Does vaginal surgery for correction of pelvic organ prolapse improve urinary function? A prospective cohort study.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) is caused by an imbalance in the stability of the pelvic organs, resulting in loss of support. The most common types of POP, anterior and apical, are associated with lower urinary tract symptoms (LUTS) such as bladder outlet obstruction and detrusor overactivity (DO). Vaginal surgery may improve LUTS and overall urinary symptoms. We assessed urodynamic (UD) parameters and urinary symptoms before and after vaginal surgery for POP correction. METHODS: A prospective cohort of 59 women with symptomatic anterior and/or apical POP associated with urinary symptoms and with indications for vaginal surgery were included. POP surgeries included anterior colporrhaphy and vaginal hysterectomy with culdoplasty (VH) and with/without concomitant posterior colporrhaphy and mid-urethral sling (MUS). All participants underwent UD evaluation and answered urinary symptom questionnaires pre- and 3 months post-surgery. RESULTS: Anterior colporrhaphy was performed in all patients: 45.7% with associated VH and 54.2% with concomitant MUS. Preoperative ICIQ-OAB score >8 points was significantly associated with DO (p<0.02) and decreased after surgery (9±4.3 to 3.2±3.0, p<0.001). All other questionnaires demonstrated improvements in urinary symptoms. Stress urinary incontinence rate decreased from 59.6% to 21% (p<0.001). Post-void residual (PVR) volume and Valsalva maneuver also decreased (p<0.001). CONCLUSIONS: Pelvic organ prolapse surgery reduced the prevalence of urgency symptoms, and all questionnaires on urinary symptoms showed clinically significant improvement. Vaginal surgery for POP, even combined with MUS, significantly reduced PVR volume and improved urgency symptoms.

The current role of local treatment in metastatic prostate cancer: systematic review and meta-analysis.

BACKGROUND: The aim of this study was to evaluate the current role of local treatment in prostate cancer with a low metastatic burden (or oligometastatic) in relation to survival and safety. METHODS: We performed a meta-analysis of studies published in the MEDLINE, EMBASE, and Cochrane databases until December 2021. Studies comparing local and nonlocal treatment in patients with metastatic prostate cancer were included. The risk of bias within studies was assessed using the Newcastle-Ottawa and Cochrane risk of bias tool. Oligo-metastasis was defined as low-volume metastasis with up to five lesions. The local treatment used was radical prostatectomy or external beam radiation therapy associated with systemic therapy (i.e., androgen deprivation therapy ± abiraterone, docetaxel, enzalutamide, or apalutamide). The endpoints evaluated were overall survival, cancer-specific survival, failure-free survival, and complication rates. RESULTS: Thirteen studies including 46,541 patients were included. The 5-year overall survival (16.0% vs. 6.5%, respectively; odds ratio (OR) 2.74; 95% confidence interval (CI), 2.18, 3.44; I2 = 0%; p < .00001) and 3-year cancer-specific survival (48.2% vs. 26.3%, respectively; OR 1.87; 95% CI: 1.44, 2.44; I2 = 0%; p < .00001) were higher in the local treatment group than that of the nonlocal treatment group. In addition, failure-free survival at 3 years was higher in the local treatment group than that of the nonlocal treatment group (40.5% vs. 28.4%, respectively; OR 1.72; 95% CI, 1.38, 2.14; I2 = 0%; p < .00001). The low complication rate of Clavien-Dindo grade ≥3 indicated that local treatment is feasible and safe in this setting. CONCLUSION: Recent data have shown that local treatment combined with systematic therapy, might improve the overall, cancer-specific, and failure-free survivals of patients diagnosed with metastatic prostate cancer. Furthermore, local treatment is both feasible and safe. Further studies evaluating the quality of life of these patients are needed.

Is a sampling transition zone important to increase the detection of prostate cancer in systematic prostatic biopsies?

