Outcome of patients with epithelialized cavity formation after excessive vesicourethral anastomotic leak post radical prostatectomy.

PURPOSE: Excessive vesicourethral anastomotic leak (EVAL) is a rare but severe complication after radical prostatectomy (RP). Epithelialized vesicourethral cavity formation (EVCF) usually develops during prolonged catheterization. To our knowledge, there is no description of postoperative outcomes, complications, or functional assessment of these patients who received conservative therapy after EVAL. METHODS: We identified 70 patients (0.56%) with radiographic evidence of EVCF out of 12,434 patients who received RP in 2016-2020 at our tertiary care center. Postoperative radiographic cystograms (CG) were retrospectively re-examined by two urologists individually. We assessed urinary continence (UC), the need for intervention due to anastomotic stricture formation, urinary tract infection (UTI), and symphysitis during the first year of follow-up post-RP. RESULTS: The median age was 66 years [interquartile range (IQR) 61-70 years], the median body mass index was 27.8 kg/m2 (IQR 25.5-30.3 kg/m2), and the median prostate specific antigen before RP was 7.1 ng/ml (IQR 4.7-11.8 ng/ml). The median catheter insertion time was 44.5 days (IQR 35.2-54 days). One-year continence follow-up was available for 27 patients (38.6%), of which 22 (81.5%) reported the use of ≤ one pad, two patients reported the use of two (7.4%) pads/24 h, and three (11.1%) patients reported use > two pads/24 h. Overall, four (5.7%) patients needed surgical reintervention for anastomotic stricture, eight (11.5%) patients presented with symphysitis, and 55 (77.1%) presented with UTI. CONCLUSION: UC in 81.5% 1-year post-RP suggests that conservative treatment in EVAL is a treatment option with an acceptable outcome on UC and should be considered before reintervention for anastomotic insufficiency.

MRI as a screening tool for prostate cancer: current evidence and future challenges.

PURPOSE: Prostate cancer (PCa) screening, which relies on prostate-specific antigen (PSA) testing, is a contentious topic that received negative attention due to the low sensitivity and specificity of PSA to detect clinically significant PCa. In this context, due to the higher sensitivity and specificity of magnetic resonance imaging (MRI), several trials investigate the feasibility of "MRI-only" screening approaches, and question if PSA testing may be replaced within prostate cancer screening programs. METHODS: This narrative review discusses the current literature and the outlook on the potential of MRI-based PCa screening. RESULTS: Several prospective randomized population-based trials are ongoing. Preliminary study results appear to favor the "MRI-only" approach. However, MRI-based PCa screening programs face a variety of obstacles that have yet to be fully addressed. These include the increased cost of MRI, lack of broad availability, differences in MRI acquisition and interpretation protocols, and lack of long-term impact on cancer-specific mortality. Partly, these issues are being addressed by shorter and simpler MRI approaches (5-20 min bi-parametric MRI), novel quality indicators (PI-QUAL) and the implementation of radiomics (deep learning, machine learning). CONCLUSION: Although promising preliminary results were reported, MRI-based PCa screening still lack long-term data on crucial endpoints such as the impact of MRI screening on mortality. Furthermore, the issues of availability, cost-effectiveness, and differences in MRI acquisition and interpretation still need to be addressed.

IL-13 as Target to Reduce Cholestasis and Dysbiosis in Abcb4 Knockout Mice.

The Th2 cytokine IL-13 is involved in biliary epithelial injury and liver fibrosis in patients as well as in animal models. The aim of this study was to investigate IL-13 as a therapeutic target during short term and chronic intrahepatic cholestasis in an Abcb4-knockout mouse model (Abcb4-/-). Lack of IL-13 protected Abcb4-/- mice transiently from cholestasis. This decrease in serum bile acids was accompanied by an enhanced excretion of bile acids and a normalization of fecal bile acid composition. In Abcb4-/-/IL-13-/- double knockout mice, bacterial translocation to the liver was significantly reduced and the intestinal microbiome resembled the commensal composition in wild type animals. In addition, 52-week-old Abcb4-/-IL-13-/- mice showed significantly reduced hepatic fibrosis. Abcb4-/- mice devoid of IL-13 transiently improved cholestasis and converted the composition of the gut microbiota towards healthy conditions. This highlights IL-13 as a potential therapeutic target in biliary diseases.

