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1.
J Endourol ; 33(7): 509-515, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31017001

RESUMO

Purpose: Today, up to one-third of newly diagnosed prostate cancer (PCa) cases may be suitable for focal treatment. The lack of data about the toxicity profiles of lesion-targeting therapies, however, has made it difficult to compare treatment modalities. The aim of the present study was to evaluate comprehensively the incidence, severity, and timing of onset of complications for PCa patients undergoing focal high-intensity focused ultrasound (HIFU) and focal cryosurgical ablation of the prostate (CSAP). Materials and Methods: A total of 336 patients were included who underwent focal HIFU or focal CSAP as a primary treatment for PCa between January 2009 and December 2017. Mean follow-up was 11 months (standard deviation: 3.0). All complications were captured and graded according to severity, and classified by timing of onset. Univariate and multivariate analysis was performed to identify predictors of the most common side effects. Results: There were 98 complications in 79/210 patients (38%) undergoing focal HIFU and 34 complications in 27/126 patients (21%) undergoing focal CSAP. In terms of severity, 95% of the complications of focal HIFU and 91% of the complications of focal CSAP were minor. Most complications presented in the early postoperative period. On multivariate analysis, subtotal HIFU was associated with acute urinary retention (AUR), while a smaller prostate size and longer catheterization time with dysuria. In CSAP patients, longer catheterization time was associated with AUR and urethral sloughing. The main limitation is the nonrandomized and retrospective nature. Conclusions: Focal HIFU and focal CSAP provide a tolerable toxicity, with primarily minor complications presenting in the early postoperative period.

2.
World J Urol ; 37(8): 1517-1534, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30710157

RESUMO

BACKGROUND: Whether focal therapy (FT) jeopardizes subsequent prostate cancer (PCa) salvage treatments, when needed, remains a major concern and is largely unknown. OBJECTIVES: To describe and report safety, oncological and functional outcomes of salvage treatments following PCa recurrence and/or persistence after FT. MATERIALS AND METHODS: A systematic review on salvage treatments for PCa recurrence/persistence after FT was carried out according to the PRISMA guidelines using an 'a priori protocol'. A comprehensive literature review was also performed to investigate options to treat FT PCa recurrence/persistence that have not yet been reported after FT. RESULTS: Four retrospective series were included (n = 67 men); overall quality of the studies was low. Salvage treatments yielded 32.8% (n = 22 of 67) biochemical recurrence rate (BCR) after a 7-62-months mean follow-up. No cancer-related deaths occurred. Patients experienced acceptable complications (n = 12 patients; n = 8 Clavien 3) and rare severe incontinence (4.5% using > 2 pads/day). Erectile function (EF) was rarely assessed (62.8% no information available), being overall poor. Other salvage options have been reported following whole-gland ablation and include: (1) re-do ablation yielding worst BCR and EF but similar complications and continence compared to first line ablation; (2) salvage radiotherapy yielding 16.6-38.8% BCR and acceptable toxicity profile with urinary and EF being poorly assessed. CONCLUSIONS: Current evidence is weak and limited to a few retrospective series. Oncological control is acceptable although it seems lower compared to a primary treatment setting. Functional outcomes are comparable to primary treatment with the exception of EF; overall, suggesting FT has little impact on subsequent salvage treatments. Future studies are needed to confirm the current findings.

3.
5.
Int. braz. j. urol ; 44(6): 1106-1113, Nov.-Dec. 2018. tab, graf
Artigo em Inglês | LILACS-Express | ID: biblio-975665

