Mesentery-Sparing Technique: a New Intracorporeal Approach for Urinary Diversion in Robot-Assisted Radical Cystectomy.

BACKGROUND: Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is associated with significant morbidity and mortality. We present an alternative technique that preserves the complete mesenteric vascularization during the isolation of the intestinal segment used in ICUD, including distal vessels. This approach aims to minimize the risk of ischemia in both the ileal anastomosis and the isolated loop at the diversion site. METHODS: This cohort study included 31 patients, both male and female, who underwent RARC with ICUD from February 2018 to November 2023, performed by a single surgeon. Intraoperative and postoperative complications data were retrieved for analysis, employing our proposed mesentery-sparing technique in all cases. The primary endpoint was the incidence of intraoperative and postoperative complications directly attributable to the mesentery-sparing approach in ICUD. Secondary endpoints included other postoperative variables not directly related to mesentery preservation, such as the incidence of postoperative ileus requiring parenteral nutrition and the duration of hospitalization. RESULTS: None of the patients experienced intraoperative or postoperative complications directly related to mesentery-sparing, such as intestinal fistulae or internal hernias. The median duration of hospitalization was 6 days, and postoperative ileus necessitating total parenteral nutrition occurred in 19% of the patients. Minor complications (Clavien-Dindo grades I-II) accounted for 27.6% of the cases and major complications (grades III-V) accounted for 20.6%. CONCLUSION: The mesentery-sparing technique outlined herein offers an alternative method for preserving the vascularization of intestinal segments and reducing the risk of intestinal complications in ICUD during RARC.

Long-term oncological and surgical outcomes after Video Endoscopic Inguinal Lymphadenectomy (VEIL) in patients with penile cancer.

OBJECTIVE: To report outcomes from the largest multicenter series of penile cancer patients undergoing video endoscopic inguinal lymphadenectomy (VEIL). MATERIALS AND METHODS: Retrospective multicenter analysis. Authors of 21 centers from the Penile Cancer Collaborative Coalition-Latin America (PeC-LA) were included. All centers performed the procedure following the same previously described standardized technique. Inclusion criteria included penile cancer patients with no palpable lymph nodes and intermediate/high-risk disease and those with non-fixed palpable lymph nodes less than 4 cm in diameter. Categorical variables are shown as percentages and frequencies whereas continuous variables as mean and range. RESULTS: From 2006 to 2020, 210 VEIL procedures were performed in 105 patients. Mean age was 58 (45-68) years old. Mean operative time was 90 minutes (60-120). Mean lymph node yield was 10 nodes (6-16). Complication rate was 15.7%, including severe complications in 1.9% of procedures. Lymphatic and skin complications were noted in 8.6 and 4.8% of patients, respectively. Histopathological analysis revealed lymph node involvement in 26.7% of patients with non-palpable nodes. Inguinal recurrence was observed in 2.8% of patients. 10y- overall survival was 74.2% and 10-y cancer specific survival was 84.8%. CSS for pN0, pN1, pN2 and pN3 were 100%, 82.4%, 72.7% and 9.1%, respectively. CONCLUSION: VEIL seems to offer appropriate long term oncological control with minimal morbidity. In the absence of non-invasive stratification measures such as dynamic sentinel node biopsy, VEIL emerged as the alternative for the management of non-bulky lymph nodes in penile cancer.

Laparoscopic Treatment of Ureteral Endometriosis: A Systematic Review.