BACKGROUND: Use of transrectal ultrasound (US)-guided biopsies improved diagnosis and treatment for patients with high prostate-specific antigen (PSA) or abnormal digital rectal exam (DRE). PURPOSE: To investigate whether taking two transition zone (TZ) biopsies in addition to routine prostate double-sextant biopsies (12-cores) would improve detection rates of prostate cancer (PCa). MATERIAL AND METHODS: A retrospective analysis of 1107 in a single institution database after Institutional Review Board approval, which underwent US-guided prostate biopsies from January 2014 to June 2016. All patients with suspected PCa based on positive DRE or high PSA submitted to US-guided prostate biopsy (double-sextant 12-cores alone and 12-cores with two TZ extra cores) were included. RESULTS: A total of 1107 patients were included; 120 patients underwent double-sextant 12-cores alone and 987 underwent 12-cores with two TZ extra cores. Among patients submitted to two TZ extra cores, TZs of 755 (76.5%) patients were negative to neoplasia and 232 (23.5%) were positive to neoplasia. Among these patients, 26 (2.6%) had their final Gleason score increased with TZ core; TZ fragments of 20 (2.0%) patients led to a treatment change (re biopsy, active surveillance or from active surveillance to radiation therapy or radical prostatectomy). When the complication rate is analyzed (with or without hospital admission), among the patients submitted to TZ cores, 259 (26.2%) complications were observed; between those submitted to double-sextant 12-cores, 26 (21.7%) complications were observed (P=0.279). CONCLUSION: Extended core biopsy protocol with two TZ extra fragments improves detection rates of cancer when compared to double-sextant biopsy protocol without increasing complication rates. TZ routine cores should be considered.

Incremental diagnostic value of targeted biopsy using mpMRI-TRUS fusion versus 14-fragments prostatic biopsy: a prospective controlled study.

OBJECTIVES: To compare the incremental diagnostic value of targeted biopsy using real-time multiparametric magnetic resonance imaging and transrectal ultrasound (mpMRI-TRUS) fusion to conventional 14-cores biopsy. PATIENTS AND METHODS: Uni-institutional, institutional review board (IRB) approved prospective blinded study comparing TRUS-guided random and targeted biopsy using mpMRI-TRUS fusion, in 100 consecutive men. We included men with clinical-laboratorial suspicious for prostate cancer and Likert score ≥ 3 mp-MRI. Patients previously diagnosed with prostate cancer were excluded. All patients were submitted to 14-cores TRUS-guided biopsy (mpMRI data operator-blinded), followed by targeted biopsy using mpMRI-TRUS fusion. RESULTS: There was an overall increase in cancer detection rate, from 56% with random technique to 62% combining targeted biopsy using mpMRI-TRUS fusion; incremental diagnosis was even more relevant for clinically significant lesions (Gleason ≥ 7), diagnosing 10% more clinically significant lesions with fusion biopsy technique. Diagnosis upgrade occurred in 5 patients that would have negative results in random biopsies and had clinically significant tumours with the combined technique, and in 5 patients who had the diagnosis of significant tumours after fusion biopsy and clinically insignificant tumours in random biopsies(p=0.0010). CONCLUSIONS: Targeted biopsy using mpMRI-TRUS fusion has incremental diagnostic value in comparison to conventional random biopsy, better detecting clinically significant prostate cancers. KEY POINTS: • mpMRI-TRUS targeted biopsy increases overall cancer detection rate, but not statistically significant. • mpMRI-TRUS targeted biopsy actually improves the diagnosis of clinically significant PCa. • There was no evidence to acquire the mpMRI-TRUS fusion cores alone.

Genitourinary and gastrointestinal toxicity among patients with localized prostate cancer treated with conventional versus moderately hypofractionated radiation therapy: systematic review and meta-analysis.