RESUMO

ABSTRACT Purpose: Ultrasound-magnetic resonance imaging (US-MRI) fusion biopsy (FB) improves the detection of clinically significant prostate cancer (PCa). We aimed to compare the Gleason upgrading (GU) rates and the concordance of the Gleason scores in the biopsy versus final pathology after surgery in patients who underwent transrectal ultrasound (TRUS) systematic random biopsies (SRB) versus US-MRI FB for PCa. Materials and Methods: A retrospective analysis of data that were collected prospectively from January 2011 to June 2016 from patients who underwent prostate biopsy and subsequent radical prostatectomy. The study cohort was divided into two groups: US-MRI FB (Group A) and TRUS SRB (Group B). US-MRI FB was performed in patients with a previous MRI with a focal lesion with a Likert score ≥3; otherwise, a TRUS SRB was performed. Results: In total, 73 men underwent US-MRI FB, and 89 underwent TRUS SRB. The GU rate was higher in Group B (31.5% vs. 16.4%; p=0.027). According to the Gleason grade pattern, GU was higher in Group B than in Group A (40.4% vs. 23.3%; p=0.020). Analyses of the Gleason grading patterns showed that Gleason scores 3+4 presented less GU in Group A (24.1% vs. 52.6%; p=0.043). The Bland-Altman plot analysis showed a higher bias in Group B than in Group A (-0.27 [-1.40 to 0.86] vs. −0.01 [-1.42 to 1.39]). In the multivariable logistic regression analysis, the only independent predictor of GU was the use of TRUS SRB (2.64 [1.11 - 6.28]; p=0.024). Conclusions: US-MRI FB appears to be related to a decrease in GU rate and an increase in concordance between biopsy and final pathology compared to TRUS SRB, suggesting that performing US-MRI FB leads to greater accuracy of diagnosis and better treatment decisions.

6.
Int Braz J Urol ; 44(6): 1106-1113, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30325600

RESUMO

PURPOSE: Ultrasound-magnetic resonance imaging (US-MRI) fusion biopsy (FB) improves the detection of clinically significant prostate cancer (PCa). We aimed to compare the Gleason upgrading (GU) rates and the concordance of the Gleason scores in the biopsy versus final pathology after surgery in patients who underwent transrectal ultrasound (TRUS) systematic random biopsies (SRB) versus US-MRI FB for PCa. MATERIALS AND METHODS: A retrospective analysis of data that were collected prospectively from January 2011 to June 2016 from patients who underwent prostate biopsy and subsequent radical prostatectomy. The study cohort was divided into two groups: US-MRI FB (Group A) and TRUS SRB (Group B). US-MRI FB was performed in patients with a previous MRI with a focal lesion with a Likert score ≥3; otherwise, a TRUS SRB was performed. RESULTS: In total, 73 men underwent US-MRI FB, and 89 underwent TRUS SRB. The GU rate was higher in Group B (31.5% vs. 16.4%; p=0.027). According to the Gleason grade pattern, GU was higher in Group B than in Group A (40.4% vs. 23.3%; p=0.020). Analyses of the Gleason grading patterns showed that Gleason scores 3+4 presented less GU in Group A (24.1% vs. 52.6%; p=0.043). The Bland-Altman plot analysis showed a higher bias in Group B than in Group A (-0.27 [-1.40 to 0.86] vs. -0.01 [-1.42 to 1.39]). In the multivariable logistic regression analysis, the only independent predictor of GU was the use of TRUS SRB (2.64 [1.11 - 6.28]; p=0.024). CONCLUSIONS: US-MRI FB appears to be related to a decrease in GU rate and an increase in concordance between biopsy and final pathology compared to TRUS SRB, suggesting that performing US-MRI FB leads to greater accuracy of diagnosis and better treatment decisions.


Assuntos
Biópsia Guiada por Imagem/métodos , Imagem por Ressonância Magnética Intervencionista , Neoplasias da Próstata/diagnóstico por imagem , Ultrassonografia de Intervenção , Idoso , Estudos de Coortes , Humanos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Prostatectomia , Neoplasias da Próstata/patologia , Estudos Retrospectivos
7.
J Urol ; 200(6): 1205, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30193090
8.
Investig Clin Urol ; 59(3): 152-157, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29744471