OBJECTIVE: To review the literature for the preoperative clinical characteristics, surgical findings, and outcomes of patients who underwent laparoscopic surgical treatment of ureteral endometriosis (UE). DATA SOURCES: A systematic search was performed in the PubMed and Scopus databases. METHODS OF STUDY SELECTION: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies in English language that assessed UE treated surgically by laparoscopy published between 2008 and 2020 were selected. TABULATION, INTEGRATION, AND RESULTS: In an initial search, 1313 articles were identified, 193 in PubMed and 1120 in Scopus databases. A total of 1291 articles that did not meet eligibility criteria were excluded. The remaining 22 studies were included in the final qualitative analysis, with a total of 1337 patients. Data on preoperative patient's characteristics, preoperative imaging examinations, intraoperative findings, and postoperative complications were abstracted by 1 author. The descriptive nature of included studies prevented the performance of meta-analysis. Preoperative symptoms included dysmenorrhea (76.3%), pelvic pain (59.6%), dyspareunia (46.2%), lower urinary tract symptoms (21.3%), and ureteral obstructive symptoms (9.9%). Intraoperative findings showed that UE lesions were left-sided in 55% of the cases, right-sided in 28.9% of the cases, and bilateral in 8.7% of the cases. Ureterolysis alone or before another technique was performed in 69.1% of the cases, ureteral resection followed by ureteroureteral anastomosis in 6%, ureteroneocystostomy after ureteral resection in 21%, and nephrectomy in 0.45% of the patients. Double-J ureteral stent placement was reported in 33.3% of the cases. Concomitant resection of the bladder owing to endometriosis involvement was performed in 15.5% of the cases. The prevalence of ureteral injury was 3.1%. Postoperative complications included ureteral fistula (2.8%), ureteral stenosis (24.2%), persistence/recurrence of UE (3.8%), and reoperation for fistula and/or stricture treatment (3.9%). CONCLUSION: UE is associated with common endometriosis pain symptoms and a low rate of lower urinary tract symptoms. The standard surgical technique for UE treatment is not yet a consensus; however, the laparoscopic approach with previous ureterolysis, leaving ureteral resection only for refractory cases, seems to be a safe and effective treatment, with improvement of symptoms and few intraoperative and postoperative complications.

Role of salvage lymph node dissection in patients previously treated for prostate cancer: systematic review.

Prostate cancer is the most common invasive cancer in men. Radical prostatectomy (RP) is a definitive treatment option, but biochemical recurrence can reach 40%. Salvage lymphadenectomy is a relatively recent approach to oligometasis and has been rapidly diffused primarily due to improvement in imaging diagnosis and results showing possibly promising therapy. A systematic literature review was performed in March 2020, according to the PRISMA statement. We excluded studies with patients with suspicion or confirmation of visceral and / or bone metastases. A total of 27 articles were included in the study. All studies evaluated were single arm, and there were no randomized studies in the literature. A total of 1,714 patients received salvage lymphadenectomy after previous treatment for localized prostate cancer. RP was the most used initial therapeutic approach, and relapses were based on PET / CT diagnosis, with Coline-11C being the most widely used radiopharmaceutical. Biochemical response rates ranged from 0% to 80%. The 5 years - Free Survival Biochemical recurrence was analyzed in 16 studies with rates of 0% up to 56.1%. The articles do not present high levels of evidence to draw strong conclusions. However, even if significant rates of biochemical recurrence are not evident in all studies, therapy directed to lymph node metastases may present good oncological results and postpone the onset of systemic therapy. The long-term impact in overall survival and quality of life, as well as the best strategies for case selection remains to be determined.

Focal Therapy for Localized Prostate Cancer with Either High Intensity Focused Ultrasound or Cryoablation: A Single Institution Experience.

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

Laparoscopic partial nephrectomy without clamping the renal pedicle.

