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1.
Int J Comput Assist Radiol Surg ; 16(7): 1181-1188, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34076803

RESUMO

PURPOSE: Intra-operative augmented reality (AR) during surgery can mitigate incomplete cancer removal by overlaying the anatomical boundaries extracted from medical imaging data onto the camera image. In this paper, we present the first such completely markerless AR guidance system for robot-assisted laparoscopic radical prostatectomy (RALRP) that transforms medical data from transrectal ultrasound (TRUS) to endoscope camera image. Moreover, we reduce the total number of transformations by combining the hand-eye and camera calibrations in a single step. METHODS: Our proposed solution requires two transformations: TRUS to robot, [Formula: see text], and camera projection matrix, [Formula: see text] (i.e., the transformation from endoscope to camera image frame). [Formula: see text] is estimated by the method proposed in Mohareri et al. (in J Urol 193(1):302-312, 2015). [Formula: see text] is estimated by selecting corresponding 3D-2D data points in the endoscope and the image coordinate frame, respectively, by using a CAD model of the surgical instrument and a preoperative camera intrinsic matrix with an assumption of a projective camera. The parameters are estimated using Levenberg-Marquardt algorithm. Overall mean re-projection errors (MRE) are reported using simulated and real data using a water bath. We show that [Formula: see text] can be re-estimated if the focus is changed during surgery. RESULTS: Using simulated data, we received an overall MRE in the range of 11.69-13.32 pixels for monoscopic and stereo left and right cameras. For the water bath experiment, the overall MRE is in the range of 26.04-30.59 pixels for monoscopic and stereo cameras. The overall system error from TRUS to camera world frame is 4.05 mm. Details of the procedure are given in supplementary material. CONCLUSION: We demonstrate a markerless AR guidance system for RALRP that does not need calibration markers and thus has the capability to re-estimate the camera projection matrix if it changes during surgery, e.g., due to a focus change.


Assuntos
Algoritmos , Imageamento Tridimensional/métodos , Próstata/diagnóstico por imagem , Prostatectomia/métodos , Robótica/instrumentação , Cirurgia Assistida por Computador/métodos , Ultrassonografia/métodos , Realidade Aumentada , Sistemas Computacionais , Desenho de Equipamento , Falha de Equipamento , Humanos , Masculino , Próstata/cirurgia
2.
Pan Afr Med J ; 38: 56, 2021.
Artigo em Francês | MEDLINE | ID: mdl-33854685

RESUMO

The purpose of this study was to assess outcomes of radical prostatectomy in patients with prostate cancer. We conducted a retrospective single-center study in the Department of Urology and Andrology at the Aristide Le Dantec Hospital in Dakar from June 1, 2010 to May 31, 2016. We collected data of 60 patients undergoing radical retropubic prostatectomy associated with dissection of the iliac and obturator nodes. After radical prostatectomy, prostate specific antigen (PSA) levels were undetectable (<0.1 ng/mL) in 20 patients (33.3%). Eleven patients (18.3%), who had biochemical relapse, received complementary hormone therapy. Patients achieved a response after initiation of treatment, and total PSA became undetectable again after an 8-month follow-up period. Mean overall survival was 17.5 months, with a median of 9.49. Cumulative overall survival rates at 1 year, 3 years and 4 years were 42.4, 13.6 and 6.8%, respectively. Mean relapse-free survival was 17.3 months, with a median biochemical relapse-free survival of eleven (11) months. The mean duration of specific survival was 8.1 months, with a median of 3 months. Seven patients had positive resection margins (11.6%). Four patients had lymph node involvement. Radical prostatectomy, suggested in some patients with prostate cancer in our practice, has been shown to be an effective therapeutic method leading to good outcomes.


Assuntos
Antígeno Prostático Específico/sangue , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Intervalo Livre de Doença , Seguimentos , Hospitais Universitários , Humanos , Excisão de Linfonodo , Metástase Linfática , Masculino , Margens de Excisão , Neoplasias da Próstata/patologia , Estudos Retrospectivos , Senegal , Taxa de Sobrevida , Resultado do Tratamento
3.
Oncology ; 99(7): 413-421, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33784675

RESUMO

BACKGROUND: There are many treatment options for localized and locally advanced prostate cancer with radiotherapy and surgery representing the main local therapeutic strategies. SUMMARY: Depending on the risk of disease recurrence, we can stratify patients into low-, intermediate- and high-risk groups, which will guide patients' treatment. For low-risk patients, active surveillance is an option. Brachytherapy is also an option for low- and intermediate-risk patients and can be used as a boost following external beam radiotherapy for high-risk patients. For intermediate- and high-risk patients, radical prostatectomy and radiotherapy should be considered. Moreover, in addition to radiotherapy, concomitant androgen deprivation therapy may be needed. Finally, after radical prostatectomy and depending on pathological, biological and clinical factors, radiotherapy ± androgen deprivation therapy can be proposed as an adjuvant or salvage treatment. Key Messages: With radiotherapy and surgery being well-established treatment options for localized prostate cancer patients with equally good overall survival rates, priority must be given to patients' choice concerning the logistics and the toxicity profile of each option.