Doença trofoblástica gestacional: diagnóstico e tratamento / Gestational trophoblastic disease: diagnosis and treatment

Objetivos: A doença trofoblástica gestacional (DTG) é um conjunto de doenças heterogêneas do trofoblasto com potencial de se transformar em doença maligna e, por isso, é um importante diagnóstico diferencial nos casos de sangramento na primeira metade da gestação. Essa revisão tem como objetivo fazer uma abordagem atual sobre o tema e esclarecer sobre os principais aspectos da DTG com vistas à aplicabilidade clínica. Métodos: Foi realizada uma revisão da literatura utilizando a base de dados do PubMed dos últimos 20 anos. Resultados: A mola hidatiforme (MH) decorre de uma aberração na fertilização e pode ser do tipo completa, quando apenas existe material genético paterno, ou incompleta, quando origina um embrião triploide com material genético materno, paterno e fetal. Essa diferenciação é importante na medida em que orienta o tratamento. A investigação inicial inclui exame físico e história clínica. Ultrassonografia (USG) transvaginal e gonadotrofina coriônica humana (ß-hCG) devem ser solicitados para todos os casos. Na suspeita de metástases à distância, exames de imagem devem ser solicitados. O tratamento de DTG é feito com vácuo-aspiração e análise histológica. No caso de neoplasia trofoblástica gestacional (NTG), a complementação do tratamento requer mono ou poliquimioterapia e o seguimento é realizado com dosagens quantitativas seriadas de ß-hCG. Conclusões: Essa revisão reúne os principais aspectos da DTG, seus achados clínicos, diagnóstico, manejo e seguimento. Algumas questões sobre o tema ainda são controversas e necessitam de mais estudos consistentes.

Objectives: Gestational trophoblastic disease (DTG) is a group of heterogeneous diseases from the trophoblastic tissue with the potential to become malignant. This should be suspected as a potential diagnosis in the first trimester bleeding. The clinical aspects and the current approach of this condition are the purpose of this review. Methods: A literature review of the last 20 years was performed in the PubMed databases. Results: Hydatiform mole (HM) came from an aberration in fertilization and it is named complete when there is only paternal genetic material and incomplete when a triploid embryo is originated and it contains maternal, paternal and fetal genetic material. This is important because it guides the treatment. The initial investigation includes a physical examination and medical history. Transvaginal ultrasound and human chorionic gonadotrophin (ß-hCG) should be always requested for all cases. If metastasis is suspected, other imaging exams should be requested. The treatment of DTG is the vacuum aspiration and the histological analysis of the tissue is mandatory. In case of gestational trophoblastic neoplasia (NTG), the complementary treatment includes mono or multi-chemotherapy and the follow-up is performed with serial quantitative ß-hCG dosages. Conclusions: This review describes the main aspects of the gestational trophoblastic disease, such as its clinical findings, diagnosis, management and follow-up. Some questions related to this disorder are still controversial and require more consistent studies.