INTRODUCTION: Renal cell carcinoma (RCC) accounts for about 2-3% of all malignancies in adults and 90-95% of renal neoplasms. Curative treatment is eminently surgical, the first reports describing the laparoscopic partial nephrectomy (LPN) date from the beginning of the 1990s since then LPN has been consolidated as a safe and reproducible procedure. In order to improve the results of the LPN in relation to the postoperative renal function, while retaining the benefits of minimally invasive surgery, some surgeons began to implement the technique of laparoscopic partial nephrectomy without renal pedicle clamping (LPNWRPC) in selected cases. OBJECTIVE: To compare the perioperative, oncological and functional results of patients submitted to LPN with renal pedicle clamping (LPNRPC) and LPNWRPC in the hospitals linked to our institution. MATERIAL AND METHOD: All patients' charts were submitted to LPN from January 2000 to January 2016. Data were collected and analyzed retrospectively, patients were divided into two groups: LPNRPC (RPC group) and LPNWRPC (WRPC group). RESULTS: Data from 177 patients submitted to LPN for renal neoplasms were collected, 88 patients (49.7%) in the RPC group and 89 (50.3%) in the WRPC group. Surgical margins were positive in 2.56% of patients in the RPC group and 3.70% in the WRPC group. There was no significant difference despite the technique applied. Clavien 3 or 4 postoperative complications occurred in five cases (5.68%) in the RPC group and three cases in the WRPC group (3.7%), with no significant difference between the groups. Patients in the RPC group developed higher levels of creatinine in the postoperative period (creatinine 1.01 ± 0.16 preoperative vs. 1.12 ± 0.18 postoperatively, p = 0.031) and worsened filtration rate (EGFR) (preoperative 79.18 ± 16.28 × 74.43 ± 21.06 post-operative, p = 0.017). DISCUSSION: Our casuistry agrees with the results of previous studies with regard to major bleeding in patients submitted to LPNWRPC when compared to those submitted to LPNWRPC. However, although bleeding and surgical time were higher in the WRPC group, there was no impact on patients' postoperative evolution regarding both the need for transfusion of blood products and serious complications. In the high-complexity tumors, the mean warm ischemia time (WIT) in the RPC group was higher, this was probably responsible for a better response in the WRPC group evolving patients with lower creatinine levels and better postoperative glomerular filtration rates. CONCLUSION: LPNWRPC has been shown to be equally effective, safe, feasible, with low blood transfusion rates and postoperative complications comparable to LPNRPC, and has similar oncological results. Main impact factor in long-term renal dysfunction is WIT, which can be completely eliminated with the use of LPNWRPC.

Characteristics and Surgical Outcomes in Very Elderly Patients (≥75 years) with Renal Cell Carcinoma: Data from the Latin American Renal Cancer Group.

BACKGROUND: The incidence of renal cell carcinoma (RCC) is increasing globally due to an aging population and widespread use of imaging studies. OBJECTIVE: The aim of this study was to describe the characteristics and perioperative outcomes of RCC surgery in very elderly patients (VEP), ≥ 75 years of age. METHODS: This is a retrospective comparative study of 3656 patients who underwent the treatment for RCC from 1990 to 2015 in 28 centers from eight Latin American countries. We compared baseline characteristics as well as clinical and perioperative outcomes according to age groups (less than 75 vs. ≥75 years). Surgical complications were classified with the Clavien-Dindo score. We performed logistic regression analysis to identify factors associated with perioperative complications. RESULTS: There were 410 VEP patients (11.2%). On bivariate analysis, VEP had a lower body mass index (p less than 0.01) and higher ASA score (ASA > 2 in 26.3% vs. 12.4%, p < 0.01). There was no difference in performance status and clinical stage between the study groups. There were no differences in surgical margins, estimated blood loss (EBL), complication, and mortality rates (1.3% vs. 0.4%, p = 0.17). On multivariate regression analysis, age ≥75 years (odds ratio [OR] 2.33, p less than 0.01), EBL ≥ 500 cc (OR 3.34, p less than 0.01), and > pT2 stage (OR 1.63, p = 0.04) were independently associated with perioperative complications. CONCLUSIONS: Surgical resection of RCC was safe and successful in VEP. Age ≥75 years was independently associated with 30-day perioperative complications. However, the vast majority were low-grade complications. Age alone should not guide decision-making in these patients, and treatment must be tailored according to performance status and severity of comorbidities.

Post-radical prostatectomy urinary incontinence: is there any discrepancy between medical reports and patients' perceptions?