Assuntos
Antagonistas de Androgênios/uso terapêutico , Braquiterapia/métodos , Quimiorradioterapia Adjuvante/métodos , Prostatectomia/métodos , Neoplasias da Próstata/mortalidade , Neoplasias da Próstata/terapia , Terapia de Salvação/métodos , Humanos , Masculino , Recidiva Local de Neoplasia , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Taxa de Sobrevida , Resultado do Tratamento
4.
JAMA Netw Open ; 4(3): e212265, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33749767

RESUMO

Importance: With the current patterns of adoption and use of robotic surgery and improvement in the overall survival of patients with prostate cancer, it is important to evaluate the immediate and long-term cost implications of treatments for patients with prostate cancer. Objective: To compare health care costs and use 1 year after open radical prostatectomy (ORP) vs robotic-assisted radical prostatectomy (RARP). Design, Setting, and Participants: This retrospective cohort study used a US commercial claims database from January 1, 2013, to December 31, 2018. A total of 11 457 men aged 18 to 64 years who underwent inpatient radical prostatectomy for prostate cancer and were continuously enrolled with medical and prescription drug coverage from 180 days before to 365 days after inpatient prostatectomy were identified. An inverse probability of treatment weighting analysis was performed to examine the differences in costs and use of health care services by surgical modality. Data analysis was conducted from September 2019 to July 2020. Exposures: Type of surgical procedure: ORP vs RARP. Main Outcomes and Measures: Three outcomes within 1 year after the inpatient prostatectomy were investigated: (1) total health care costs, including reimbursement paid by insurers and out of pocket by patients; (2) health care use, including inpatient readmission, emergency department, hospital outpatient, and office visits; and (3) estimated days missed from work due to health care use. Results: Of the 11 457 patients who underwent inpatient prostatectomy, 1604 (14.0%) had ORP and 9853 (86.0%) had RARP and most patients (8467 [73.9%]) were aged 55 to 64 years. Compared with patients who underwent ORP, those who received RARP had a higher cost at the index hospitalization (mean difference, $2367; 95% CI, $1821-$2914; P < .001), but similar total cumulative costs were observed within 180 days (mean difference, $397; 95% CI, -$582 to $1375; P = .43) and 1 year after discharge (-$383; 95% CI, -$1802 to $1037; P = .60). One-year postdischarge health care use was significantly lower in the RARP compared with ORP group for mean numbers of emergency department visits (-0.09 visits; 95% CI, -0.11 to -0.07 visits; P < .001) and hospital outpatient visits (-1.5 visits; -1.63 to -1.36 visits; P < .001). The reduction in use of health care services among patients who underwent RARP translated into additional savings of $2929 (95% CI, $1600-$4257; P < .001) and approximately 1.69 fewer days (95% CI, 1.49-1.89 days; P < .001) missed from work for health care visits. Conclusions and Relevance: Total cumulative cost in this study was similar between ORP and RARP 1 year post discharge; this finding suggests that lower postdischarge health care use after RARP may offset the higher costs during the index hospitalization.


Assuntos
Custos de Cuidados de Saúde , Hospitalização/economia , Prostatectomia/economia , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/economia , Adolescente , Adulto , Gerenciamento de Dados , Humanos , Masculino , Pessoa de Meia-Idade , Prostatectomia/métodos , Neoplasias da Próstata/economia , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
5.
Orv Hetil ; 162(13): 483-487, 2021 03 28.
Artigo em Húngaro | MEDLINE | ID: mdl-33774598

RESUMO

Összefoglaló. Bevezetés: Az utóbbi években az oligometastaticus prosztatadaganatok kezelése során a szisztémás kezelés mellett egyre gyakrabban végzik a primer tumor lokális kezelését is. Célkituzés: A szerzok a tanulmányban a cytoreductiv radikális prostatectomia szerepét vizsgálták az oligometastaticus prosztatadaganatok kezelése során. Módszer: 2012. 01. 01. és 2019. 01. 01. között összesen hét betegben végeztek cytoreductiv radikális prostatectomiát oligometastaticus prosztatadaganat esetében. A betegek átlagos életkora 64 év, az átlagos PSA-koncentráció 43 ng/ml volt. Az áttétek száma minden beteg vonatkozásában maximum három volt, és valamennyi esetben csontáttét volt jelen. A betegek androgéndeprivatiós hormonkezelést kaptak, és közülük négy esetben már a mutét elott elkezdték a hormonterápiát. Négy betegnél a csontmetastasisok miatt az áttétek sugárkezelése is megtörtént. Eredmények: A cytoreductiv prostatectomia szövettana öt esetben igazolt lokálisan elorehaladott (pT3) daganatot, és két alkalommal marginpozitivitás volt jelen. Emiatt öt beteg kapott adjuváns lokális irradiációt a metastasisok besugárzásán kívül. A mutétet követoen biokémiai progresszió egy esetben jelentkezett. Ennek oka lokális recidíva volt, mely miatt a beteg 'salvage' irradiációt kapott. Az átlagosan 38 hónapos utánkövetés során új metastasist nem diagnosztizáltak, és tumor okozta halálozás nem fordult elo. Következtetés: A cytoreductiv prostatectomia oligometastaticus prosztatarákos betegek kezelésében - válogatott beteganyagon - megvalósítható lehetoség. Ugyanakkor a cytoreductiv prostatectomia elonyei a tumorprogresszió szempontjából még nem egyértelmuek, ennek eldöntéséhez további vizsgálatok szükségesek. Orv Hetil. 2021; 162(13): 483-487. INTRODUCTION: In recent years, in addition to systemic therapy, local treatment of primary tumor has become increasingly common in the treatment of oligometastatic prostate cancers. Objectve: The authors measured the role of cytoreductive radical prostatectomy in the treatment of oligometastatic prostate carcinoma. METHODS: From Janury 2012 to January 2019, they performed cytoreductive radical prostatectomy in seven patients with oligometastatic prostate cancer. The mean age of the patients was 64 years, and the mean PSA value was 43 ng/ml. The patients had maximum three distant metastases and all metastases were localized to the bones. The patients received androgene deprivation therapy and this treatment was started before the surgery in four cases. Irradiation of the bone metastasis was performed in four cases. RESULTS: The histology of the cytoreductive radical prostatectomy showed locally advanced tumor (pT3) in five patients and margin-positive status was present in two cases. Hence, adjuvant irradiation was administered locally in five patients in addition to the irradiation of bone metastases. Biochemical progression was detected in one patient during the follow-up period. It was caused by local recurrence of the tumor and the patient was treated with salvage irradiation. During the 38 months follow-up period neither new distant metastasis nor cancer-related mortality was detected. CONCLUSION: The cytoreductive radical prostatectomy is a feasible option in selected cases with oligometastatic prostate cancer. However, the benefits of cytoreductive radical prostatectomy regarding tumor progression are not clear yet and further studies are required. Orv Hetil. 2021; 162(13): 483-487.