RESUMO

Purpose: To describe the salvage radical prostatectomy (sRP) experience in patients presenting with recurrent, clinically localized prostate cancer after multiple failed local treatments. Materials and Methods: Among the 251 sRP performed during 2000-2016, 11 patients had failed multiple local therapies. We describe baseline clinical characteristics at primary cancer diagnosis and prior to sRP, surgical information, complications and oncological outcomes. Results: The mean±standard deviation age at sRP was 65±5 years and the median (interquartile range) serum prostate-specific antigen (PSA) level was 2 (1.3) ng/mL. The most common first and subsequent treatments were radiotherapy and cryotherapy, respectively, with median time of 24 months from the last local treatment. The median operative time was 180 minutes and median estimated blood loss was 750 mL. Five (45.5%) patients underwent additional procedures during sRP for pre-operative morbidity from prior treatments (rectourethral fistula, urethral stricture, incontinence). Post-operative complications requiring invasive intervention occurred in 7 (63.6%) patients. Over a median follow-up of 29 (12-96) months, 10 of the 11 men (90.9%) achieved an undetectable PSA in after sRP. Three of these men with an initially undetectable PSA level experienced biochemical recurrence; the remaining 7 are without evidence of disease. Overall, no local recurrence or systemic metastasis was identified at last follow-up. Conclusions: sRP is technically feasible and offers durable cancer control in patients with recurrent prostate cancer despite having undergone multiple prior attempts at cure. These patients experience higher rates of post-operative complications and such patients must be appropriately counseled regarding the potential risks and benefits.


Assuntos
Recidiva Local de Neoplasia/cirurgia , Prostatectomia , Neoplasias da Próstata/terapia , Terapia de Salvação , Idoso , Perda Sanguínea Cirúrgica , Criocirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/cirurgia , Antígeno Prostático Específico/sangue , Prostatectomia/efeitos adversos , Neoplasias da Próstata/sangue , Neoplasias da Próstata/patologia , Radioterapia , Reoperação , Falha de Tratamento
9.
Eur Urol ; 74(5): 537-539, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29724502

RESUMO

The literature on focal therapy is currently insufficient to recommend it as first-line treatment. We need information from both randomised controlled trials and prospective registries for every available energy. That said, important research is under way in this field, and the door should be kept open to an approach that has the potential to offer adequate cancer control with lower morbidity and better post-treatment quality of life in properly selected patients.


Assuntos
Técnicas de Ablação , Neoplasias da Próstata/cirurgia , Técnicas de Ablação/efeitos adversos , Tomada de Decisão Clínica , Humanos , Biópsia Guiada por Imagem , Imagem por Ressonância Magnética , Masculino , Seleção de Pacientes , Valor Preditivo dos Testes , Neoplasias da Próstata/diagnóstico por imagem , Neoplasias da Próstata/patologia , Fatores de Risco , Resultado do Tratamento
10.
Investig Clin Urol ; 59(2): 83-90, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29520383

RESUMO

Purpose: To verify the quality of pelvic lymph node dissection (PLND) performed at radical prostatectomy (RP) and its impact on nodal recurrence in patients undergoing salvage lymph node dissection (sLND). Materials and Methods: Retrospective review of 48 patients who underwent sLND for presumed nodal recurrence, to describe the PLND characteristics at RP and correlate the anatomical sites and number of suspicious nodes reported in radiological imaging and final pathology of sLND. Results: Overall, at RP, 8 (16.7%) did not undergo PLND, 32 (66.7%) and 8 (16.7%) received a "limited" (between external iliac vein and obturator nerve) and an "extended" (external iliac, hypogastric, and obturator) dissection, respectively. Median nodes removed during limited and extended dissection were 2 and 24, respectively. At sLND, the mean age was 61.3 years and median prostate specific antigen (PSA) was 1.07 ng/mL. Median nodes removed at sLND were 17 with a median of 2 positive nodes. Recurrent nodes were identified within the template of an extended PLND in 62.5%, 50.0% and 12.5% patients, respectively, following prior no, limited and extended dissection at RP. Recurrence outside the expected lymphatic drainage pathway was noted in 37.5% patients with prior extended dissection at RP. There was a correlation between imaging and pathology specimen in 83% for node location and 58.3% for number of anatomical sites involved. Conclusions: In prostate cancer patients undergoing sLND, most had inadequate PLND at the original RP. Pattern of nodal recurrence may be influenced by the prior dissection and pre sLND imaging appears to underestimate the nodal recurrence.