BACKGROUND: Post-radical prostatectomy urinary incontinence (PPI) negatively affects the quality of life of patients. Accurate identification of the problem by physicians is essential for adequate postoperative management. In this study we sought to access whether there is, for urinary incontinence, any discrepancy between medical reports and the perception of patients. METHODS: We performed a retrospective analysis of medical records of 337 patients subjected to radical retropubic prostatectomy (RRP) between 2005 and 2010. Sociodemographic variables were collected, as well as continence status over the course of treatment. Next, we contacted patients by phone to determine continence status at present and at time of their last appointment, as well as to apply ICIQ - SF questionnaire. Poisson regression model with robust variance was used to estimate the factors associated with discrepancy, using the stepwise backward strategy. Software used was Stata® (StataCorp, LC) version 11.0. RESULTS: There is discrepancy between medical reports and patients' perceptions in 42.2% of cases. This discrepancy was found in 56% of elderly patients and 52% of men with low schooling, with statistical significance in these groups (p = 0.069 and 0.0001, respectively), whereas in multivariate regression analysis the discrepancy rate was significantly higher in black men (discrepancy rate of 52.6%) with low schooling (p = 0.004 and 0.043, respectively). CONCLUSION: There is discrepancy between medical reports and the perception of black men with low schooling in respect to post-radical prostatectomy urinary incontinence and a need for more thorough investigation of this condition in patients that fit this risk profile.

Robot-assisted Simple Prostatectomy with Tunnel-Shaped Trigonization (RASP-TST) - A Novel Technique.

To describe a technical modifi cation for robotic-assisted simple prostatectomy (RASP) using three-steps reconstructive technique to achieve a 360 trigonization of the bladder mucosa. Through fi ve-trocars transperitoneal access, we perform a longitudinal incision of the bladder wall and prostate capsule. Our technique of RASP is very similar to the standard operative technique described during laparoscopic and robotic removal of adenoma, however, for reconstruction, we propose the Tunnel-Shaped Trigonization (TST). The fi rst step is the advancement of a bladder mucosa fl ap until the posterior part of the prostatic urethra. The second step, a running suture between the advanced mucosa and the prostatic capsule is done bilaterally. At this point, the prostate capsule should be totally isolated from the rest of the urinary tract. Finally, the third step is closing both sides of the capsule and bladder mucosa anteriorly identical to a tunnel conformation. Hiding the prostatic capsule optimizes the patient recovery since hematuria is the most related factor for hospital stay length. This pilot-case has shown satisfactory results without the need for continuous bladder irrigation. The prostate volume in the TRUS was 130 cm3 and the preoperative International Prostate Symptom score was 24. He was discharged at second postoperative day and no late complications were detected. In conclusion, the TST-RASP seems to be a safe and feasible modifi cation of the RASP. We hope that the application of the TST can lead us to lower rates of blood loss, transfusion and postoperative complications in comparison to the standard technique.

Initial experience of video endoscopic inguinal Lymphadenectomy in a center located at northeast brazilian region.

INTRODUCTION: Video endoscopic inguinal lymphadenectomy - VEIL - has emerged as an alternative to reduce post-surgical complications (PSC) in patients with penile cancer submitted to inguinal lymphadenectomy (IL). In some series, these PSC are observed in more than 50% of patients. The objectives of the present study are to describe the initial experience of VEIL in a Hospital in Teresina, PI, Brazil, and to analyze PSC incidence. MATERIAL AND METHODS: Retrospective descriptive study of patients submitted to VEIL from March 2014 to November 2015. Data were collected regarding surgical time, bleeding, complications, lymph node number, conversion, global complications, drainage time, cellulitis, lymphocele, cutaneous necrosis, miocutaneous necrosis and hospitalization time. RESULTS: 20 lower limbs of 11 patients were operated. Mean age was 51.4 (24-72) years. Mean surgical time was 85 (60-120) minutes. No patient showed intrasurgical complications, bleeding > 50 mL or conversion. Three surgeries evolved with lower limb edema, 2 with lymphoceles and one patient had cutaneous necrosis and another bulging of surgical wound. Mean time of hospitalization was 4 (2-11) days. A mean of 5.8 (1-12) lymph nodes were dissected in each surgery. CONCLUSION: VEIL is a safe and easy technique with lower incidence of PSC that can be reproduced in small centers.