Assuntos
Procedimentos Cirúrgicos de Citorredução , Prostatectomia , Neoplasias da Próstata , Estudos de Viabilidade , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prostatectomia/métodos , Neoplasias da Próstata/patologia , Neoplasias da Próstata/cirurgia , Resultado do Tratamento
6.
Anticancer Res ; 41(3): 1377-1386, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33788729

RESUMO

BACKGROUND/AIM: The purpose of this study was to examine the expression of estrogen receptor α (ERα) and ß (ERß), androgen receptor (AR), SIRT1, SIRT2 and SIRT3 in prostate cancer (PCa). MATERIALS AND METHODS: From October 2010 to January 2015, 70 patients who had undergone radical prostatectomy following a PCa diagnosis were enrolled in our study. Normal prostate tissue (NPT) and prostate cancer tissues (PCAT) were separated, and the expression of each receptor in each tissue was analyzed with immunochemical staining. Univariate and multivariate analyses were performed to identify factors affecting the development of PCa. RESULTS: ERß and AR were highly expressed in PCAT compared with NPT (p<0.05). SIRT2 was highly expressed in NPT and PCAT (p<0.05). Univariate and multivariate analyses showed that AR and SIRT2 affect PCa development. CONCLUSION: AR is a risk factor for PC, and SIRT2 is associated with a lower incidence of PCa.


Assuntos
Receptor alfa de Estrogênio/biossíntese , Receptor beta de Estrogênio/biossíntese , Neoplasias da Próstata/metabolismo , Receptores Androgênicos/biossíntese , Sirtuína 1/biossíntese , Sirtuína 2/biossíntese , Sirtuína 3/biossíntese , Idoso , Humanos , Imuno-Histoquímica/métodos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia
7.
Actas urol. esp ; 45(2): 139-145, mar. 2021. tab
Artigo em Espanhol | IBECS | ID: ibc-201619

RESUMO

INTRODUCCIÓN: Existe muy poca literatura española que compare resultados oncológicos tras prostatectomía radical (PR) según la vía de abordaje y la metodología es inadecuada. OBJETIVO: Comparar los resultados oncológicos en cuanto a márgenes quirúrgicos (MQ) y recidiva bioquímica (RB) entre PR abierta (PRA) y laparoscópica (PRL). MATERIAL Y MÉTODOS: Comparación de 2 cohortes (307 con PRA y 194 con PRL) entre 2007 y 2015. El estado de los MQ se clasificaron como positivos o negativos y la RB como la elevación del PSA después de la PR > 0,4 ng/ml. Para el contraste de variables cualitativas se utilizó el test Chi-cuadrado y ANOVA para las cuantitativas. Para evaluar los factores predictores de los MQ se ha realizado un análisis multivariante mediante regresión logística. Para evaluar los factores predictores de RB se ha realizado un análisis multivariable mediante regresión de Cox. RESULTADOS: El 43,5% de pacientes tuvieron un Gleason 7 (3 + 4) en la pieza quirúrgica y un 31,7% MQ positivos siendo el estadio patológico más frecuente pT2c en el 61,9%. No existieron diferencias significativas entre ambos grupos, excepto la afectación extracapsular (p = 0,001), más frecuente en la PRL. La mediana de seguimiento fue de 49 meses, evidenciando RB en el 23% de pacientes, sin diferencias significativas entre cohortes. En el análisis multivariable solo el grupo de riesgo D'Amico se comportó como factor predictor independiente de MQ positivos y el score de Gleason y los MQ positivos como factores predictores independientes de RB. CONCLUSIÓN: La vía de abordaje no influyó en el estado de MQ ni en la RB


INTRODUCTION: There are very few Spanish studies that compare oncological outcomes following radical prostatectomy (RP) based on surgical approach, and their methodology is not appropriate. OBJECTIVE: To compare oncological outcomes in terms of surgical margins (SM) and biochemical recurrence (BR) between open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP). MATERIAL AND METHODS: Comparison of two cohorts (307 with ORP and 194 with LRP) between 2007-2015. Surgical margin status was defined as positive or negative, and BR as a PSA rise of > 0.4 ng/ml after surgery. To compare the qualitative variables, we employed the Chi-squared test, and ANOVA was used for quantitative variables. We performed a multivariate analysis using logistic regression to evaluate the predictive factors of SM, and a multivariate analysis using Cox regression to evaluate the predictive factors of BR. RESULTS: Gleason 7 (3 + 4) was determined in the surgical specimens of 43.5% of patients, and 31.7% had positive SM. The most frequent pathological stage was pT2c, on the 61.9% of the cases. No significant differences were found between both groups, except for extracapsular extension (p = 0.001), more frequent in LRP. The median follow-up was 49 months. BR was seen in the 23% of patients, without significant differences between groups. In the multivariable analysis, only the D'Amico risk group behaved as an independent predictive factor of positive SM, and Gleason score and positive SM acted as independent predictive factors of BR. CONCLUSION: The surgical approach did not influence SM status or BR


Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Idoso , Prostatectomia/métodos , Laparoscopia/métodos , Adenocarcinoma/cirurgia , Neoplasias da Próstata/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Neoplasias da Próstata/patologia , Adenocarcinoma/patologia , Gradação de Tumores , Margens de Excisão
8.
Rev. int. androl. (Internet) ; 19(1): 49-52, ene.-mar. 2021.
Artigo em Inglês | IBECS | ID: ibc-201670