BACKGROUND: Hypofractionated (HRT) prostate radiation therapy has the potential to deliver a higher biologically effective dose over a shorter time compared with conventional fractionation (CRT). HRT, giving fewer fractions each with higher dose, might improve the therapeutic ratio, resource use and patient convenience but the toxicity is still controversial. Our objective was to compare the gastroinstestinal (GI) and genitourinary (GU) toxicity of HRT versus CRT. METHODS: Systematic review and meta-analysis of randomized clinical trials studies in PubMed, Cochrane and EMBASE databases published through December 2016 was done. Only randomized trials that evaluated patients with localized prostate cancer (PCa) undergoing CRT or HRT were included. In these studies, the daily dose was 1.8 Gy or 2 Gy per day for CRT and 2.4 to 3.4 Gy for HRT. RESULTS: 7317 patients in nine studies were analyzed. Six studies included acute GU toxicity data which showed similar rates for both HRT and CRT (32.6vs. 31.9%; RD 0.00; 95% CI; -0.03,0.03; p = .81; I2 = 0%). Similarly, seven studies showed no difference in late GU toxicity based on treatment schedule (28.7 vs. 28.0%; RD -0.01; 95% CI; -0.04,0.03; p = .67; I2 = 52%). GI toxicity at three months after radiotherapy was higher in patients treated with HRT in six studies (27.5 vs. 21.9%; RD 0.06; 95% CI; 0.02,0.10; p = .004; I2 = 39%); however, eight studies showed GI toxicity 12 months or more after radiotherapy that was statistically the same (12.9 HRT vs. 16.2% CRT; RD -0.01; 95% CI; -0.04,0.02; p = .41; I2 = 58%). CONCLUSION: In meta-analysis of the available randomized trials on moderate HRT versus CRT for prostate cancer, acute and late GU toxicity were similar for both treatment schemes. While HRT was associated with higher acute GI toxicity, late toxicity was similar.

Robotic-assisted partial Nephrectomy: initial experience in South America.

OBJECTIVE: To report the initial outcomes of robotic-assisted partial nephrectomy in a tertiary center in South America. MATERIAL AND METHODS: From 11/2008 to 12/2009, a total of 16 transperitoneal robotic-assisted partial nephrectomies were performed in 15 patients to treat 18 kidney tumors. One patient with bilateral tumor had two procedures, while two patients with two synchronous unilateral tumors had a single operation to remove them. Eleven (73%) patients were male and the right kidney was affected in 7 (46%) patients. The median patient age and tumor size were 57 years old and 30 mm, respectively. Five (28%) tumors were hilar and/or centrally located. RESULTS: The median operative time, warm ischemia time and estimated blood loss was 140 min, 27 min and 120 mL, respectively. Blood transfusion was required in one patient with bilateral tumor, and one additional pyelolithotomy was performed due to a 15 mm stone located in the renal pelvis. The histopathology analysis showed 15 (83%) malignant tumors, which 10 (67%) were clear cell carcinoma. The median hospital stay was 72 hrs and no major complication was observed. CONCLUSION: Robotic-assisted partial nephrectomy is safe and represents a valuable option to perform minimally invasive nephron-sparing surgery.

Surgical Treatment of Peyronie's Disease: Systematic Review of Techniques Involving or Not Tunica Albuginea Incision.

INTRODUCTION: Peyronie's disease is characterized by abnormal healing of the tunica albuginea (TA), resulting in the production of a fibrotic plaque that leads to penile curvature and considerable psychological impact. Precise knowledge of various surgical techniques is of fundamental importance for proper management of the patient. AIM: To compare results (including surgical success on quality of life and sexual satisfaction and complications) between 2 different techniques: with TA incision vs without TA incision. METHODS: The search was performed according to PRISMA in PubMed and Embase through September 2018. Key words searched were ["Peyronie" or "Peyronie's disease" or "penile curvature" or "penile induration"] and ["technique" or "surgery" or "surgical"] and ["quality of life" or "sexual quality of life" or "sexual satisfaction" or "outcome" or "outcomes"]. MAIN OUTCOME MEASURE: Thirty-one articles were considered for this review. The main outcomes were reported descriptively. RESULTS: The most significant results included penile straightening (88.5% vs 70.9% favoring not opening TA), perception of a palpable nodule (13.2% vs 27.4% favoring not opening TA), and loss of sensibility (11% vs 20% favoring not opening TA). Neither a prospective randomized study nor a direct comparison study has been performed for these techniques. There is no consensus among the studies on how to measure results. Subjective criteria were primarily used for evaluation, and there is a paucity of objective tools to quantify the outcomes. CONCLUSION: There is no consensus on which technique achieves better results or fewer complications; therefore, the decision on which technique to use is a matter of surgeon preference. Studies comparing distinctive techniques and either opening or not opening the tunica albuginea should be performed to support surgical decision making. In addition, guidelines that could assist in the standardization of criteria should be investigated in future studies, with the aim of better evaluating outcomes. Barbosa, ARG, Takemura LS, Cha JD, et al. Surgical Treatment of Peyronie's Disease: Systematic Review of Techniques Involving or Not Tunica Albuginea Incision. Sex Med Rev 2020;8:324-332.