Are localized prostate cancer biomarkers useful in the clinical practice?

Prostate cancer presents itself in a heterogeneous way with both aggressive and indolent forms. Despite the controversy surrounding its use, prostate-specific antigen screening ultimately leads to a greater number of diagnosed patients. One of the biggest challenges in clinical practice is to select the right patients for biopsy and, among diagnosed patients, to differentiate tumors with an indolent course from those with an unfavorable prognosis, in order to determine the best therapeutic decision for each case, avoiding unnecessary interventions. Currently, several types of biomarkers are available for clinical use in patients with prostate cancer, which include blood-based (prostate-specific antigen, Prostate Health Index®, 4K score®); urine sample-based (PCA3, SelectMDx®, ExoDx Prostate IntelliScore®); and biopsy, transurethral resection, or radical prostatectomy tissue-based (ConfirmMDx®, Oncotype®, Prolaris®, Decipher®). The aim of this review is to provide an overview of the current state of evidence and to highlight recent advances in the evaluation and diagnosis of prostate cancer, with emphasis on biomarkers related to diagnosis and to prognostic evaluation of localized prostate cancer.

Prospective Evaluation of Chondroitin Sulfate, Heparan Sulfate and Hyaluronic Acid in Prostate Cancer.

PURPOSE: The present study evaluates chondroitin sulfate (CS) and heparan sulfate (HS) in the urine and hyaluronic acid (HA) in the plasma of patients with prostate cancer before and after treatment compared to a control group. MATERIALS AND METHODS: Plasma samples were used for HA dosage and urine for quantification of CS and HS from forty-four cancer patients and fourteen controls. Clinical, laboratory and radiological information were correlated with glycosaminoglycan quantification by statistical analysis. RESULTS: Serum HA was significantly increased in cancer patients (39.68 ± 30.00 ng/ mL) compared to control group (15.04 ± 7.11 ng/mL; p=0.004) and was further increased in high-risk prostate cancer patients when compared to lower risk patients (p = 0.0214). Also, surgically treated individuals had a significant decrease in seric levels of heparan sulfate after surgical treatment, 31.05 ± 21.01 µg/mL (before surgery) and 23.14 ± 11.1 µg/mL (after surgery; p=0.029). There was no difference in the urinary CS and HS between prostate cancer patients and control group. Urinary CS in cancer patients was 27.32 ± 25.99 µg/mg creatinine while in the men unaffected by cancer it was 31.37 ± 28.37 µg/mg creatinine (p=0.4768). Urinary HS was 39.58 ± 32.81 µg/ mg creatinine and 35.29 ± 28.11 µg/mg creatinine, respectively, in cancer patients and control group (p=0.6252). CONCLUSIONS: Serum HA may be a useful biomarker for the diagnosis and prognosis of prostate cancer. However, urinary CS and HS did not altered in the present evaluation. Further studies are necessary to confirm these preliminary findings.

A Safe teaching protocol of LRP (laparoscopic radical prostatectomy).