RESUMO

INTRODUCTION: Adverse effects in the sexual sphere are common in patients who have undergone radical prostatectomy (RP). Climacturia, involuntary loss of urine during orgasm, occurs in 20-40% of cases after PR. We analyse its prevalence and associated risk factors after Robotic-assisted laparoscopic radical prostatectomy (RALRP). OBJECTIVES: We analyse the climacturia prevalence after robotic-assisted laparoscopic radical prostatectomy (RALRP) and the association with other related factors. MATERIALS AND METHODS: Retrospective study of 100 patients underwent PRLAR from May 2011 to July 2014. After excluding patients who received radiotherapy after surgery (17), those who did not have sexual activity (7) and those with whom it could not be possible contacted (14), a structured telephone interview was conducted in 62 patients, investigating: presence and intensity of climacturia, orgasmic quality, incontinence and erectile dysfunction (ED). Other factors analysed included neurovascular preservation and rehabilitative treatment for ED. The statistical analysis consisted of Chi2test and logistic regression to evaluate associated factors. RESULTS: The mean age was 56 vs 59 years and the mean follow-up time was 26.6 vs 20.3 months, in the group with climacturia and without climacturia, respectively. The prevalence of climacturia was 17.9% (slight leaks-82% and severe leaks-18%). In 37% of these patients occurred in all orgasms. The quality of orgasm after surgery was worse in 47%, better in 13% and equal in 40%. The quality of the orgasm worsened more frequently in the climacturia group (63% vs 37%). The urinary incontinence rate was 41%, always effort incontinence. It was more frequent in patients with climacturia (62% vs 38%). In all patients with climacturia, bilateral neurovascular bundles preservation was performed. 32% of the patients had undergone post-surgical erectile rehabilitation with oral drugs. No statistically significant differences were found between patients with or without climacturia respect to the parameters analysed. CONCLUSIONS: Climacturia rate after PRLAR in our series was 17.9%. Patients with climacturia presented worse quality orgasms and a higher incontinence rate (p> 0.05). None of the analysed parameters could be defined as predictors of climacturia


INTRODUCCIÓN: Los efectos adversos en la esfera sexual son comunes en pacientes sometidos a prostatectomía radical (PR). La climaturia, pérdida involuntaria de orina durante el orgasmo, se presenta en un 20-40% de casos tras PR. Analizamos su prevalencia y asociación con otros factores relacionados tras prostatectomía radical laparoscópica asistida por robot (PRLAR). OBJETIVOS: Analizamos la prevalencia de climaturia tras PRLAR y su asociación con otros posibles factores riesgo relacionados. MATERIAL Y MÉTODOS: Estudio retrospectivo de 100 pacientes, sometidos a PRLAR desde mayo-2011 a julio-2014. Tras excluir a pacientes que recibieron radioterapia tras la cirugía (17), a los que no tenían actividad sexual (7) y aquellos con los que no se pudo contactar (14), se realizó entrevista telefónica estructurada a 62 pacientes, indagando sobre: presencia e intensidad de climaturia, calidad orgásmica, incontinencia y disfunción eréctil (DE). Otros factores analizados incluyeron la preservación neurovascular y el tratamiento rehabilitador para DE. El análisis estadístico consistió en prueba de Chi2 y regresión logística para evaluar factores asociados. RESULTADOS: La edad media fue 56 vs 59 años y el tiempo medio de seguimiento de 26,6 vs 20,3 meses, en el grupo con climaturia y sin climaturia respectivamente. La prevalencia de climaturia fue del 17.9% (pérdidas leves el 82% y severas el 18%). En el 37% de estos pacientes ocurrió en todos los orgasmos. La calidad del orgasmo tras cirugía fue peor en el 47%, mejor en el 13% e igual en el 40%. La calidad del orgasmo empeoró con más frecuencia en el grupo con climaturia (63% vs 37%). La tasa de incontinencia urinaria fue del 41%, siempre de esfuerzo. Fue más frecuente en pacientes con climaturia (62% vs 38%). El 68% de los pacientes usaba fármacos para DE. En todos los pacientes con climaturia se realizó preservación nerviosa bilateral. El 32% de los pacientes habían realizado rehabilitación eréctil postquirúrgica con fármacos orales. No se encontraron diferencias estadísticamente significativas entre pacientes con o sin climaturia respecto a los parámetros analizados. CONCLUSIONES: La tasa de climaturia tras PRLAR en nuestra serie fue del 17,9%. Los pacientes con climaturia presentaron orgasmos de peor calidad y una tasa de incontinencia superior (p > 0,05). Ninguno de los parámetros analizados pudieron definirse como factores predictivos de climaturia


Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Incontinência Urinária/etiologia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Complicações Pós-Operatórias/fisiopatologia , Prostatectomia/efeitos adversos , Disfunção Erétil/diagnóstico , Procedimentos Cirúrgicos Robóticos/métodos , Prostatectomia/métodos , Fatores de Risco , Estudos Retrospectivos , Disfunção Erétil/tratamento farmacológico , Disfunção Erétil/reabilitação
9.
Cancer Treat Res Commun ; 27: 100331, 2021.
Artigo em Inglês | MEDLINE | ID: covidwho-1064990

RESUMO

PURPOSE: To adapt the management of prostate malignancy in response to the COVID-19 pandemic. METHODS: In according to the recommendations of the European Association of Urology, we have developed practical additional document on the treatment of prostate cancer. RESULTS: Low-Risk Group Watchful Waiting should be offered to patients >75 years old, with a limited life expectancy and unfit for local treatment. In Active Surveillance (AS) patients re-biopsy, PSA evaluation and visits should be deferred for up to 6 months, preferring non-invasive multiparametric-MRI. The active treatment should be delayed for 6-12 months. Intermediate-Risk Group AS should be offered in favorable-risk patients. Short-course neoadjuvant androgen deprivation therapy (ADT) combined with ultra-hypo-fractionation radiotherapy should be used in unfavorable-risk patients. High-Risk Group Neoadjuvant ADT combined with moderate hypofractionation should be preferred. Whole-pelvis irradiation should be offered to patients with positive lymph nodes in locally advanced setting. ADT should be initiated if PSA doubling time is < 12 months in radio-recurrent patients, as well as in low priority/low volume of metastatic hormone sensitive prostate cancer. If radiotherapy cannot be delayed, hypo-fractionated regimens should be preferred. In high priority class metastatic disease, treatment with androgen receptor-targeted agents should be offered. When palliative radiotherapy for painful bone metastasis is required, single fraction of 8 Gy should be offered. CONCLUSIONS: In Covid-19 Era, the challenge should concern a correct management of the oncologic patient, reducing the risk of spreading the virus without worsening tumor prognosis.