Comparison of complications rates between multiparametric magnetic resonance imaging-transrectal ultrasound (TRUS) fusion and systematic TRUS prostatic biopsies.

PURPOSE: The aim of this study was to compare the complication rates between transrectal ultrasound (TRUS) systematic prostate biopsy and multiparametric magnetic resonance imaging (MRI)-TRUS fusion prostate biopsy techniques. MATERIALS AND METHODS: This is a single-center retrospective study, institutional review board approved. Systematic TRUS and MRI-TRUS fusion prostate biopsy complication rates were compared in 967 men. A total of 319 patients were received systematic TRUS prostate biopsy and 648 patients underwent systematic TRUS + MRI-TRUS fusion prostate biopsy. Complications were divided into immediate (those that occurred during the hospital observation period) and late (those that occurred within 5 days after biopsy). RESULTS: Seventeen complications were observed in patients who received either a systematic prostate biopsy or MRI-TRUS fusion prostate biopsy. Severe complications were not observed in both groups. Among patients who underwent systematic prostate biopsy, 6 (1.9%) cases of complications were observed and between those who received MRI-TRUS fusion prostate biopsy 11 (1.7%) cases of complications after the procedure (p = 0.873) were observed, with no statistical difference between groups. Also, no statistical differences between early and late complication groups (p > 0.999) were observed. CONCLUSIONS: The complication rates were low in both groups, with no critical clinical outcomes and no significant difference of complication rates between systematic TRUS prostate biopsy and MRI-TRUS fusion prostate biopsy techniques.

Magnetic resonance/transrectal ultrasound fusion biopsy of the prostate compared to systematic 12-core biopsy for the diagnosis and characterization of prostate cancer: multi-institutional retrospective analysis of 389 patients.

OBJECTIVE: To determine the incremental diagnostic value of targeted biopsies added to an extended sextant biopsy scheme on a per-patient, risk-stratified basis in 2 academic centers using different multiparametric magnetic resonance imaging (MRI) protocols, a large group of radiologists, multiple biopsy systems, and different biopsy operators. MATERIALS AND METHODS: All patients with suspected prostate cancer (PCa) who underwent multiparametric MRI of the prostate in 2 academic centers between February 2013 and January 2015 followed by systematic and targeted MRI-transrectal ultrasound fusion biopsy were reviewed. Risk-stratified detection rate using systematic biopsies was compared with targeted biopsies on a per-patient basis. The McNemar test was used to compare diagnostic performance of the 2 approaches. RESULTS: A total of 389 men met eligibility criteria. PCa was diagnosed in 47% (182/389), 52%(202/389), and 60%(235/389) of patients using the targeted, systematic, and combined (targeted plus systematic) approach, respectively. Compared with systematic biopsy, targeted biopsy diagnosed 11% (37 vs. 26) more intermediate-to-high risk (P<0.0001) and 16% (10 vs. 16) fewer low-risk tumors (P<0.0001). These results were replicated when data from each center, biopsy-naïve patients, and men with previous negative biopsies were analyzed separately. CONCLUSION: Targeted MRI-transrectal ultrasound fusion biopsy consistently improved the detection of clinically significant PCa in a large patient cohort with diverse equipment, protocols, radiologists, and biopsy operators as can be encountered in clinical practice.