PURPOSE: The LRP has a steep learning curve to obtain proficiency during which patient safety may be compromised. We present an adapted modular training system which purpose to optimize the learning curve and perform a safe surgery. MATERIALS AND METHODS: A retrospective analysis of the LRP safe learning protocol applied during a fellowship program over eight years (2008-2015). The surgery was divided in 12 steps and 5 levels of difficulty. A maximum time interval was stipulated in 240 minutes. After an adaptation, the fellows had 120 minutes to perform all the corresponding modules to its accumulated skill. The participants gradually and safely pass through the steps and difficulty levels. Surgeries performed by fellows were analyzed as a single group and compared to a prior series performed by tutor. RESULTS: In eight years, 250 LRP were performed (25 per apprentice) during fellowship program and 150 procedures after completion. The baseline characteristics were comparable. Most cases operated were of intermediate risk. Mean operative time was longer in the fellow group when compared to the tutor (150 min). Mean estimated blood loss were similar among the groups. Functional and oncological outcomes were better in the Tutor´s group. No conversion to open surgery was performed. CONCLUSIONS: The LRP safe learning protocol proved to be an effective method to optimize the learning curve and perform safe surgery. However, the tutor's functional and oncological results were better, showing that this is a procedure with a steep learning curve and proficiency demands more than 25 cases.

The pubovesical complex-sparing technique on laparoscopic radical prostatectomy.

INTRODUCTION: Preservation of urinary continence is a great challenge in Radical Prostatectomy. In order to improve functional results, Asimakopoulos et al. (2010) described a robot-assisted surgical technique with preservation of the pubovesical complex (PVC). We present a pure laparoscopic execution. PRESENTATION: A 61-year-old male patient with a diagnosis of prostate cancer, with PSA 6.54ng/ml, DRE: T1C and Gleason 6 (3+3) 1/12 fragments. All therapeutic possibilities were discussed, including active surveillance. The patient opted for surgical treatment. A transperitoneal technique was used. We started the dissection on the left side, in the limit between the detrusor and the base of the prostate. The left seminal vesicle was dissected and left neurovascular bundle released by a high anterior dissection. We repeated the same procedure on the right side. The urethra was then divided, prostatic apex was laterally drawn and PVC was released. The bladder neck was divided and an urethrovesical anastomosis was achieved. A pelvic drain was placed. RESULTS: The total operative time was 150 minutes. The estimated blood loss was 300mL. The drain was removed on the 1st postoperative day and the patient was discharged. The Foley catheter was removed after 7 days and the patient remained completely dry. Hystopathology revealed adenocarcinoma Gleason 6, negative margins. PSA after 30 days was <0.04ng/mL, and the patient reported partial penile erection. CONCLUSION: The Pubovesical Complex-Sparing Technique on Laparoscopic Radical Prostatectomy was feasible and safe. Further adequately designed studies are needed to confirm whether this technique enhances early functional outcomes.

Synchronous abdominal tumors: is combined laparoscopic surgery in a single approach a safe option?

BACKGROUND AND PURPOSE: Recent advances in cancer treatment have resulted in better prognosis with impact on patient's survival, allowing an increase in incidence of a second primary neoplasm. The development of minimally invasive surgery has provided similar outcomes in comparison to open surgery with potentially less morbidity. Consequently, this technique has been used as a safe option to simultaneously treat synchronous abdominal malignancies during a single operating room visit. The objective of this study is to describe the experience of two tertiary cancer hospitals in Brazil, in the minimally invasive treatment of synchronous abdominal neoplasms and to evaluate its feasibility and peri-operative results. MATERIALS AND METHODS: We retrospectively reviewed the data from patients who were submitted to combined laparoscopic procedures performed in two tertiary hospitals in Brazil from May 2009 to February 2015. RESULTS: A total of 12 patients (9 males and 3 females) with a mean age of 58.83 years (range: 33 to 76 years) underwent combined laparoscopic surgeries for the treatment of at least one urological disease. The total average duration of surgery was 339.8 minutes (range: 210 to 480 min). The average amount of intraoperative bleeding was 276.6mL (range: 70 to 550mL) and length of hospitalization was 5.08 days (range: 3 to 10 days). Two patients suffered minor complications regarding Clavien system during the immediate postoperative period. CONCLUSIONS: Combined laparoscopic surgery for the treatment of synchronous tumors is feasible, viable and safe. In our study, there was a low risk of postoperative morbidity.