Assuntos
Antagonistas de Androgênios/uso terapêutico , COVID-19/prevenção & controle , Neoplasias da Próstata/terapia , Hipofracionamento da Dose de Radiação , SARS-CoV-2/isolamento & purificação , Idoso , COVID-19/epidemiologia , COVID-19/virologia , Quimiorradioterapia , Intervalo Livre de Doença , Humanos , Masculino , Terapia Neoadjuvante , Pandemias , Antígeno Prostático Específico/análise , Prostatectomia/métodos , Neoplasias da Próstata/diagnóstico , Fatores de Risco , SARS-CoV-2/fisiologia , Fatores de Tempo , Conduta Expectante/métodos
10.
J Urol ; 205(6): 1671-1680, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33605794

RESUMO

PURPOSE: Catheter-related bladder discomfort occurs in up to 63% of patients following robot-assisted radical prostatectomy. The optimal intraoperative anesthesia regime to prevent patients from catheter-related bladder discomfort is unknown. MATERIALS AND METHODS: A prospective cohort analysis was conducted. Patients with biopsy-proven prostate cancer selected for robot-assisted radical prostatectomy were included between January 2017 and April 2020 from a high volume prostate cancer center. Eight different treatment regimens were compared, ie a combination of general anesthesia and a transversus abdominis plane block with either an additional dose of clonidine or an additional dose of ketamine, or perivesical infiltrations (with 20 ml ropivacaine), or periurethral infiltrations (with ropivacaine); or a dorsal penile nerve block (with 20 ml ropivacaine). Multiple logistic regression and linear mixed models were used to analyze differences in catheter-related bladder discomfort and pain (0-10) at the postoperative recovery unit between the treatment protocols. RESULTS: Of the 391 patients included, those with a combination transversus abdominis plane block, perivesical and periurethral block with ropivacaine had the lowest incidence of catheter-related bladder discomfort, clinically relevant and statistically significantly lower compared to our baseline protocol (transversus abdominis plane block only), ie 36% vs 70%, p=0.001. Overall, patients who were treated with periurethral and/or perivesical infiltrations reported a statistically significantly lower incidence of catheter-related bladder discomfort compared to patients who did not receive this local infiltration (46.5% vs 60.7%, p=0.001). CONCLUSIONS: Perivesical and periurethral injections with ropivacaine have the potential to reduce the incidence of early postoperative catheter-related bladder discomfort by up to 49%. Further randomized studies are necessary to determine the optimal treatment regime to prevent early postoperative catheter-related bladder discomfort.


Assuntos
Cuidados Intraoperatórios/métodos , Dor Processual/etiologia , Dor Processual/prevenção & controle , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Prostatectomia , Procedimentos Cirúrgicos Robóticos , Bexiga Urinária , Cateteres Urinários/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso , Estudos Prospectivos , Prostatectomia/métodos , Fatores de Tempo
11.
J Urol ; 206(1): 88-96, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33617326

RESUMO

PURPOSE: Salvage lymph node dissection is a rescue treatment for patients with nodal recurrence after radical prostatectomy. Very limited data are available on robotic salvage lymph node dissection. Our purpose was to investigate perioperative and oncological outcomes of robotic salvage lymph node dissection in a large monocentric series. MATERIALS AND METHODS: Perioperative data, complications within 30 days after surgery and oncological outcomes as assessed by histology, prostate specific antigen changes, prostate specific antigen nadir after salvage lymph node dissection, and time to further therapy were analyzed. To identify predictive factors for oncological outcome, Kaplan-Meier and Cox-regression analyses were performed. For cases with a mismatch between preoperative positron emission tomography/computed tomography and the number of histologically positive lymph nodes, prostate specific membrane antigen immunohistochemistry was performed on removed lymph nodes. RESULTS: A total of 68 patients underwent robotic salvage lymph node dissection with a median operation time of 126 minutes, a blood loss of 50 ml, and a length of stay of 4 days. No major complications (>Clavien 3) occurred. Median followup was 12.1 months. Median time to further therapy was 12.4 months, 37% of patients experienced complete biochemical response (prostate specific antigen <0.2 ng/ml) and 11% reached an undetectable prostate specific antigen, which was maintained for >1 year in 3 cases. Lower preoperative prostate specific antigen, longer time between radical prostatectomy and salvage lymph node dissection, preoperative prostate specific membrane antigen positron emission tomography/computed tomography and complete biochemical response after salvage lymph node dissection were significant predictors of longer therapy-free survival (all p <0.005). Prostate specific membrane antigen immunohistochemistry revealed that prostate specific membrane antigen positron emission tomography/computed tomography tends to miss small lymph node metastases <5 mm. CONCLUSIONS: Robotic salvage lymph node dissection is a feasible approach with low perioperative morbidity and delays further systemic therapy in most patients. Prostate specific membrane antigen positron emission tomography/computed tomography detection is mostly limited to tumor foci >5 mm.


Assuntos
Excisão de Linfonodo/métodos , Recidiva Local de Neoplasia/cirurgia , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos , Terapia de Salvação/métodos , Idoso , Idoso de 80 Anos ou mais , Previsões , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico por imagem , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Neoplasias da Próstata/diagnóstico por imagem , Estudos Retrospectivos , Resultado do Tratamento
12.
J Urol ; 206(1): 104-108, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33617333

RESUMO

PURPOSE: Holmium laser enucleation of the prostate has proven to be efficacious and safe for the treatment of benign prostatic hyperplasia. New laser technologies, such as the MOSES™ pulse laser system, improve energy delivery and may improve operative times. We sought to prospectively evaluate holmium laser enucleation of the prostate using MOSES technology in a double-blind randomized controlled trial. MATERIALS AND METHODS: This is a single-center, prospective, double-blind, randomized controlled trial comparing holmium laser enucleation of the prostate using MOSES technology to holmium laser enucleation of the prostate. Patients were randomized in a 1:1 fashion. The study was powered to evaluate for a difference in operative time. Secondary end points included enucleation, morcellation, and hemostasis times, as well as blood loss, functional outcomes and complications 6 weeks postoperatively. RESULTS: A total of 60 patients were analyzed without difference in preoperative characteristics in either group (holmium laser enucleation of the prostate using MOSES technology: 30/60, 50%, holmium laser enucleation of the prostate: 30/60, 50%). Shorter total operative time was seen in the holmium laser enucleation of the prostate using MOSES technology group compared to the holmium laser enucleation of the prostate group (mean: 101 vs. 126 minutes, p <0.01). This difference remained significant on multiple linear regression. Additionally, the holmium laser enucleation of the prostate using MOSES technology group had shorter enucleation times (mean: 68 vs. 80 minutes, p=0.03), hemostasis time (mean: 18 vs. 29 minutes, p <0.01), and less blood loss (mean: -6.3 vs. -9.0%, p=0.03), measured by a smaller change in hematocrit postoperatively, compared to the traditional holmium laser enucleation of the prostate. There was no difference in functional or safety outcomes at followup. CONCLUSIONS: We report the results of a prospective, double-blind, randomized controlled trial comparing holmium laser enucleation of the prostate using MOSES technology to traditional holmium laser enucleation of the prostate. MOSES technology resulted in an improvement in operative time and a reduction in blood loss with comparable functional outcomes and complications compared to traditional holmium laser enucleation of the prostate.


Assuntos
Lasers de Estado Sólido/uso terapêutico , Prostatectomia/métodos , Hiperplasia Prostática/cirurgia , Idoso , Método Duplo-Cego , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
13.
J Urol ; 205(6): 1681-1688, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33530745

RESUMO

PURPOSE: Erectile dysfunction significantly impacts quality of life for men undergoing radical prostatectomy for prostate cancer. Erythropoietin is a promising neurotrophic factor for neurogenic erectile dysfunction based on preclinical and retrospective data. MATERIALS AND METHODS: ERECT (NCT00737893) is a phase 2, double-blinded, randomized, placebo-controlled trial (July 2017-December 2019) evaluating the impact of perioperative erythropoietin on recovery of erectile function and other patient-reported, health-related quality of life outcomes after bilateral nerve-sparing radical prostatectomy (3, 6, 9, and 12 months). Erythropoietin (20,000 units) or saline placebo was injected subcutaneously the day before, day of, and day after surgery for 3 total doses. RESULTS: Of 63 patients assessed for eligibility, 56 patients were randomized. Arms (29 erythropoietin, 27 placebo) were well balanced (89.3% robotic, median age 55.5 years). International Index of Erectile Function-Erectile Function Domain (IIEF-EF) scores increased from median 12.5 at 3 months to 24.5 at 12 months. Median 2-week serum hemoglobin was higher for the erythropoietin arm compared to placebo (14.7 vs 13.6, p=0.02). There was no statistically significant difference in IIEF-EF scores at 6 months comparing erythropoietin to placebo (p=0.50) or at other time points (mixed model regression coefficient: -1.7, 95% CI -6.1-2.7, p=0.45). Excellent nerve-sparing rating (10/10) was associated with improved IIEF-EF recovery (+5.2, p=0.022). Other patient-reported, health-related quality of life domains as well as oncologic outcome and complications were similar between arms during followup. CONCLUSIONS: In the context of brief perioperative dosing, erythropoietin did not improve recovery of erectile function for men undergoing radical prostatectomy for prostate cancer compared to placebo. Further research to identify effective adjuncts to improve health-related quality of life for these men is needed.


Assuntos
Disfunção Erétil/tratamento farmacológico , Eritropoetina/uso terapêutico , Complicações Pós-Operatórias/tratamento farmacológico , Prostatectomia , Neoplasias da Próstata/cirurgia , Método Duplo-Cego , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Prostatectomia/métodos , Qualidade de Vida , Recuperação de Função Fisiológica , Resultado do Tratamento
14.
J Urol ; 205(6): 1663-1670, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33535796

RESUMO

PURPOSE: We sought to address the impact of preoperative prostate specific membrane antigen (PSMA) positron emission tomography (PET) findings prior to radical prostatectomy and pelvic lymph node dissection on biochemical recurrence and time to adjuvant or salvage treatment. MATERIALS AND METHODS: Between 2013 and 2017, 64 intermediate and 166 high risk (230) prostate cancer patients received 68Ga-PSMA-11 PET followed by radical prostatectomy and pelvic lymph node dissection. Biochemical recurrence-free and therapy-free survivalwere determined. For all time-to-event analyses, univariable and multivariable Cox proportional hazards models and univariable Kaplan-Meier analyses were applied, with a significance threshold of p <0.05. RESULTS: The overall sensitivity, specificity, positive predictive value and negative predictive value of PSMA PET for pN1 disease was 48.5%, 95.7%, 82.1% and 82.2%, respectively. Median followup was 30.2 months. Biochemical recurrence occurred in 50.4% (116) of patients and adjuvant or salvage treatment was performed in 46.5% (107). Worst biochemical recurrence-free and therapy-free survival was observed in pN1 patients who also exhibited PSMA PET positive lymph node, followed by pN1 patients without PSMA PET positive lymph node and patients without evidence of lymph node metastasis on histology and PSMA PET (median biochemical recurrence-free survival 1.7 vs. 7.5 vs. >36 months, median therapy-free survival 2.6 vs. 8.9 vs. >36 months). CONCLUSIONS: Patients with positive lymph node on PSMA PET prior to radical prostatectomy have to expect early biochemical recurrence and adjuvant/salvage therapy, despite thorough pelvic lymph node dissection. Therefore, results from PSMA PET can be used for patients' consultation and more stringent followup as well as for planning of neoadjuvant/adjuvant therapy.


