Robot-assisted retroperitoneal lymph node dissection as primary treatment for stage II seminoma germ cell tumor.

INTRODUCTION: Historically, therapeutic avenues for patients with clinical stage II seminoma germ cell tumors (SGCT) were confined to radiotherapy and chemotherapy. While survival rates with these modalities are commendable, both entail substantial long-term morbidities. Furthermore, this youthful patient cohort exhibits elevated rates of secondary malignancies, surfacing decades post-successful primary cancer treatment (1). Recently, retroperitoneal lymph node dissection (RPLND) has emerged as a primary treatment consideration for individuals with low-volume metastatic seminoma (2-4). However, there is a dearth of video documentation illustrating the robotic assisted (RA) bilateral approach (5- 7). METHODS: We present the case of a 24-year-old male who underwent prior left orchiectomy for seminoma (pT1b). Despite negative serum tumor markers, a 1.7 x 1.4cm lymph node enlargement was identified in the aortic bifurcation after 4 months, classifying the patient as stage IIA per the IGCCCG risk classification. Subsequently, a RA bilateral template RPLND was performed due to the patient's refusal of chemotherapy, citing concerns about offspring. RESULTS: The surgery was performed, incorporating nerve sparing techniques, lasting 4h13minutes, an estimated bleeding rate of 400ml, without intraoperative complications. The patient was discharged within 24 hours of the procedure, following a prescribed low-fat diet. CONCLUSION: The patient experienced postoperative well-being, painlessness, and resumed work three weeks post-procedure. Preserved ejaculation was noted, and adjuvant therapy was performed with 2 cycles of EP due to the anatomopathological result. The feasibility of robotic primary RPLND for SGCT was demonstrated, showing reduced postoperative pain and early hospital discharge. Further studies are necessary to validate our findings regarding oncological, safety, and functional outcomes.

Outcomes of ablative therapy and radical treatment for prostate cancer: a systematic review and meta-analysis.

PURPOSE: To compare biochemical recurrence, sexual potency and urinary continence outcomes of ablative therapy and radical treatment (radical prostatectomy or radiotherapy with androgen deprivation therapy). MATERIAL AND METHODS: A systematic review and meta-analysis followed the PRISMA guidelines were performed. We searched MEDLINE/PubMed. Biochemical recurrence at three and five years; incontinence rate (patients who used one pad or more) and erectile dysfunction rate at 12 and 36 months (patients who did not have sufficient erection to achieve sexual intercourse) were evaluated. The Mantel-Haenszel method was applied to estimate the pooled risk difference (RD) in the individual studies for categorical variables. All results were presented as 95% confidence intervals (95%CI). Random effects models were used regardless of the level of heterogeneity (I²). (PROSPERO CRD42022296998). RESULTS: Eight studies comprising 2,677 men with prostate cancer were included. There was no difference in biochemical recurrence between ablative and radical treatments. We observed the same biochemical recurrence between ablative therapy and radical treatment within five years (19.3% vs. 16.8%, respectively; RD 0.07; 95%CI=-0.05, 0.19; I2=68.2%; P=0.08) and continence rate at 12 months (9.2% vs. 31.8%, respectively; RD -0.13; 95%CI, -0.27, 0.01; I2=89%; P=0.32). When focal treatment was analyzed alone, two studies with 582 patients found higher erectile function at 12 months in the ablative therapy group than in the radical treatment (88.9% vs. 30.8%, respectively; RD -0.45; 95%CI -0.84, -0.05; I2=93%; P=0.03). CONCLUSION: Biochemical recurrence and urinary continence outcomes of ablative therapy and radical treatment were similar. Ablative therapy appears to have a high rate of sexual potency.

Postoperative Mortality Rate after Radical Cystectomy: A Systematic Review of Epidemiologic Series.

INTRODUCTION: Mortality after radical cystectomy (RC) varies widely in the literature. In cohort studies, mortality rates can vary from as low as 0.5% in large-volume academic centers (2) to as high as 25% in developing countries series. This study aims to perform a systematic review of population-based studies reporting mortality after RC. METHODS: A Systematic search was performed in Medline (PubMed®), Embase, and Cochrane for epidemiologic studies reporting mortality after RC. Institutional cohorts and those reporting mortality for specific groups within populations were excluded. Case series and non-epidemiologic series were also excluded. The aim of this review is to evaluate in-hospital mortality (IHM), 30-day mortality (30M), and 90-day mortality (90M). RESULTS: Systematic search resulted in 42 papers comprising 449,661 patients who underwent RC from 1984 to 2017. Mean age was 66.1. Overall IHM, 30M, and 90M were 2.6%, 2.7%, and 4.9%, respectively, with 90M being 2.6 times higher than IHM on average. Lowest IHM was found in Canada and Australia (0.2% and 0.6%, respectively), while the highest IHM was 7.8% (Brazil). Canada and Spain showed the highest 90M (6.5%). 159,584 urinary diversions were analyzed, being mostly ileal conduits (76.8%). CONCLUSIONS: The majority of the studies available are from major developed economies with paucity of data in the developing world. 90M after RC tends to be at least twice as high as IHM. The knowledge of such epidemiologic data is vital to guide public policies, such as centralization, in order to reduce mortality.

Impact of COVID-19 pandemic on prostate cancer outcomes at an uro-oncology referral center.

INTRODUCTION: To evaluate the possible effects of the coronavirus disease 2019 (COVID-19) pandemic on the oncologic results of patients with prostate cancer regarding clinical staging, presence of adverse pathological outcomes, and perioperative complications. MATERIALS AND METHODS: This retrospective study included patients who underwent radical prostatectomy. The time between biopsy and surgery, staging tests, final histopathological evaluation after surgery, lymphadenectomy rate, postoperative complications, and prostatic specific antigen (PSA) levels (initial and 30 days after surgery) were analyzed and compared in a group of patients before and during the pandemic period. RESULTS: We included 226 patients: 88 in the pre-pandemic period and 138 during the pandemic period. There was no statistically significant difference in mean age, body mass index, ASA, pathological locally advanced disease, the proportion of patients who underwent lymphadenectomy, and ISUP grade in the biopsy between the groups. Positive surgical margins, prostatic extracapsular extension, and PSA levels at 30 days were also similar between the groups. The mean time between medical consultation and surgery was longer in the pandemic period than in the pre-pandemic (124 vs. 107 days, p<0.001), and the mean time between biopsy and medical consultation (69.5 days vs. 114 days, p<0.001) and between biopsy and surgery (198.5 days vs. 228 days, p=0.013) was shorter during the pandemic. The incidence of severe early and late perioperative complications was similar between the periods. CONCLUSIONS: There was no delay between diagnosis and treatment at our institution during the COVID-19 pandemic period. No worsening of the prostate cancer features was observed.

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.

Bricker ileal conduit vs. