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4.
BJU Int ; 125(2): 253-259, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31220396

RESUMO

OBJECTIVES: To evaluate the technical feasibility, oncological and functional outcomes of nerve sparing cystoprostatectomy (NSCP) and prostate capsule-sparing cystectomy (PCSC) for the treatment of organ-confined bladder cancer at a single referral centre. PATIENTS AND METHODS: From April 2001 to June 2012, 60 patients underwent PCSC and 47 were treated with NSCP. Inclusion criteria for PCSC were: fully informed consent for the well-motivated patient; negative transurethral resection of the bladder neck; normal prostatic specific antigen (PSA) level (defined as <4 ng/dL during the first year of the study, which was later lowered to 2.5 ng/dL); and normal transrectal ultrasonography, with biopsy for any suspicious nodule. Patients received a complete oncological and functional follow-up. The Kaplan-Meier method was used to depict survival outcomes after surgery. RESULTS: After a median follow-up of 73 and 62 months for PCSC and NSCP, respectively, the 5-year cancer-specific survival was 90% for the PCSC group and 78% for the NSCP group (P = 0.055). Considering complications within 30 days after surgery, 13% and 21% patients had Clavien ≥III complications in the PCSC and NSCP groups, respectively (P = 0.2). For functional outcomes, at 3 months after surgery, 54 (90%) and 24 (51%) patients reported full recovery of daytime urinary continence in the PCSC and NSCP groups, respectively (P < 0.001); and for erectile function recovery, 32 (53%) and four (9%) patients in the PCSC group and in the NSCP group were respectively potent without any treatment (P < 0.001). CONCLUSIONS: NSCP and PCSC are appropriate for a subset of patients with bladder cancer, with excellent oncological and functional results. These surgical procedures should be proposed to well-motivated patients.

5.
J Urol ; 203(2): 320-330, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31437121

RESUMO

PURPOSE: We report oncologic outcomes in patients treated with focal therapy for prostate cancer. MATERIALS AND METHODS: We retrospectively analyzed a single institution cohort of men with localized prostate cancer who received focal therapy using high intensity focused ultrasound or cryotherapy from 2009 to 2018. Focal therapy was offered for low or intermediate risk disease (prostate specific antigen less than 20 ng/ml, Gleason score 7 or less and clinical stage T2b or less). Patients with previous prostate cancer treatment or less than 6 months of followup were excluded from study. Failure was defined as local or systemic salvage treatment, a positive biopsy Gleason score of 7 or greater in-field or out-of-field in nontreated patients, prostate cancer metastasis or prostate cancer specific death. Cox regression analysis was done to identify independent predictors of failure after focal therapy. RESULTS: Of the 309 patients included in study 190 and 119 were treated with high intensity focused ultrasound and cryotherapy, respectively. Median followup was 45 months. At 1, 3 and 5 years the failure-free survival rate was 95%, 67% and 54%, and the radical treatment-free survival rate was 99%, 79% and 67%, respectively. The 5-year metastasis-free survival rate was 98% and no prostate cancer specific death was registered in this cohort. Before focal therapy a biopsy Gleason score of 7 (3 + 4) or greater (HR 2.4, p <0.001) and nadir prostate specific antigen (HR 2.2, p <0.001) were independently associated with failed focal therapy. In the salvage focal therapy setting in-field recurrence after primary focal therapy was associated with poorer failure-free survival (p=0.02). CONCLUSIONS: Almost half of the men were free of focal therapy failure 5 years after treatment. Still, a significant proportion experienced recurrence at the midterm followup. The preoperative biopsy Gleason score and nadir prostate specific antigen were significantly associated with treatment failure.


Assuntos
Criocirurgia , Ablação por Ultrassom Focalizado de Alta Intensidade , Prostatectomia/métodos , Neoplasias da Próstata/patologia , Neoplasias da Próstata/cirurgia , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
6.
Eur Urol ; 77(1): 1-2, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31506227

RESUMO

The evidence available suggests that open and robot-assisted radical cystectomy lead to similar outcomes in bladder cancer. True advances will come from a better understanding of the biology of the disease, and a comprehensive, multimodal approach that aims to improve patient survival and quality of life is more critical than the surgical technique.

7.
Int Braz J Urol ; 45(6): 1094-1104, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31808396

RESUMO

INTRODUCTION: The health-related QoL is a patient-centered evaluation covering several aspects. This evaluation seems to be particularly important in patients submitted to radical cystectomy (RC) and urinary diversion with ileal conduit (IC) or a neobladder (NB). OBJECTIVE: Review all recent data comparing QoL outcomes after radical cystectomy with NB and IC diversions. EVIDENCE ACQUISITION: A systematic search in PubMed/Medline, Embase, and Cochrane databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement in December 2018. All articles published from January 01, 2012 to December 31, 2018, were included. A study was considered relevant if it compared QoL outcomes using validated questionnaires (EORTC QLQ C30, FACT-G, FACT-BL, FACT-VCI, and BCI). EVIDENCE SYNTHESIS: In 11 included studies, a total of 1389 participants were accounted (730 NB and 659 IC cases). The studies were conducted in 8 different countries, two were prospective, and none was randomized. There were two studies favoring results with a neobladder, 3 with incontinent diversion and 6 with no differences. The EORTC-QLQ-C30 was the most used instrument (5 studies) followed by FACT VCI and BCI (3 studies each). Given the heterogeneity of data and lack of prospective studies, a meta-analysis was not performed. CONCLUSION: No superiority of one urinary diversion was characterized. It seems that the choice must be individualized with an extensive preoperative orientation of the patient and their relatives. That will probably infl uence how the patient accepts the new condition.


Assuntos
Cistectomia/reabilitação , Qualidade de Vida , Derivação Urinária/reabilitação , Cistectomia/métodos , Cistectomia/psicologia , Feminino , Humanos , Masculino , Qualidade de Vida/psicologia , Inquéritos e Questionários/normas , Fatores de Tempo , Resultado do Tratamento , Derivação Urinária/métodos , Derivação Urinária/psicologia
8.
J Urol ; : 101097JU0000000000000692, 2019 Dec 10.
Artigo em Inglês | MEDLINE | ID: mdl-31821099

RESUMO

PURPOSE: We compared cancer detection rates in patients who underwent magnetic resonance imaging cognitive guided micro-ultrasound biopsy vs robotic ultrasound magnetic resonance imaging fusion biopsy for prostate cancer. MATERIALS AND METHODS: Among 269 targeted biopsy procedures 222 men underwent robotic ultrasound magnetic resonance imaging fusion biopsy and 47 micro-ultrasound biopsy. Robotic ultrasound magnetic resonance imaging fusion biopsy was performed using the transperineal Artemis™ device while micro-ultrasound biopsy was performed transrectally with the high resolution ExactVu™ system. Random biopsies were performed in addition to targeted biopsy in both modalities. Prostate cancer detection rates and concordance between random and target biopsies were also assessed. RESULTS: Groups were comparable in terms of age, prostate specific antigen, prostate volume and magnetic resonance PI-RADS (Prostate Imaging Reporting and Data System) version 2 score. The micro-ultrasound biopsy group presented fewer biopsied cores in random and target approaches. In targeted biopsies micro-ultrasound biopsy cases presented higher detection of clinically significant disease (Gleason score greater than 6) than the robotic ultrasound magnetic resonance imaging fusion biopsy group (38% vs 23%, p=0.02). When considering prostate cancer detection regardless of Gleason score or prostate cancer detection by random+target biopsies, no difference was found between the groups. However, on a per core basis overall prostate cancer detection rates favored micro-ultrasound biopsy in random and targeted scenarios. In addition, the PRI-MUS (Prostate Risk Identification Using Micro-Ultrasound) score yielded by micro-ultrasound visualization was independently associated with improved cancer detection rates of clinically significant prostate cancer. CONCLUSIONS: In our initial experience micro-ultrasound biopsy featured a higher clinically significant prostate cancer detection rate in target cores than robotic ultrasound magnetic resonance imaging fusion biopsy, which was associated with target features in micro-ultrasound (PRI-MUS score). These findings reinforce the role of micro-ultrasound technology in targeted biopsies.