Nutcracker Syndrome: laparoscopic external stenting of the renal vein (″the shield technique″).

Nutcracker syndrome refers to the complex of clinical symptoms caused by the compression of the left renal vein (LRV) between the abdominal aorta and the superior mesenteric artery, leading to stenosis of the aortomesenteric portion of the LRV and dilatation of the distal portion. Hematuria, proteinuria, flank pain, varicocele and pelvic congestion may occur, occurring more frequently in young adults. Conservative management, might be the option whenever it is possible. When surgical treatment is required, classically open surgery have been performed, with major surgeries as LRV transposition or bypass techniques. The main caveats regards the fact that these are large and risky surgeries. Endovascular surgery with venous stent placement has gained some space as it is minimally invasive alternative. However, venous stents are associated with a high number of trombotic complications and in many cases requirement of life-long anticoagulants. External stenting of the LRV with this "shield technique" is a minimally invasive alternative, with good medium term results. We herein demonstrate our second experience with the technique of this surgery in a patient with 12 months of follow up and excellent results.

Laparoscopic resection of prescral and obturator fossa schwannoma.

INTRODUCTION: Pelvic Schwannoma is an extremely rare event. Laparoscopic approach for radical resection on pelvic region already has been described in the literature. However, with better image quality provided by optic in the laparoscopy we can assure an improvement in this kind of approach for tumor resection. OBJECTIVE: Our goal is to describe and evaluate the results of one laparoscopic resection of presacral and obturator fossa tumor. MATERIALS AND METHODS: We present a case of a 60-year-old man with progressive congestion in the right inferior member and CT scan revealing a mass with miscellaneous content located behind of the right iliac vessels and right obturator nerve. Exploratory transperitoneal laparoscopy was indicated. During laparoscopy it was possible to see the mass between the spermatic cord and external iliac artery. We made the identification and preservation of iliac vessels and obturator nerve. Resection of the tumor was performed carefully, allowing the safe removal of the specimen with complete preservation of the iliac vessels and obturator nerve. RESULTS: Mean operative time of 150 minutes. No perioperative complications occurred. Two days of hospital stay. Posterior histopathological exam confirmed that the mass was a Schwannoma. CONCLUSION: The maximization of the image in the laparoscopic surgery offers dexterity and capacity of dissection required for complex mass dissection on pelvic region.

LHRH analog therapy is associated with worse metabolic side effects than bilateral orchiectomy in prostate cancer.

PURPOSE: The morbidity associated with metabolic syndrome induced by androgen deprivation therapy (ADT) in prostate cancer (PCa) has not been widely studied. There are no studies comparing surgical and pharmacological castration with regards to their metabolic side effects. The aim of this study was to compare both modalities. METHODS: A prospective observational study was conducted in men with PCa and with indications of any ADT. The participants were divided into two groups: (1) bilateral orchiectomy and (2) LHRH analogs. The metabolic profile was assessed before and during the period of ADT. Bioelectrical impedance analysis (BIA) and bone mineral density were measured before and after 6 months of treatment. The data were analyzed using the Chi-squared test, Student's t test, Bonferroni's test, and ANOVA. RESULTS: We enrolled 102 men for analysis, of whom 46 (54.9 %) had been subjected to bilateral orchiectomy and 56 (54.9 %) had been subjected to treatment with LHRH analogs. The basal metabolic profile, body mass index, and BIA were similar between the two groups. The oncologic control (PSA and testosterone) was also similar in both groups. In the intergroup comparison, insulin resistance (p = 0.044) and hemoglobin (p = 0.001) were worse in the group that used LHRH analogs, which was mainly diabetic patients (p = 0.007). CONCLUSION: This study showed that LHRH analogs had worse effects relative to insulin resistance, mainly in diabetic patients, and induced more anemia and bone demineralization compared to surgical castration. Further prospective, randomized, and comparative studies are needed for metabolic syndrome in ADT modalities.