Indicação de testagem genética para câncer de mama e ovário hereditários no Hospital São Lucas da PUCRS / The indication of genetic counselling for hereditary breast and ovarian cancer syndrome at Hospital São Lucas da PUCRS

Introdução: O câncer de mama e ovário hereditário ("hereditary breast and ovarian cancer", HBOC) associa-se a mutações herdadas nos genes BRCA1/2. Nesses casos, o aconselhamento genético é mandatório, e a investigação do indivíduo tem como base características pessoais, a história familiar e as características da neoplasia. Uma vez que o diagnóstico HBOC é estabelecido através de testagem genética, existem protocolos bem estabelecidos para manejo do paciente e familiares em risco com objetivo de reduzir risco de câncer nos indivíduos não afetados e personalizar o tratamento nos pacientes já com diagnóstico de neoplasia. Métodos: Esse é um estudo observacional, transversal, de prevalência. Foi realizada uma revisão pelo banco de dados do "Projeto Amazona III" em todas pacientes incluídas do Hospital São Lucas de Porto Alegre. O objetivo do atual estudo foi avaliar as pacientes com critérios de indicação de testagem genética para HBOC através de 2 critérios. Para discussão, foram pesquisados artigos científicos dos últimos 12 anos. Resultados: Dentre os 112 participantes do estudo, 23% preenchiam critérios para testagem genética da Síndrome HBOC. Conclusão: Esse estudo revelou que um expressivo número (23%) de pacientes incluídas no Projeto Amazona III no Hospital São Lucas da PUCRS apresenta critérios para testagem da síndrome HBOC, considerando apenas 2 critérios indicadores de testagem. Além disso, 27% das pacientes apresentavam história familiar de até terceiro grau de câncer de mamãe/ ou ovário, necessitando de aconselhamento genético. A não identificação dessas pacientes significa em diagnósticos de câncer evitáveis.

Objectives: The primary objective is to examine the necessity of genetic testing for Hereditary Breast and Ovarian Cancer (HBOC) syndrome as a preventive measure. Basically, HBOC genetically inherited disorder arising out of mutations in the BRCA1 and BRCA2 genes. The HBOC diagnosis can be conducted through genetic testing. The investigation in these cases is carried out on the basis of individual characteristics, family history and features of the cancer. There are well-established protocols to manage patients and family members whom carry these mutations and to personalize the treatment for the patients already diagnosed with cancer. Methods: This is an observational, cross-sectional, and prevalence study. We conducted a review applying the database of the "Projeto Amazona III" on patients enrolled at the Hospital São Lucas de Porto Alegre (HSL-PUCRS). The purpose of the study was to evaluate patients that fall within the criteria for HBOC genetic testing. We considered only two criteria. We also analyzed the relevant scientific articles of the past 12 years to discuss the subject. Results: 23% of the 112 participants of the study met with the criteria for HBOC genetic testing. Conclusion: This study revealed that a significant number (23%) of the patients enrolled in the "Projeto Amazona III" at the HSL-PUCRS have the two criteria for HBOC genetic testing. Furthermore, 27% of the patients required genetic testing since they had a third-degree family history of breast cancer or ovarian cancer. The failure to identify these patients leads to the absence of the diagnosis of preventable cancer.

O papel da videolaparoscopia nas emergências ginecológicas e obstétricas / The role of videolaparoscopy in gynecological and obstetric emergencies

Introdução: A videolaparoscopia (VLP) tem sido cada vez mais empregada na prática clínica uma vez que auxilia, tanto no diagnóstico, quanto no manejo de diversas condições ginecológicas. Essa revisão tem como objetivo esclarecer a importância da VLP nas principais emergências ginecológicas. Métodos: Foi realizada uma revisão da literatura no mês de maio de 2018 nos bancos de dados Pubmed, Medline e Portal Periódico Capes. Foram incluídos no estudo os artigos que abordavam o uso de VLP no manejo de emergências e foram excluídos os relatos de caso. Resultados: A VLP é importante na medida em que permite a visualização direta das condições que constituem emergências ginecológicas, contribuindo dessa forma para o seu diagnóstico definitivo e precoce. A abordagem VLP frequentemente está relacionada a uma menor morbidade nesses casos. Na torção ovariana a VLP é útil tanto para identificar a viabilidade do ovário acometido quanto para desfazer a torção. No abscesso tubo ovariano, entretanto, estudos indicam que não há superioridade da técnica laparoscópica em relação à laparotomia no manejo cirúrgico desses pacientes. Na rotura de cisto ovariano, a VLP é o método preferencial nas patologias benignas, enquanto a laparotomia é o método de escolha na suspeita de lesões malignas. Na gestação ectópica, a VLP pode ser empregada nos casos de instabilidade hemodinâmica, gravidez tubária rota e quando há ascensão dos títulos de ß-hCG nas dosagens séricas associada à massa de 5 cm. Conclusão: A combinação entre o conhecimento adequado das patologias ginecológicas, a correta indicação do método VLP e a habilidade do cirurgião são fatores determinantes no sucesso terapêutico desse método.