10.
Arch Esp Urol ; 72(8): 825-830, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31579041

RESUMO

OBJECTIVE: High-intensity focused ultrasound (HIFU) Focal therapy appears to have encouraging oncologic outcomes and urinary and erectile function. The control of the treated area can be done using contrast enhanced ultrasound with sulfur hexafluoride (Sonovue®) at the end of the procedure. We report oncological and functional outcomes in HIFU focal therapy (FT) for prostate cancer (PCa) management using sonovue. METHODS: A total of 274 HIFU procedures were found in our registry in the period between June 2014 and July 2018. Prospective data of 59 consecutive patients after focal high-intensity focused ultrasound (HIFU) using Sonovue were collected. FT failure was defined as positive biopsy Gleason score (GS) ≥ 7 in- or out-field, local or systemic salvage treatment, PCa-metastasis or PCa-specific death. RESULTS: A total of 59 patients submitted to HIFU with median follow-up of 18 months were included in the analysis. Median age was 66.7 yr (IQR 59.1-74.3). Median preoperative prostate-specific antigen (PSA) was 7.6 ng/ml (IQR 5-10.2) and preoperative biopsies GS 6, 7(3+4), 7(4+3) were found in 26 (44%), 30 (50.8%) and 3 (5%), respectively. Failure was found in 16 (27.1%) patients. Failure-free survival (FFS) in 2 and 4yr was 83% and 74% respectively (Figure 1). No PCa-specific death was registered in the period of study. Median nadir PSA after FT was 2.67 ng/ml. Sexual potency was achieved in 75% of previous potent patients and urinary continence in 93.4% of patients at 3 months. Fourteen (23%) patients presented with complications. Four (6.7%) patients have presented complications grade 1 and 10 (16.9%) patients have presented complications grade 2. Six (10.1%) patients have presented acute urinary retention. CONCLUSIONS: Our study shows that the use of Sonovue after HIFU FT was safe. Patients present a significant proportion of failure after HIFU FT but with good functional outcomes and without incidence of severe complications.


Assuntos
Ablação por Ultrassom Focalizado de Alta Intensidade , Neoplasias da Próstata , Humanos , Masculino , Estudos Prospectivos , Antígeno Prostático Específico , Neoplasias da Próstata/terapia , Terapia de Salvação , Resultado do Tratamento
11.
Arch. esp. urol. (Ed. impr.) ; 72(8): 825-830, oct. 2019. tab, graf, ilus
Artigo em Espanhol | IBECS-Express | ID: ibc-FGT-3141

RESUMO

Objective: High-intensity focused ultrasound (HIFU) Focal therapy appears to have encouraging oncologic outcomes and urinary and erectile function. The control of the treated area can be done using contrast enhanced ultrasound with sulfur hexafluoride (Sonovue(R)) at the end of the procedure. We report oncological and functional outcomes in HIFU focal therapy (FT) for prostate cancer (PCa) management using sonovue. Methods: A total of 274 HIFU procedures were found in our registry in the period between June 2014 and July 2018. Prospective data of 59 consecutive patients after focal high-intensity focused ultrasound (HIFU) using Sonovue were collected. FT failure was defined as positive biopsy Gleason score (GS) ≥ 7 in- or out-field, local or systemic salvage treatment, PCa-metastasis or PCa-specific death.Results: A total of 59 patients submitted to HIFU with median follow-up of 18 months were included in the analysis. Median age was 66.7 yr (IQR 59.1-74.3). Median preoperative prostate-specific antigen (PSA) was 7.6 ng/ml (IQR 5-10.2) and preoperative biopsies GS 6, 7(3 + 4), 7(4 + 3) were found in 26 (44%), 30 (50.8%) and 3 (5%), respectively. Failure was found in 16 (27.1%) patients. Failure-free survival (FFS) in 2 and 4yr was 83% and 74% respectively (Figure 1). No PCa-specific death was registered in the period of study. Median nadir PSA after FT was 2.67 ng/ml. Sexual potency was achieved in 75% of previous potent patients and urinary continence in 93.4% of patients at 3 months. Fourteen (23%) patients presented with complications. Four (6.7%) patients have presented complications grade 1 and 10 (16.9%) patients have presented complications grade 2. Six (10.1%) patients have presented acute urinary retention. Conclusions: Our study shows that the use of Sonovue after HIFU FT was safe. Patients present a significant proportion of failure after HIFU FT but with good functional outcomes and without incidence of severe complications