Assuntos
Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Tomografia por Emissão de Pósitrons , Prostatectomia , Neoplasias da Próstata/patologia , Neoplasias da Próstata/cirurgia , Idoso , Idoso de 80 Anos ou mais , Correlação de Dados , Intervalo Livre de Doença , Humanos , Excisão de Linfonodo , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Pelve , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodos , Prostatectomia/métodos , Estudos Retrospectivos
15.
Neurourol Urodyn ; 40(3): 840-847, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33604977

RESUMO

AIMS: To identify the definition for urinary continence (UC) after radical prostatectomy (RP) which reflects best patients' perception of quality of life (QoL). METHODS: Continence was prospectively assessed in 634 patients, 12 months after RP using the International Consultation on Incontinence Questionnaire Short-Form (ICIQ-SF) and the number of pads employed in a 24-hour period (pad usage). We used the one-way ANOVA technique with posthoc pairwise comparisons according to Scheffé's method (homogeneous subsets) for assessing the degree of QoL deficit related to urinary incontinence (UI). RESULTS: The continence prevalence is 64.4%, 74.1%, 88.3%, and 35.8% using "0 pads," "1 safety pad," "1 pad," and "ICIQ score 0" definitions, respectively. Pad usage is moderately strongly associated with ICIQ 1, 2, and 3 (ρ = 0.744, 0.677, and 0.711, respectively; p < 0.001). Concordance between classical UC definitions is acceptable between "0 pads-ICIQ score 0" (K = 0.466), but poor for "1 safety pad" and "1 pad" (K = 0.326 and 0.137, respectively). Patients with "0 pad usage" have better QoL related to urine leakage than patients with "1 safety pad" or "1 pad" (1.41 vs. 2.44 and 3.11, respectively; p < 0.05). There were no significant differences found regarding QoL between patients with ICIQ score 0 and ICIQ score 2 (1.01 vs. 1.63; p = 0.63). CONCLUSIONS: Pad usage and the ICIQ-SF's answers provide useful information. We propose a combined definition (0 pads and ICIQ score ≤2) as it is the definition with the least impact on daily QoL.


Assuntos
Prostatectomia/métodos , Qualidade de Vida/psicologia , Encaminhamento e Consulta/normas , Incontinência Urinária/etiologia , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Próstata/cirurgia , Inquéritos e Questionários
16.
Med Sci Monit ; 27: e928596, 2021 Feb 22.
Artigo em Inglês | MEDLINE | ID: mdl-33612711

RESUMO

BACKGROUND The Chinese 2018 guidelines and the current 2014 Chinese Urological Association guidelines for prostate cancer recommend radical prostatectomy for Chinese men with localized prostate cancer as the first choice, but it has treatment-related adverse effects. This study aimed to study morbidity and all-cause mortality following radical prostatectomy compared with observation for localized prostate cancer in Chinese men from a single center. MATERIAL AND METHODS Men diagnosed (histologically) as stage T1-T2N×M0 prostate cancer of any grade with 1-year history were included in the analysis. A total of 201 men underwent radical prostatectomy (RP cohort) and 209 men did not undergo radical prostatectomy (OS cohort). RESULTS During follow-up (17-24 years), 135 (67%) men died in the RP cohort and 156 (75%) men died in the OS cohort (P=0.103). All-cause mortality was lower for men with prostate-specific antigen level >10 ng/mL (P<0.0001), Gleason score ≥7 (P=0.004), and high D'Amico tumor risk scores (P=0.007) if they underwent radical prostatectomy. Age ≥65 years (P=0.041), Gleason score ≥7 (P=0.049), and tumor stage ≥2c (P=0.045) were associated with all-cause mortality. CONCLUSIONS The findings from this study showed that radical prostatectomy has no significant beneficial effects when compared with observation for Chinese men with localized prostate cancer, unless they had a prostate-specific antigen level >10 ng/mL, Gleason score ≥7, and high D'Amico tumor risk scores.


Assuntos
Prostatectomia/mortalidade , Neoplasias da Próstata/mortalidade , Idoso , Grupo com Ancestrais do Continente Asiático , China/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade , Gradação de Tumores , Estadiamento de Neoplasias , Próstata/patologia , Antígeno Prostático Específico/análise , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Estudos Retrospectivos
17.
Cancer Treat Res Commun ; 27: 100331, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33581491

RESUMO

PURPOSE: To adapt the management of prostate malignancy in response to the COVID-19 pandemic. METHODS: In according to the recommendations of the European Association of Urology, we have developed practical additional document on the treatment of prostate cancer. RESULTS: Low-Risk Group Watchful Waiting should be offered to patients >75 years old, with a limited life expectancy and unfit for local treatment. In Active Surveillance (AS) patients re-biopsy, PSA evaluation and visits should be deferred for up to 6 months, preferring non-invasive multiparametric-MRI. The active treatment should be delayed for 6-12 months. Intermediate-Risk Group AS should be offered in favorable-risk patients. Short-course neoadjuvant androgen deprivation therapy (ADT) combined with ultra-hypo-fractionation radiotherapy should be used in unfavorable-risk patients. High-Risk Group Neoadjuvant ADT combined with moderate hypofractionation should be preferred. Whole-pelvis irradiation should be offered to patients with positive lymph nodes in locally advanced setting. ADT should be initiated if PSA doubling time is < 12 months in radio-recurrent patients, as well as in low priority/low volume of metastatic hormone sensitive prostate cancer. If radiotherapy cannot be delayed, hypo-fractionated regimens should be preferred. In high priority class metastatic disease, treatment with androgen receptor-targeted agents should be offered. When palliative radiotherapy for painful bone metastasis is required, single fraction of 8 Gy should be offered. CONCLUSIONS: In Covid-19 Era, the challenge should concern a correct management of the oncologic patient, reducing the risk of spreading the virus without worsening tumor prognosis.