Assuntos
Excisão de Linfonodo , Linfonodos , Recidiva Local de Neoplasia , Prostatectomia , Neoplasias da Próstata , Terapia de Salvação , Humanos , Excisão de Linfonodo/efeitos adversos , Excisão de Linfonodo/métodos , Linfonodos/patologia , Linfonodos/cirurgia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/cirurgia , Estadiamento de Neoplasias , Pelve , Próstata/patologia , Antígeno Prostático Específico/análise , Prostatectomia/efeitos adversos , Prostatectomia/métodos , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/patologia , Neoplasias da Próstata/cirurgia , Estudos Retrospectivos , Terapia de Salvação/métodos , Terapia de Salvação/estatística & dados numéricos , Estados Unidos
11.
J Urol ; 199(1): 140-146, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28823768

RESUMO

PURPOSE: We analyzed the oncologic and functional outcomes of partial gland ablation compared with robot-assisted radical prostatectomy in patients with low and intermediate risk prostate cancer. MATERIALS AND METHODS: A total of 1,883 patients underwent robot-assisted radical prostatectomy and 373 underwent partial gland ablation from July 2009 to September 2015. We selected 1,458 of these participants for analysis, including 1,222 and 236 treated with robot-assisted radical prostatectomy and partial gland ablation, respectively. Patients had a Gleason score of 3 + 3 or 3 + 4, clinical stage T2b or less, prostate specific antigen 15 ng/dl or less, unilateral disease and life expectancy greater than 10 years. Propensity score matching analysis (1:2) was applied in the overall robot-assisted radical prostatectomy sample, which selected 472 patients for comparison. For partial gland ablation 188 men underwent high intensity focused ultrasound and 48 underwent cryotherapy. Oncologic outcomes were analyzed in terms of the need for salvage treatment. Partial gland ablation failure was defined as any positive control biopsy after treatment. Functional outcomes were assessed by validated questionnaires. RESULTS: Matching was successful across the 2 groups, although men treated with partial gland ablation were older (p <0.001). Mean followup in the partial gland ablation group was 38.44 months. Partial gland ablation failure was observed in 68 men (28.8%), including 53 (28.1%) treated with high intensity focused ultrasound and 15 (31.2%) treated with cryotherapy. Partial gland ablation was associated with a higher risk of salvage treatment (HR 6.06, p <0.001). Complications were comparable between the groups (p = 0.06). Robot-assisted radical prostatectomy was associated with less continence recovery and a lower potency rate 3, 6 and 12 months after surgery (p <0.001). CONCLUSIONS: In select patients with organ confined prostate cancer partial gland ablation offered good oncologic control with fewer adverse effects that required additional treatments. Potency and continence appeared to be better preserved after partial gland ablation.


Assuntos
Técnicas de Ablação/métodos , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Humanos , Expectativa de Vida , Masculino , Gradação de Tumores , Estadiamento de Neoplasias , Pontuação de Propensão , Estudos Prospectivos , Neoplasias da Próstata/patologia , Risco , Resultado do Tratamento
12.
Urol Oncol ; 35(7): 461.e7-461.e14, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28359746

RESUMO

BACKGROUND: According to the novel prostate cancer (PCa) grade grouping, men with Gleason score 8 should be included in the grade group 4 regardless of primary and secondary scores. We aimed at evaluating the effect of Gleason patterns on the risk of recurrence in men with grade group 4 PCa. PATIENTS AND METHODS: Overall, 1,089 patients treated with radical prostatectomy with grade group 4 PCa at final pathology were identified. Biochemical recurrence (BCR) was defined as 2 consecutive prostate-specific antigen values≥0.2ng/ml and rising. Clinical recurrence (CR) was defined as positive imaging after BCR. Kaplan-Meier analyses assessed time to BCR and CR. Multivariable Cox regression analyses assessed the impact of Gleason patterns on the risk of BCR and CR. RESULTS: Overall, 295 (27.1%), 651 (59.8%), and 143 (13.1%) patients had pathologic Gleason pattern 3+5, 4+4, and 5+3. Overall, 435 (39.9%) patients had positive margins and 439 (30.2%), 300 (27.5%), 350 (32.1%), and 216 (19.8%) had pT2, pT3a, pT3b/4, and pN1 disease. Median follow-up was 83 months. Overall, 536 and 221 patients experienced BCR and CR. The 10-year BCR- and CR-free survival rates were 42.9% and 67.5% vs. 38.3% and 59.7% vs. 40.6% and 50.4% for patients with pathologic Gleason pattern 3+5 vs. 4+4 vs. 5+3, respectively (all P≤0.005). In multivariable analyses, patients with Gleason pattern 3+5 were at lower risk of BCR compared to those with 4+4 (P = 0.002). Men with Gleason pattern 3+5 were at lower risk of CR compared to those with 4+4 and 5+3 (all P≤ 0.01). CONCLUSIONS: Patients with a primary Gleason score 3 are at reduced risk of recurrence as compared to their counterparts with 4 or 5. Primary and secondary Gleason scores should be considered to stratify the risk of recurrence after surgery in patients with grade group 4 PCa.