Robotic-assisted partial Nephrectomy: initial experience in South America

OBJECTIVE:To report the initial outcomes of robotic-assisted partial nephrectomy in a tertiary center in South America. MATERIAL AND METHODS: From 11/2008 to 12/2009, a total of 16 transperitoneal robotic-assisted partial nephrectomies were performed in 15 patients to treat 18 kidney tumors. One patient with bilateral tumor had two procedures, while two patients with two synchronous unilateral tumors had a single operation to remove them. Eleven (73 percent) patients were male and the right kidney was affected in 7 (46 percent) patients. The median patient age and tumor size were 57 years old and 30 mm, respectively. Five (28 percent) tumors were hilar and/or centrally located. RESULTS: The median operative time, warm ischemia time and estimated blood loss was 140 min, 27 min and 120 mL, respectively. Blood transfusion was required in one patient with bilateral tumor, and one additional pyelolithotomy was performed due to a 15mm stone located in the renal pelvis. The histopathology analysis showed 15 (83 percent) malignant tumors, which 10 (67 percent) were clear cell carcinoma. The median hospital stay was 72 hrs and no major complication was observed. CONCLUSION: Robotic-assisted partial nephrectomy is safe and represents a valuable option to perform minimally invasive nephron-sparing surgery.

Leiomyosarcoma of the renal vein.

Leiomyosarcoma of the renal vein is a rare tumor of complex diagnosis. We presented a case of renal vein leiomyosarcoma detected in a routine study. The primary treatment was complete surgical removal of the mass. In cases where surgical removal is not possible the prognosis is poor, with high rates of local recurrence and distant spread.

Rigid ureteroscopy for diagnosis and treatment of ureteral calculi during pregnancy.

OBJECTIVE: To evaluate ureteroscopy as a treatment option for women presenting ureteral calculi during pregnancy. MATERIALS AND METHODS: Eighteen pregnant patients presenting renal colic and indication of surgical treatment for ureteral calculi were analyzed. Patients were 20 to 34 years old (medium = 28), and the gestation period ranged from 12 to 34 weeks (medium = 18). Lumbar pain was present in 14 patients, and 4 had diffuse abdominal pain. Four patients were febrile in the occasion of the examination. Thirteen patients presented microscopic hematuria, 8 leucocituria, and 4 positive urine culture. The stone was detected by ultrasonography (US) in 12 patients. Magnetic resonance imaging (MRI) was performed in 2 cases, and did not demonstrate calculi. The stone location was: 1 in the superior ureter (pregnancy of 15 weeks), 4 in the medium ureter (pregnancy of 12, 15, 18 and 20 weeks), 12 in the inferior ureter, and 1 was not determined. The surgical indication was difficult pain control, fever, and presence of uterine contractions. RESULTS: Double-J insertion, as single treatment, was possible in 4 patients and it was kept in place for up to 2 weeks after delivery. Among the patients submitted to ureteroscopy, the calculi retrieval was always possible, except in 1 case where the calculus was not located by US, MRI or ureteroscopy. In 2 patients, the ultrasonic lithotriptor was used and in 11 the stone was removed intact with a basket. There were no complications due to the procedure and all pregnancies were carried to full term. CONCLUSION: Rigid ureteroscopy for extraction of ureteral calculi during pregnancy is efficient and safe.

Leiomyosarcoma of the renal vein

Leiomyosarcoma of the renal vein is a rare tumor of complex diagnosis. We presented a case of renal vein leiomyosarcoma detected in a routine study. The primary treatment was complete surgical removal of the mass. In cases where surgical removal is not possible the prognosis is poor, with high rates of local recurrence and distant spread

Tratamento atual dos cálculos localizados no ureter lombar / Modern treatment of lumbar ureteral calculi

No período de um ano, foram estudados 168 pacientes portadores de cálculos ureterais lombares. Os pacientes foram divididos em três grupos de acordo com o tratamento: grupo 1, 24 pacientes submetidos à ureterolitomia por lombotomia posterior; grupo 2, 100 pacientes tratados por método endourológico e grupo 3, 44 pacientes tratados por litotrícia extracorpórea por ondas de choque (L.E.O.C) com o LITHOSTAR da Siemens. O tempo de hospitalizaçäo e a taxa de complicaçöes foram menores no grupo 3. O sucesso foi considerado nos casos em que houve a completa eliminaçäo dos cálculos, sendo 100% no grupo submetido à lombotomia posterior, 92% no grupo tratado por endourologia e 97% por LEOC. A baixa morbidade, grande possibilidade de näo existir internaçäo e anestesia, associados ao alto índice de sucesso, permitem a conclusäo de que a LEOC é o método de eleiçäo no tratamento dos cálculos ureterais lombares