Assuntos
Antagonistas de Androgênios/uso terapêutico , COVID-19/prevenção & controle , Neoplasias da Próstata/terapia , Hipofracionamento da Dose de Radiação , SARS-CoV-2/isolamento & purificação , Idoso , COVID-19/epidemiologia , COVID-19/virologia , Quimiorradioterapia , Intervalo Livre de Doença , Humanos , Masculino , Terapia Neoadjuvante , Pandemias , Antígeno Prostático Específico/análise , Prostatectomia/métodos , Neoplasias da Próstata/diagnóstico , Fatores de Risco , SARS-CoV-2/fisiologia , Fatores de Tempo , Conduta Expectante/métodos
18.
Isr Med Assoc J ; 23(2): 111-115, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33595217

RESUMO

BACKGROUND: Little is known about oncologic outcomes following robot-assisted-radical-prostatectomy (RALP) for clinical T3 (cT3) prostate cancer. OBJECTIVES: To investigate oncologic outcomes of patients with cT3 prostate cancer treated by RALP. METHODS: Medical records of patients who underwent RALP from 2010 to 2018 were retrieved. cT3 cases were reviewed. Demographic and pre/postoperative pathology data were analyzed. Patients were followed in 3-6 month intervals with repeat PSA analyses. Adjuvant/salvage treatments were monitored. Biochemical recurrence (BCR) meant PSA levels of ≥ 0.2 ng/ml. RESULTS: Seventy-nine patients met inclusion criteria. Median age at surgery was 64 years. Preoperative PSA level was 7.14 ng/dl, median prostate weight was 54 grams, and 23 cases (29.1%) were down-staged to pathological stage T2. Positive surgical margin rate was 42%. Five patients were lost to follow-up. Median follow-up time for the remaining 74 patients was 24 months. Postoperative relapse in PSA levels occurred in 31 patients (42%), and BCR in 28 (38%). Median time to BCR was 9 months. The overall 5-year BCR-free survival rate was 61%. Predicting factors for BCR were age (hazard-ratio [HR] 0.85, 95% confidence interval [95%CI] 0.74-0.97, P = 0.017) and prostate weight (HR 1.04, 95%CI 1.01-1.08, P = 0.021). Twenty-six patients (35%) received adjuvant/salvage treatments. Three patients died from metastatic prostate cancer 31, 52, and 78 months post-surgery. Another patient died 6 months post-surgery of unknown reasons. The 5-year cancer-specific survival rate was 92. CONCLUSIONS: RALP is an oncologic effective procedure for cT3 prostate cancer. Adjuvant/salvage treatment is needed to achieve optimal disease-control.


Assuntos
Antígeno Prostático Específico/análise , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Intervalo Livre de Doença , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Neoplasias da Próstata/patologia , Estudos Retrospectivos , Terapia de Salvação , Taxa de Sobrevida , Resultado do Tratamento
19.
Curr Urol Rep ; 22(4): 20, 2021 Feb 08.
Artigo em Inglês | MEDLINE | ID: mdl-33554295

RESUMO

PURPOSE OF REVIEW: To discuss mechanical and surgical innovations in inflatable penile prosthesis (IPP) surgery and their implications on reservoir placement and patient outcomes. RECENT FINDINGS: The past decade has seen a new emphasis on optimizing outcomes and minimizing complications associated with IPP reservoirs. Innovations in device design have accordingly yielded safer, more durable IPP outcomes over the past four decades. Modifications in surgical approach for reservoir placement abound for both traditional space of Retzius and ectopic reservoir placement techniques. Surgical and medical history, patient anatomy, and patient preference should all be considered when choosing approach for IPP reservoir placement. Prosthetic urologists should be proficient in multiple approaches to provide the best care to their patients.


Assuntos
Disfunção Erétil/cirurgia , Implante Peniano/métodos , Prótese de Pênis , Desenho de Prótese , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Masculino , Pelve/cirurgia , Implante Peniano/efeitos adversos , Implante Peniano/instrumentação , Implante Peniano/tendências , Prótese de Pênis/efeitos adversos , Prótese de Pênis/tendências , Prostatectomia/efeitos adversos , Prostatectomia/métodos , Desenho de Prótese/tendências , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Resultado do Tratamento
20.
Curr Urol Rep ; 22(4): 22, 2021 Feb 08.
Artigo em Inglês | MEDLINE | ID: mdl-33554322

RESUMO

PURPOSE: To provide a comprehensive review on the new da Vinci SP (single port) robotic surgical system. The published literature to date within urology and a description of the new system will be discussed. FINDINGS: There are currently no high-quality published studies with the SP robotic system. All studies are case series, many with 10 or fewer patients. However, all studies have found the SP system to be safe and feasible in performing most urological procedures. Renal and pelvic surgery using the SP robotic system is safe and feasible in the hands of expert robotic surgeons. Long-term, high-quality data is lacking. While the current high price and the learning curve will limit the SP systems' use in many health care systems, new updates and the release of robotic surgical systems from other developers may help drive down costs and encourage uptake.


Assuntos
Procedimentos Cirúrgicos Robóticos/instrumentação , Doenças Urológicas/cirurgia , Procedimentos Cirúrgicos Urológicos/instrumentação , Cistectomia/instrumentação , Cistectomia/métodos , Endoscopia , Humanos , Imageamento Tridimensional , Pelve Renal/cirurgia , Curva de Aprendizado , Nefrectomia/instrumentação , Nefrectomia/métodos , Prostatectomia/instrumentação , Prostatectomia/métodos , Procedimentos Cirúrgicos Reconstrutivos/instrumentação , Procedimentos Cirúrgicos Reconstrutivos/métodos , Procedimentos Cirúrgicos Robóticos/economia , Procedimentos Cirúrgicos Robóticos/educação , Procedimentos Cirúrgicos Robóticos/tendências , Ureter/cirurgia , Bexiga Urinária/cirurgia , Procedimentos Cirúrgicos Urológicos/economia , Procedimentos Cirúrgicos Urológicos/educação , Procedimentos Cirúrgicos Urológicos/tendências
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