Assuntos
Gradação de Tumores/métodos , Neoplasias da Próstata/patologia , Idoso , Humanos , Masculino , Prostatectomia/métodos
14.
Urol Oncol ; 35(4): 149.e1-149.e6, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28117215

RESUMO

BACKGROUND AND OBJECTIVE: The primary objective was to evaluate the learning curve of minimally invasive radical prostatectomy (MIRP) in our institution and analyze the salient learning curve transition points regarding oncological outcomes. METHODS: Clinical, pathologic, and oncological outcome data were collected from our prospectively collected MIRP database to estimate positive surgical margin (PSM) and biochemical recurrence (BCR) trends during a 15-year period from 1998 to 2013. All the radical prostatectomies (laparoscopic prostatectomy [LRP]/robot-assisted laparoscopic radical prostatectomy [RARP]) were performed by 9 surgeons. PSM was defined as presence of cancer cells at inked margins. BCR was defined as serum prostate-specific antigen >0.2ng/ml and rising or start of secondary therapy. Surgical learning curve was assessed with the application of Kaplan-Meier curves, Cox regression model, cumulative summation, and logistic model to define the "transition point" of surgical improvement. RESULTS: We identified 5,547 patients with localized prostate cancer treated with MIRP (3,846 LRP and 1,701 RARP). Patient characteristics of LRP and RARP were similar. The overall risk of PSM in LRP was 25%, 20%, and 17% for the first 50, 50 to 350, and>350 cases, respectively. For the same population, the 5-year BCR rate decreased from 30% to 16.7%. RARP started 3 years after the LRP program (after approximately 250 LRP). The PSM rate for RARP decreased from 21.8% to 20.4% and the corresponding 5-year BCR rate decreased from 17.6% to 7.9%. The cumulative summation analysis showed significantly lower PSM and BCR at 2 years occurred at the transition point of 350 cases for LRP and 100 cases for RARP. In multivariable analysis, predictors of BCR were prostate-specific antigen, Gleason score, extraprostatic disease, seminal vesicle invasion, and number of operations (P<0.05). Patients harboring PSM showed higher BCR risk (23% vs. 8%, P< 0.05). CONCLUSIONS: Learning curve trends in our large, single-center experience show correlation between surgical experience and oncological outcomes in MIRP. Significant reduction in PSM and BCR risk at 2 years is noted after the initial 350 cases and 100 cases of LRP and RARP, respectively.


Assuntos
Laparoscopia/mortalidade , Curva de Aprendizado , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Recidiva Local de Neoplasia/mortalidade , Prostatectomia/mortalidade , Neoplasias da Próstata/mortalidade , Procedimentos Cirúrgicos Robóticos/mortalidade , Idoso , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/cirurgia , Estudos Prospectivos , Neoplasias da Próstata/patologia , Neoplasias da Próstata/cirurgia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento
15.
Expert Rev Anticancer Ther ; 16(10): 1039-52, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27636115

RESUMO

INTRODUCTION: In the era of minimally-invasive surgery, urinary incontinence (UI) after radical prostatectomy (RP) still represents a troublesome issue for a considerable rate of patients. Factors associated with the risk of post-RP UI, need to be carefully assessed throughout the overall clinical management process thus including the pre-operative, intra-operative and post-operative setting. AREAS COVERED: This review analyses current published evidences regarding clinical and surgical aspects associated with urinary continence (UC) recovery after RP. A careful evaluation of patient's clinical characteristics should be carried out before surgery in order to properly counsel the patients regarding the risk of UI. In the last two decades, the advent of robotic surgery has led to an overall improvement of functional outcomes after RP, thanks to the development of different surgical strategies based on either the 'preservation' or the 'reconstruction' of the anatomical elements responsible for urinary continence. Finally, several therapeutic strategies including either a conservative approach, or pharmacological and surgical treatments, should be carefully considered for the post-operative management of UI. Expert commentary: A comprehensive pre-operative patient's clinical assessment, along with a proper and well-conducted surgical procedure and an effective post-operative care management are essential element to achieve a high probability of UC recovery.