Introduction: Video-laparoscopy (VLP) has been increasingly used in clinical practice since it assists in the diagnosis and management of various gynecological conditions. This review aims to clarify the importance of VLP in major gynecological emergencies. Methods: A literature review was performed in the month of May, 2018 in Pubmed, Medline and Capes Periodical Portal databases. The articles that addressed the use of VLP in emergency management were included in the study and the case reports were excluded. Results: VLP is important because it allows direct visualization of conditions that constitute gynecological emergencies, thus contributing to its definitive and early diagnosis. The VLP approach is often related to lower morbidity in these cases. In ovarian torsion the VLP is useful both to identify the viability of the affected ovary and to undo the torsion. In the ovarian tube abscess, however, studies indicate that there is no superiority of the laparoscopic technique in relation to laparotomy in the surgical management of these patients. In ruptured ovarian cyst, VLP is the preferred method in benign pathologies, while laparotomy is the method of choice in the suspicion of malignant lesions. In ectopic pregnancy, VLP may be used in cases of hemodynamic instability, tubal rupture, and when there is a rise in ß-hCG serum levelst associated with a 5 cm mass. Conclusion: The combination of adequate knowledge of the gynecological pathologies, the correct indication of VLP and the surgeon's ability are determining factors in the therapeutic success of this method. Keywords: videolaparoscopy,

Insuficiência adrenal aguda ("crise adrenal") / Acute adrenal insufficiency (adrenal crisis)

Insuficiência adrenal aguda é uma emergência endocrinológica que contribui para o aumento da morbidade e da mortalidade dos pacientes com insuficiência adrenal. O diagnóstico desta situação é dificultado pelo pouco conhecimento que os médicos, em geral, têm desta emergência metabólica e da inespecificidade de suas manifestações clínicas. O objetivo do capítulo é tentar facilitar o diagnóstico e o tratamento de uma crise adrenal na sala de emergência.

Acute adrenal insufficiency is an endocrine emergency and it contributes to increased morbidity and mortality in patients with adrenal insufficiency. The diagnosis of the situation is complicated by the little knowledge that the physicians have about this metabolic emergency and the little specificity of its clinical manifestation. The goal of the chapter is try to facilitate the diagnosis and treatment of adrenal crisis in the emergency room.

Manejo do câncer de reto / Rectum cancer manegement

O adenocarcinoma de reto é uma doença de diagnóstico relativamente simples e com tratamento resolutivo em muitos casos, especialmente naqueles identificados em estágios iniciais e manejados precocemente. O desconhecimento do manejo do câncer de reto pode levar ao atraso do tratamento e, consequentemente, à redução da sobrevida dos pacientes. O objetivo deste artigo é abordar o manejo adequado da neoplasia de reto, evitando, portanto, retardar seu tratamento.

Cancer of the rectum is a simple diagnostic pathology and resolving treatment in many cases, especially those identified in the early stages and managed as soon as possible. The step-by-step the lack of rectal cancer management can lead to delayed treatment and therefore a significantly higher survival difficulty and quality of life and the success of therapy. The purpose of this article is to discuss the steps to a suitable management in rectal cancer, thus avoiding delay its treatment.