Perioperative, Oncological, and Functional Outcomes Between Robot-Assisted Laparoscopic Prostatectomy and Open Radical Retropubic Prostatectomy: A Randomized Clinical Trial.

PURPOSE: Limited high-quality studies have compared robot-assisted laparoscopic prostatectomy (RALP) vs open retropubic radical prostatectomy. We sought to compare their postoperative outcomes in a randomized setting. MATERIALS AND METHODS: In a single center, 354 men with newly diagnosed prostate cancer were assessed for eligibility; 342 were randomized (1:1). The primary outcome was 90-day complication rates. Functional outcomes and quality of life were assessed over 18 months, and oncological outcomes, biochemical recurrence-free survival, and additional treatment over 36 months. RESULTS: From 2014 to 18, 327 patients underwent surgery (retropubic radical prostatectomy = 156, RALP = 171). Complications occurred in 27 (17.3%) vs 19 (11.1%; P = .107). Patients undergoing RALP experienced lower median bleeding (250.0 vs 719.5 mL; P < .001) and shorter hospitalization time. Urinary EPIC (Expanded Prostate Cancer Index Composite) median scores were better for RALP over 18 months, with higher continence rate at 3 months (80.5% vs 64.7%; P = .002), 6 months (90.1% vs 81.6%; P = .036) and 18 months (95.4% vs 78.8%; P < .001). Sexual EPIC and Sexual Health Inventory for Men median scores were higher with RALP up to 12 months, while the potency rate was superior at 3 months (23.9% vs 5.3%; P = .001) and 6 months (30.6% vs 6.9%; P < .001). Quality of life over the 18 months and oncological outcomes over 36 months were not significantly different between arms. CONCLUSIONS: Complications at 90 days were similar. RALP showed superior sexual outcomes at 1 year, improved urinary outcomes at 18 months, and comparable oncological outcomes at 36 months.

"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.

Neutrophil-to-Lymphocyte Ratio Predicts Cancer Outcome in Locally Advanced Clear Renal Cell Carcinoma.

BACKGROUND: To evaluate the association of neutrophil-to-lymphocyte ratio (NLR) with recurrence-free survival (RFS) and overall survival (OS) in patients with locally advanced nonmetastatic clear cell renal cell carcinoma (ccRCC) undergoing radical nephrectomy. MATERIAL AND METHODS: We retrospectively identified 880 nephrectomies performed between January 2009 and December 2016 in a single center, reviewed data from 478 radical nephrectomies for kidney tumors and identified 187 patients with locally advanced nonmetastatic ccRCC (pT3-T4 N0M0). NLR was obtained preoperatively and calculated by dividing absolute neutrophil count by absolute lymphocyte count. OS and RFS were evaluated by the Kaplan-Meier method. Cox proportional-hazards regression models were used to evaluate predictors of RFS and OS. RESULTS: Among 187 patients with ccRCC (mean age 63.4 ± 11.5 years; 118 [63.1%] male), the median follow-up was 48.7 months. On univariate analysis, in patients with Fuhrman nuclear grade of differentiation 3-4, the median time to recurrence was significantly shorter with NLR ≥ 4 than < 4 (24 vs. 55 months, P = .045). On multivariable analysis adjusted for NLR ≥ 4, among all variables analyzed (NLR, microvascular invasion, sarcomatoid differentiation, tumor size and body mass index), only nuclear grade of differentiation was an independent predictor of recurrence (hazard ratio 2.18; 95% confidence interval 1.07-4.92, P = .03). The 3-year OS had no statistically significant difference between patients with NLR ≥ 4 or < 4. CONCLUSION: For patients with locally advanced, nonmetastatic ccRCC, RFS was reduced with high nuclear grade of differentiation and high preoperative NLR. These findings suggest an association between higher NLR and worse outcomes in locally advanced ccRCC.

Consensus on Screening, Diagnosis, and Staging Tools for Prostate Cancer in Developing Countries: A Report From the First Prostate Cancer Consensus Conference for Developing Countries (PCCCDC).

PURPOSE: To generate and present the survey results on critical issues relevant to screening, diagnosis, and staging tools for prostate cancer (PCa) focused on developing countries. METHODS: A total of 36 of 300 questions concern the main areas of interest of this paper: (1) screening, (2) diagnosis, and (3) staging for various risk levels of PCa in developing countries. A panel of 99 international multidisciplinary cancer experts voted on these questions to create recommendations for screening, diagnosing, and staging tools for PCa in areas of limited resources discussed in this manuscript. RESULTS: The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion not a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations consider cost-effectiveness and the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. The results were tabulated in real time. CONCLUSION: The voting results and recommendations presented in this document can be used by physicians to support the screening, diagnosis, and staging of PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for screening, diagnosis, and staging of PCa in developing countries have not been developed, this document will serve as a point of reference when confronted with this disease.

Consensus on Prostate Cancer Treatment of Localized Disease With Very Low, Low, and Intermediate Risk: A Report From the First Prostate Cancer Consensus Conference for Developing Countries (PCCCDC).