Assuntos
Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Incontinência Urinária/etiologia , Humanos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Cuidados Pós-Operatórios/métodos , Prostatectomia/efeitos adversos , Recuperação de Função Fisiológica , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Incontinência Urinária/prevenção & controle
16.
Arch. esp. urol. (Ed. impr.) ; 69(6): 311-316, jul.-ago. 2016. tab
Artigo em Inglês | IBECS | ID: ibc-154263

RESUMO

High Intensity Focused Ultrasound (HIFU) is a heat based energy source used for tissue ablation. HIFU has several clinical applications and prostate cancer ablation is one of the uses that have been explored for more than a decade. Focal therapy is an alternative treatment option for selected patients with low/intermediate PCa, that is based on complete ablation of tumor within the prostate with preservation of normal parenchyma and better preservation of Genitourinary functions. In spite of PCa being predominantly a multi-centric disease, it is postulated that a specific dominant (large volume) ‘index lesion’ dictates the biological behavior of the cancer and subsequent lethality of the disease. The use of HIFU for focal ablation of PCa, have demonstrated satisfactory cancer control with fewer morbidity and better preservation of continence and erection. The aim of this article is to present the Arch. Esp. Urol. 2016; 69 (6): 311-316 311 readers with a brief review of the principles, devices available for clinical uses, published clinical experience and future directions and research opportunities in focal HIFU ablation of prostate cáncer (AU)


El HIFU (High intensity focused ultrasound) es una fuente de energía basada en calor utilizada para la ablación de tejido. El HIFU tiene varias aplicaciones clínicas y la ablación del cáncer de próstata es una de las que se ha explorado desde hace más de una década. La terapia focal es una opción de tratamiento alternativa para pacientes seleccionados con cáncer de próstata de riesgo bajo/intermedio. Se basa en la ablación completa del tumor dentro de la próstata con preservación del parénquima normal y mejor conservación de las funciones genitourinarias. A pesar de ser el cáncer de próstata una enfermedad predominantemente multicéntrica, se postula que una “lesión índice” dominante específica (gran volumen) dicta el comportamiento biológico del cáncer y la subsecuente letalidad de la enfermedad. El uso de HIFU para ablación local de cáncer de próstata ha demostrado un control del cáncer satisfactorio con menor morbilidad y mejor conservación de la continencia y la erección. El objetivo de este artículo es presentar a los lectores una breve revisión de los principios, los instrumentos disponibles para uso clínico, la experiencia clínica publicada y la dirección futura y oportunidades de investigación en la ablación focal del cáncer de próstata con HIFU (AU)


Assuntos
Humanos , Masculino , Ablação por Ultrassom Focalizado de Alta Intensidade/instrumentação , Ablação por Ultrassom Focalizado de Alta Intensidade/métodos , Neoplasias da Próstata/radioterapia , Condutas Terapêuticas/normas , Condutas Terapêuticas/organização & administração , Radioterapia de Alta Energia/instrumentação , Radioterapia de Alta Energia/métodos , Radioterapia de Alta Energia , Ablação por Ultrassom Focalizado de Alta Intensidade/classificação , Ablação por Ultrassom Focalizado de Alta Intensidade/economia , Ablação por Ultrassom Focalizado de Alta Intensidade/tendências
17.
Arch. esp. urol. (Ed. impr.) ; 69(6): 345-352, jul.-ago. 2016. tab, ilus
Artigo em Espanhol | IBECS | ID: ibc-154267