Objetivos: La terapia focal con HIFU (High-intensity focused ultrasound) parece tener unos resultados oncológicos y de función urinaria y eréctil prometedores. El control del área tratada puede realizarse al final de la intervención utilizando Sonovue(R), el contraste de ecografía con hexafluoruro de azufre. Presentamos los resultados oncológicos y funcionales de la terapia focal con HIFU en el tratamiento cáncer de próstata utilizando Sonovue. Métodos: Se encontraron en nuestro registro un total de 274 intervenciones con HIFU entre Junio 2014 y Julio 2018. Se recogieron los datos prospectivamente en 59 pacientes consecutivos después de HIFU utilizando Sonovue. Se define fracaso de la terapia focal como biopsia positiva con puntuación de Gleason (GS) > 7 dentro o fuera del campo, tratamiento de salvamento local o sistémico, metástasis del CaP o muerte cáncer específica por CaP. Resultados: Se incluyeron en el análisis un total de 59 pacientes sometidos a HIFU con una mediana de seguimiento de 18 meses. La mediana de edad fue 66,7 años (Rango intercuartílico (RIC) 59,1-74,3). La mediana de PSA preoperatorio fue 7,6 ng/mL (RIC 5-10,2) y las biopsias fueron GS 6, 7 (3+4) y 7 (4+3) en 26 (44%), 30 (50,8%) y 3 (5%) casos, respectivamente. En 16 pacientes (27,1%) fracasó el tratamiento. La supervivencia libre de fracaso del tratamiento a 2 y 4 años fue 83% y 74% respectivamente (Figura 1). No se ha registrado ninguna muerte cáncer específica por el CaP en el periodo de estudio. La mediana del nadir de PSA después de la terapia focal fue 2,67 ng/ml. El 75% de los pacientes previamente potentes consiguieron mantener su potencia sexual y el 93,4% eran continentes a los 3 meses. Catorce pacientes (23%) presentaron complicaciones. Cuatro (6,7%) presentaron complicaciones grado 1 y 10 (16,9%) grado 2. Seis pacientes (10,1%) presentaron retención aguda de orina. Conclusiones: Nuestro estudio muestra que el uso de Sonovue después de terapia focal con HIFU es seguro. Los pacientes presentan una proporción significativa de fracasos después de terapia focal con HIFU aunque tiene buenos resultados funcionales y sin incidencia de complicaciones graves

12.
Minerva Urol Nefrol ; 71(5): 544-548, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31508924

RESUMO

Focal therapy (FT) for localized prostate cancer (PCa) is emerging to reduce adverse effects of radical treatments, while maintaining comparable oncological outcomes. However, an area for improvement still exists and a gap in cancer control needs to be filled by complementing FT with additional forms of treatment to minimize failures. Part of the recurrences/persistences after FT may be related to PCa microenvironment favouring tumorigenesis of benign tissue or indolent PCa left untreated. FT-induced inflammation may alter microenvironment in a pro-tumorigenic fashion. On the contrary, androgen deprivation therapy (ADT) modifies PCa microenvironment and suppresses PCa tumorigenesis. So far, ADT has proven effective in combination with radiotherapy, has been evaluated in the context of AS and to reduce prostate volume in the context of whole-gland high-intensity focused ultrasound (HIFU). However, no prospective data exist evaluating FT/ADT combination in terms of cancer control for the treatment of localized PCa. We will perform the ENHANCE pilot study (EvaluatioN of HIFU Hemiablation and short-term AndrogeN deprivation therapy Combination to Enhance prostate cancer control). Twenty men with localized unilateral csPCa will receive HIFU hemi-ablation and concomitant short-term ADT. Oncologic efficacy will be assessed 1-year post-treatment considering the persistence/recurrence of csPCa. Complications and functional outcomes will be evaluated using internationally validated questionnaires. If the hypothesis of an oncological benefit together with no relevant additional toxicity is confirmed, the ENHANCE study will allow an evidence-based starting point for a large randomized controlled trial against the standard of care and/or HIFU hemiablation alone.