PURPOSE: A group of international urology and medical oncology experts developed and completed a survey on prostate cancer (PCa) in developing countries. The results are reviewed and summarized, and recommendations on consensus statements for very low-, low-, and intermediate-risk PCa focused on developing countries were developed. METHODS: A panel of experts developed more than 300 survey questions of which 66 questions concern the principal areas of interest of this paper: very low, low, and intermediate risk of PCa in developing countries. A larger panel of 99 international multidisciplinary cancer experts voted on these questions to create the recommendations for treatment and follow-up for very low-, low-, and intermediate-risk PCa in areas of limited resources discussed in this manuscript. RESULTS: The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion not a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations consider cost-effectiveness and the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. The results were tabulated in real time. CONCLUSION: The voting results and recommendations presented in this document can be used by physicians to support management for very low, low, and intermediate risk of PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for treatment for very low, low, and intermediate risk of PCa in developing countries have not been developed, this document will serve as a point of reference when confronted with this disease.

Robotic-assisted radical cystectomy: the first multicentric Brazilian experience.

The objective of this study is to report the first multicentric Brazilian series and learning curve of robotic radical cystectomy (RARC) with related intra- and postoperative outcomes. We retrospectively analyzed 37 RARC prospectively collected at four different centers in Brazil, from 2013 to 2019. We analyzed the patient's demographics, pathological tumor, and nodal status, as well as intra- and postoperative outcomes. Statistical analysis was performed with the IBM (SPSS version 25) software. Overall, 86% were male, and the median age was 69 years. 83% had muscle-invasive bladder cancer, and 17% a high-grade, recurrent non-muscle-invasive tumor. The median operative time was 420 min with 300 min as console time. Median blood loss was 350 ml and transfusion rate was 10%. In 68% of the cases, we performed an intracorporeal Bricker urinary diversion, 24% intracorporeal neobladder, and 8% ureterostomy. Six patients (16%) had a Clavien 1-2, 8% had Clavien 3, 2.5% had a Clavien 4, and 5% had Clavien 5. The median length of hospital stay was 7 days. The final pathological exam pointed out pT0 in 16%, pT1 in 8%, pT2 in 32%, ≥ pT3 in 27%, and 16% pTis. 95% had negative surgical margins. The survival at 30, 90, and 180 days was 98%, 95%, and 95%, respectively. To our knowledge, this is the first multicentric series of RARC reporting the learning curve in Brazil; even if still representing a challenging procedure, RARC could be safely and effectively faced by experienced surgeons at centers with high volumes of robotic surgery.

Preditores de recorrência e progressão do câncer de bexiga: validação externa do escore de risco EORTC e a Classificaçãodo Instituto do Câncer do Estado de São Paulo / Predicting bladder cancer recurrence and progression: EORTC risk score external validation and the Sao Paulo Cancer Institute Classification

Introdução: Classificações de risco baseadas em fatores preditivos de recorrência e progressão são essenciais para condutas no câncer de bexiga. Tabelas de risco combinam essas variáveis para uso clínico. As tabelas de risco da Organização Europeia para Pesquisa e Tratamento do Câncer (EORTC) são aceitas para esse propósito, mas nunca foram validadas no Brasil. Objetivos: Validar as tabelas de risco EORTC e criar uma classificação de risco baseada na população de pacientes acompanhados em um centro terciário de câncer. Métodos: Estudo retrospectivo de 561 pacientes submetidos a ressecção transuretral (RTU) de câncer de bexiga superficial de fevereiro de 2005 a junho de 2011. As variáveis analisadas foram as mesmas das tabelas de risco EORTC. A regressão logística foi realizada usando SPSS. A análise da curva COR determinou o limite de tamanho do tumor. Resultados: As tabelas de risco EORTC não conseguiram prever recorrência nem progressão. Na análise para prever recorrência isoladamente, estadio T e tamanho do tumor previram o desfecho. O limite de tamanho do tumor foi definido em <4cm vs ≥4cm (AUC=0,61; p=0,001). Criamos uma classificação: Ta/CIS=0 pontos, T1=4 pontos, tamanho do tumor=0 ou 3 pontos. A classificação de risco foi obtida somando os pontos. A taxa de recorrência em 2 anos foi: escore 0=11,2%; escore 3=20,7%; escore 4=29,2%; escore 7=37,9%. Para prever recorrência e progressão, estadio T e tamanho do tumor previram significativamente o desfecho. A classificação em escores foi: Ta/CIS=0 pontos, T1=2 pontos, tamanho do tumor = 0 ou 2 pontos. A classificação de risco foi obtida somando os pontos. A taxa de recorrência em 2 anos foi: escore 0=17%; escore 2=28,6%; escore 4=40,7%. Conclusões: Constatamos que as tabelas de risco EORTC não conseguiram prever recorrência ou progressão do câncer de bexiga na nossa população. Portanto, desenvolvemos uma classificação de risco para auxiliar urologistas a individualizar as condutas por paciente.

