS, P = 0.3). Compared with low-grade conventional clear cell RCC, chromophobe (hazard ratio [HR] = 0.72, 95% CI: 0.30-1.75) and papillary RCC (HR = 0.30, 95% CI: 0.09-0.97) conferred lower risk of recurrence. Chromophobe (HR = 0.67, 95% CI: 0.30-1.52) and clear cell papillary RCC (HR = 0.91, 95% CI: 0.12-6.78) conferred the lowest risk of all-cause mortality. CONCLUSIONS: In the era of PN for RCC, histological subtype remained a significant predictor of survival, regardless of type of surgical resection or tumor stage.
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Carcinoma de Células Renales/patología , Neoplasias Renales/patología , Nefrectomía/métodos , Anciano , Carcinoma de Células Renales/cirugía , Supervivencia sin Enfermedad , Femenino , Humanos , Neoplasias Renales/cirugía , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Estadificación de Neoplasias , Pronóstico , Tasa de SupervivenciaRESUMEN
ABSTRACT Objectives: Based on imaging features, nephrometry scoring systems have been conceived to create a standardized and reproducible way to characterize renal tumor anatomy. However, less is known about which of these individual measures are important with regard to clinically relevant perioperative outcomes such as ischemia time (IT), estimated blood loss (EBL), length of hospital stay (LOS), and change in estimated glomerular filtration rate (eGFR) after robotic partial nephrectomy (PN). We aimed to assess the utility of the RENAL and PADUA scores, their subscales, and C-index for predicting these outcomes. Materials and Methods: We analyzed imaging studies from 283 patients who underwent robotic PN between 2008 and 2014 to assign nephrometry scores (NS): PADUA, RENAL and C-index. Univariate linear regression was used to assess whether the NS or any of their subscales were associated with EBL or IT. Multivariable linear regression and linear regression models were created to assess LOS and eGFR. Results: The three NS were significantly associated with EBL, IT, LOS, and eGFR at 12 months after surgery. All subscales with the exception of anterior/posterior were significantly associated with EBL and IT. Collecting system, renal rim location, renal sinus, exophytic/endophytic, and nearness to collecting system were significant predictors for LOS. Only renal rim location, renal sinus invasion and polar location were significantly associated with eGFR at 12 months. Conclusions: Tumor size and depth are important characteristics for predicting robotic PN outcomes and thus could be used individually as a simplified way to report tumors features for research and patient counseling purposes.
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Humanos , Masculino , Femenino , Procedimientos Quirúrgicos Robotizados , Tasa de Filtración Glomerular/fisiología , Neoplasias Renales/cirugía , Nefrectomía/métodos , Estudios Retrospectivos , Pérdida de Sangre Quirúrgica , Resultado del Tratamiento , Carga Tumoral , Isquemia/etiología , Isquemia/fisiopatología , Neoplasias Renales/fisiopatología , Persona de Mediana Edad , Estadificación de NeoplasiasRESUMEN
ABSTRACT Introduction and Objective Radical cystectomy (RC) with pelvic lymph node dissection is the standard treatment for muscle invasive bladder cancer and the oncologic outcomes following it are directly related to disease pathology and surgical technique. Therefore, we sought to analyze these features in a cohort from a Brazilian tertiary oncologic center and try to identify those who could negatively impact on the disease control. Patients and Methods We identified 128 patients submitted to radical cystectomy, for bladder cancer treatment, from January 2009 to July 2012 in one oncology tertiary referral public center (Mario Penna Institute, Belo Horizonte, Brazil). We retrospectively analyzed the findings obtained from their pathologic report and assessed the complications within 30 days of surgery. Results We showed similar pathologic and surgical findings compared to other large series from the literature, however our patients presented with a slightly higher rate of pT4 disease. Positive surgical margins were found in 2/128 patients (1.5%). The medium number of lymph nodes dissected were 15. Major complications (Clavien 3 to 5) within 30 days of cystectomy occurred in 33/128 (25.7%) patients. Conclusions In the management of invasive bladder cancer, efforts should focus on proper disease diagnosis and staging, and, thereafter, correct treatment based on pathologic findings. Furthermore, extended LND should be performed in all patients with RC indication. A critical analysis of our complications in a future study will help us to identify and modify some of the factors associated with surgical morbidity.