RESUMO

La terapia focal se ha instaurado como una alternativa al tratamiento radical en casos seleccionados de cáncer de próstata localizado. La selección de pacientes candidatos a terapia focal se basa en un diagnóstico por imagen apoyado en la resonancia magnética multiparamétrica y las técnicas de fusión de imagen. Debido a los resultados oncológicos y los perfiles de seguridad de series iniciales, se han desarrollado distintas fuentes de energía en los últimos años. La disponibilidad de múltiples tipos de energía para el tratamiento focal, nos compromete a evaluar qué tipo de energía será la óptima según el perfil de paciente y el tipo de lesión. Una energía única para el tratamiento focal sería el ideal, pero ante la investigación de los diversos tipos de energías debemos identificar cuál es la recomendada para cada lesión. Con la experiencia de nuestro centro en distintos abordajes de terapia focal, proponemos el MODELO “À LA CARTE” basado en la localización de la lesión. Presentamos los criterios en los que se basa el modelo “à la carte”, apoyados por la evidencia publicada en el uso de distintos tratamientos ablativos para el tratamiento de cáncer de próstata localizado. Tanto la localización de la lesión, las características técnicas de cada tipo de energía, el perfil del paciente y los efectos secundarios, han de contemplarse en toda elección de tratamiento focal (AU)


Focal therapy has settled as an alternative to radical treatment in selected cases of localized prostate cancer. The selection of patients who are candidates for focal therapy is based on imaging diagnosis relying on multiparametric MRI and image fusion techniques. Thanks to the oncological results and safety profiles of initial series, various energy sources have been developed over the last years. The availability of multiple types of energy sources for focal therapy, commits us to evaluate what type of energy would be the optimal depending on patient´s profile and type of lesion. A unique energy for focal therapy would be ideal, but facing the research of the various types of energy we must identify which one is recommended for each lesion. With the experience of our center in different approaches of focal therapy we propose the “A LA CARTE” MODEL based on localization of the lesion. We present the criteria the “a la carte” model is based on, supported by the published evidence on the use of different ablative therapies for the treatment of localized prostate cancer. Lesion localization, technical characteristics of each type of energy, patient`s profile and secondary effects must be considered in every choice of focal therapy (AU)


Assuntos
Humanos , Masculino , Condutas Terapêuticas , Imagem por Ressonância Magnética Intervencionista/métodos , Neoplasias da Próstata/terapia , Incontinência Urinária/complicações , Incontinência Urinária/terapia , Qualidade de Vida , Seguimentos , Bibliometria , Neoplasias da Próstata/complicações , Neoplasias da Próstata/psicologia , Avaliação de Processos e Resultados (Cuidados de Saúde) , Eletroporação/métodos , Eletroporação
18.
Urology ; 94: 111-6, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27154045

RESUMO

OBJECTIVE: To analyze oncologic, functional and morbidity outcomes for patients undergoing minimally invasive salvage prostatectomy (MISP) at our institution. PATIENTS AND METHODS: Between 2001 and 2015, 5841 patients underwent radical prostatectomy at our institution, out of which 28 were MISP. Indications for MISP were prostate-specific antigen nadir +2 ng/dL in radio-recurrent patients and biopsy-proven prostate cancer (PCa) in other ablative treatments. We analyzed primary cancer characteristics, surgical data, perioperative complications, oncologic and functional outcomes of MISP, and further compared results between MISP after primary whole-gland treatment (WT) and focal treatment (FT). RESULTS: Median age at salvage treatment was 65 (interquartile range [IQR] 61-68). Compared with WT, MISP after FT had significantly lower operative time (133 vs 176 min, P = .001) and fewer upstaging (≥pT3a) (28% vs 79%, P = .008) at final pathology. Overall, positive surgical margin (PSM) were noted in 4 patients (14%). Perioperative complications were observed in 9 patients with no difference between groups. At 12-months follow-up, 57% were continent and 33% had moderate to severe urinary leak. Potency was preserved in 6 out of 10 preoperatively potent patients. Over a median follow-up of 62 months (IQR 43-110), 11 patients relapsed with a median time to biochemical recurrence of 16 months (IQR 7-25). Recurrences were managed with salvage radiotherapy in 6 patients, 4 with hormone therapy and 1 castration-resistant prostate cancer. Overall, 24 patients are alive at last follow-up and 18 (72%) remain disease free. CONCLUSION: MISP after primary radiation or ablation for prostate cancer is feasible and safe with acceptable oncological outcomes. Compared with FT, MISP after WT appears to have longer operative time and more frequent upstaging.