Assuntos
Antagonistas de Androgênios/uso terapêutico , Terapia Combinada/métodos , Neoplasias da Próstata/terapia , Humanos , Masculino , Projetos Piloto , Estudos Prospectivos , Neoplasias da Próstata/radioterapia , Radioterapia , Projetos de Pesquisa , Resultado do Tratamento
14.
J Clin Med ; 8(8)2019 Aug 09.
Artigo em Inglês | MEDLINE | ID: mdl-31395826

RESUMO

BACKGROUND: To assess the differential effect of robotic assisted radical cystectomy (RARC) versus open radical cystectomy (ORC) on survival outcomes in matched analyses performed on a large multicentric cohort. METHODS: The study included 9757 patients with urothelial bladder cancer (BCa) treated in a consecutive manner at each of 25 institutions. All patients underwent radical cystectomy with bilateral pelvic lymphadenectomy. To adjust for potential selection bias, propensity score matching 2:1 was performed with two ORC patients matched to one RARC patient. The propensity-matched cohort included 1374 patients. Multivariable competing risk analyses accounting for death of other causes, tested association of surgical technique with recurrence and cancer specific mortality (CSM), before and after propensity score matching. RESULTS: Overall, 767 (7.8%) patients underwent RARC and 8990 (92.2%) ORC. The median follow-up before and after propensity matching was 81 and 102 months, respectively. In the overall population, the 3-year recurrence rates and CSM were 37% vs. 26% and 34% vs. 24% for ORC vs. RARC (all p values > 0.1), respectively. On multivariable Cox regression analyses, RARC and ORC had similar recurrence and CSM rates before and after matching (all p values > 0.1). CONCLUSIONS: Patients treated with RARC and ORC have similar survival outcomes. This data is helpful in consulting patients until long term survival outcomes of level one evidence is available.

17.
Minerva Urol Nefrol ; 71(5): 445-456, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31353876

RESUMO

INTRODUCTION: In the last years, there have been significant developments in the therapeutic armamentarium of metastatic castration-resistant prostate cancer (mCRPC). New evidence shows that the addition of bone-targeted agents (BTA) to "life-prolonging agents" result in improved clinical benefit. This review aims to give an overview of data for the use of BTAs in a new era of mCRPC where new agents are used in daily practice. EVIDENCE ACQUISITION: A non-systematic review of the literature was performed combining the keywords: "castration-resistant prostate cancer" and "bone-targeted therapy". The primary objective was to provide a critical assessment of data for the use of BTAs in mCRPC, and the secondary objective was to assess novel targeted therapy. EVIDENCE SYNTHESIS: Zoledronic acid and denosumab have shown to be effective in reducing the risk of SREs in patients with mCRPC. The point at which treatment with bisphosphonates or denosumab should be initiated during PCa evolution has yet to be determined. The EMA has restricted the usage of Ra-223 to patients who have had two previous treatments for mCRPC to the bone or who cannot receive other treatments. Ra-223 should only be used as monotherapy or in combination with ADT for the treatment of mCRPC, symptomatic bone metastases and without visceral metastases. With recent developments in PSMA-targeted radiopharmaceuticals, PSMA RLT agents are now under investigation for the treatment of mCRPC. CONCLUSIONS: Reducing skeletal-related morbidity remains a crucial goal of palliative life-extending therapy in mCRPC. New data about dosing schedules and combinations of different treatments will continue to refine the optimal strategy for incorporating BTAs into the new treatment paradigms for PCa. Novel molecules such as PSMA-targeted small molecules promise theranostic agents in the management of PCa patients.


Assuntos
Antineoplásicos/uso terapêutico , Doenças Ósseas/tratamento farmacológico , Doenças Ósseas/etiologia , Neoplasias Ósseas/secundário , Neoplasias Ósseas/terapia , Osso e Ossos/efeitos dos fármacos , Neoplasias de Próstata Resistentes à Castração/tratamento farmacológico , Neoplasias de Próstata Resistentes à Castração/patologia , Antineoplásicos/administração & dosagem , Antineoplásicos/farmacologia , Neoplasias Ósseas/tratamento farmacológico , Neoplasias Ósseas/radioterapia , Sistemas de Liberação de Medicamentos , Humanos , Masculino
18.
Cancer Immunol Res ; 7(7): 1091-1105, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31164356

RESUMO

Clear-cell renal cell carcinoma (ccRCC) possesses an unmet medical need, particularly at the metastatic stage, when surgery is ineffective. Complement is a key factor in tissue inflammation, favoring cancer progression through the production of complement component 5a (C5a). However, the activation pathways that generate C5a in tumors remain obscure. By data mining, we identified ccRCC as a cancer type expressing concomitantly high expression of the components that are part of the classical complement pathway. To understand how the complement cascade is activated in ccRCC and impacts patients' clinical outcome, primary tumors from three patient cohorts (n = 106, 154, and 43), ccRCC cell lines, and tumor models in complement-deficient mice were used. High densities of cells producing classical complement pathway components C1q and C4 and the presence of C4 activation fragment deposits in primary tumors correlated with poor prognosis. The in situ orchestrated production of C1q by tumor-associated macrophages (TAM) and C1r, C1s, C4, and C3 by tumor cells associated with IgG deposits, led to C1 complex assembly, and complement activation. Accordingly, mice deficient in C1q, C4, or C3 displayed decreased tumor growth. However, the ccRCC tumors infiltrated with high densities of C1q-producing TAMs exhibited an immunosuppressed microenvironment, characterized by high expression of immune checkpoints (i.e., PD-1, Lag-3, PD-L1, and PD-L2). Our data have identified the classical complement pathway as a key inflammatory mechanism activated by the cooperation between tumor cells and TAMs, favoring cancer progression, and highlight potential therapeutic targets to restore an efficient immune reaction to cancer.

19.
Arch Esp Urol ; 72(3): 239-246, 2019 Apr.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-30945650

RESUMO

OBJECTIVE OF THE REVIEW: Robot assisted Radical prostatectomy (RARP) has generated a new trend in the binomial teaching/learning, grouping these techniques in training modules such as theoretical learning, practice, personalized counseling, and modern tools like simulation and practice in virtual models. This review summarizes the current trend in the teaching process of RARP. RECENT FINDINGS: Current trends in the acquisition of the RARP learning curve is to provide the Urologist with a well-structured teaching process, implementing gradual training modules, which make possible to understand all aspects of the development of prostate surgery with a robotic system. This process consists in analyzing the theoretical aspects, perform training with high quality simulators and proctorization, in both cases in vivo and as assistant, until completion of the advanced phase in console with haptic training and proctor's direct advice, while the learning curve is being completed. The evidence shows that student and proctor feedback with the use of virtual models, immediately post-procedure video analysis, and a high-volume center are able to shorten the teaching process. The learning process never culminates, in other words, the final phase of the student, is when he is prepared to teaching the multiplier effect of his learning curve. CONCLUSIONS: Virtual models in Robotic surgery has changed the perspective teaching process of medicine. Theoretical knowledge, virtual training and Proctor's advice are essential steps in the learning curve. Future directions,evolution of virtual models in a similar fashion to the real scenario.


Assuntos
Prostatectomia , Neoplasias da Próstata , Procedimentos Cirúrgicos Robóticos , Humanos , Curva de Aprendizado , Masculino , Próstata , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Urológicos
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