Introduction: Risk classification based on predictive factors of bladder cancer recurrence and progression is essential for management decision. Risk tables combine these variables for clinical practice use. European Organization for Research and Treatment of Cancer (EORTC) risk tables are widely accepted for this purpose, however they were never validated in Brazil. Our aim was to validate the EORTC risk tables and create a risk classification based on our population. Methods: Retrospective study of 561 patients who underwent transurethral resection of superficial bladder from February 2005 to June 2011. Variables analyzed were the same as EORTC risk tables. Logistic regression was performed using SPSS. ROC curve analysis was used for determining the cut-off for tumor size. Results: EORTC risk tables were not able to predict neither disease recurrence nor progression. In our analysis for predicting bladder cancer recurrence alone, we found that T stage and tumor size predicted outcome. Tumor size cut-off was defined as < 4 cm vs ≥ 4 (AUC=0.61; p=0.001). We created a scoring classification: Ta/CIS=0 points, T1=4 points, tumor size=0 or 3 points. Risk classification was obtained by adding the points accordingly and the following recurrence rate at 2 yrs by group: score 0=11.2%; score 3=20.7%; score 4=29.2%; score 7=37.9%. The statistical model for bladder cancer recurrence or progression found that T stage and tumor size predicted the outcome. The scoring classification was: Ta/CIS=0 points, T1=2 points, tumor size=0 or 2 points. Risk classification was obtained by adding the points accordingly and the following recurrence rate at 2 yrs by group: score 0=17%; score 2=28.6%; score 4=40.7%. Conclusions: We found that EORTC risk tables could not predict bladder cancer recurrence or progression in our patient population, possibly due to differences in patient characteristics. Therefore, we developed a new risk classification to aid urologists to individualize the management decision per patient.

Plasmacytoid urothelial carcinoma: a case of histological variant of urinary bladder cancer with aggressive behavior.

Plasmocytoid variant urothelial carcinoma (PVUC) of the urinary bladder is a rare histological variant of transitional cell carcinoma. Data regarding PVUC shows that this neoplasia presents a distinctive clinical outcome represented by aggressive behavior and poor survival rate. The authors report a case of a 57-year-old male patient with a 3-month history of hematuria and pelvic pain. Radical cystectomy with lymphadenectomy was performed and pathological examination showed a pT3pN0 PVUC of the bladder. The patient remained free of recurrence for 8 months, but the disease recurred involving the abdominal wall and subcutaneous tissue. Chemotherapy provided a positive clinical response and relief of symptoms. The authors call attention to the aggressiveness of this rare variant of bladder cancer and recommend radical surgery and multidisciplinary management of this neoplasm.

Benign glandular inclusion in obturator lymph node of a man treated for prostate carcinoma.

Benign glandular inclusions in lymph nodes are extremely rare in men. Their identification is essential because it changes dramatically the prognosis and therapy of neoplasms. Described herein is the first case of benign glandular inclusion in an obturator lymph node dissected during a radical prostatectomy for treatment of prostate adenocarcinoma. A 60-year-old man underwent radical prostatectomy and obturator-hypogastric lymph node dissection for treatment of prostate adenocarcinoma. Benign glandular inclusion was found in microscopic examination. The lesion was characterized by two glandular spaces lined by a single, cuboid, benign epithelium localized in the sinus of one of four dissected lymph nodes. Immunohistochemistry showed mesothelial differentiation. Pathologists should be aware of benign glandular inclusion in obturator lymph nodes dissected during a radical prostatectomy for treatment of prostate cancer in order to avoid the incorrect diagnosis of metastatic disease.

Resultados do tratamento cirúrgico do câncer da córdia e terço inferior do esôfago / Results of surgical treatment of cordia and lower third of the esophagus

Os autores analisam os resultados obtidos com o tratamento cirúrgico de 72 portadores de câncer da cárdia e terço inferior do esôfago, empregando três técnicas distintas: Grupo I - esofagogastrectomia parcial com reconstituiçäo por anastomose esofagogástrica valvulada intratorácica, através de laparotomia e toracotomia direita - 37 casos; Grupo II - acesso transmediastinal para a) esofagogastrectomia parcial com reconstituiçäo pela técnica de Merendino - três casos; b) gastrectomia polar e esofagectomia subtotal, seguida de esofagogastroplastia - 21 casos; Grupo III - esofagogastrectomia parcial através de toracofrenolaparotomia esquerda e reconstituiçäo pela técnica de Merendino - 11 casos. Referem 16,2% de mortalidade no Grupo I; no Grupo II sem óbito pela técnica de Merendino e 14,2% na esofagectomia subtotal por via cervicoabdominal; no Grupo III, 9% de óbitos. Como complicaçöes, referem fístulas, empiemas e processo broncopneumônicos principalmente nos pacientes do Grupo I. Concluem que o tratamento cirrugico do câncer da cárdia e terço inferior do esôfago deve visar obter: a) ampla margem de segurança na ressecçäo tumoral; b) métodos de reconstituiçäo do trânsito digestivo que evitem o refluxo gastroesofágico; c) evitar anastomoses intrapleurais