Assuntos
Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Técnicas de Ablação , Idoso , Terapia Combinada , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Neoplasias da Próstata/radioterapia , Estudos Retrospectivos , Terapia de Salvação , Resultado do Tratamento
19.
Urology ; 91: 104-10, 2016 05.
Artigo em Inglês | MEDLINE | ID: mdl-26948530

RESUMO

OBJECTIVE: To report a comparative analysis of laparoscopic simple prostatectomy (LSP) vs robot-assisted simple prostatectomy (RASP). PATIENTS AND METHODS: Consecutive cases of LSP and RASP done between 2003 and 2014 at 3 participating institutions were included in this retrospective analysis. The effectiveness of the two procedures was determined by performing a paired analysis of main functional and surgical outcomes. A multivariate analysis was also conducted to determine the factors predictive of "trifecta" outcome (combination of International Prostate Symptom Score <8, Qmax > 15 mL/second, and no perioperative complications). RESULTS: A total of 319 patients underwent minimally invasive simple prostatectomy at the participating institutions over the study period. Total prostate volume was larger in the RASP group (median 118.5 mL vs 109 mL, P = .02). Median estimated blood loss tended to be higher for LSP (300 mL vs 350 mL, P = .07). There was no difference in terms of catheterization time (P = .3) and hospital stay (P = .42). A higher rate of overall postoperative complications was recorded in the RASP group (17.7% vs 5.3%), but rate of major complications was not significantly different between the two techniques (2.3 vs 2.1, P = .6). Subjective and objective parameters significantly improved for both LSP and RASP. On multivariable analysis, only two factors were associated with likelihood of obtaining a favorable (trifecta) outcome: age (odds ratio: 0.94; P = .03) and body mass index (odds ratio: 0.84; P = .03). CONCLUSION: Both LSP and RASP can be regarded as safe and effective minimally invasive surgical treatments for bladder outlet obstruction due to large prostate glands.


Assuntos
Laparoscopia , Prostatectomia/métodos , Hiperplasia Prostática/cirurgia , Procedimentos Cirúrgicos Robóticos , Obstrução do Colo da Bexiga Urinária/cirurgia , Idoso , Humanos , Masculino , Hiperplasia Prostática/complicações , Estudos Retrospectivos , Resultado do Tratamento , Obstrução do Colo da Bexiga Urinária/etiologia
20.
Urology ; 90: 195-8, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26724413

RESUMO

INTRODUCTION: To describe a new technique for superficial implantation of the I-Stop TOMS transobturator sling and present the clinical outcomes on patients treated for mild to moderate urinary incontinence after radical prostatectomy. TECHNICAL CONSIDERATIONS: We evaluated the four-arm sub urethral sling I-Stop TOMS performed in our institution between March 2012 and March 2015 using a superficial implantation technique. After a small incision, the perineal aponeurosis was incised but no muscle dissection was performed. Inclusion criteria for sling procedure used in the study was mild (1-2 pads/day) to moderate (3-5 pads/day) postprostatectomy incontinence and at least 12 months after radical prostatectomy. Improvement was defined as the patient having 50% reduction in the number of pads and success as patient either not wearing pads or using one security pad. The primary objective was to evaluate the proportion of patients achieving continence after the modified sling implantation technique at 12 months after surgery. Fifty-two patients underwent our new technique and 34 had completed 12 months follow-up. The procedure was successful for 28 patients (82.4%). There was an improvement in 25 patients (73.5%). Pad use at 12 months had decreased significantly compared with baseline (mean 0.7 vs 2.2, P < .00001). The complications were rare and the procedure was well tolerated as shown by median visual analogic scale of 1.5 (interquartile range, 2 to 1). CONCLUSION: This novel approach for insertion of the transobturator I-Stop TOMS male sling is a quick, simple, and well-tolerated procedure with low complication rate, allowing a significant improvement in postprostatectomy incontinence.


Assuntos
Implantação de Prótese/métodos , Slings Suburetrais , Incontinência Urinária/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Prostatectomia/efeitos adversos , Desenho de Prótese , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Incontinência Urinária/etiologia
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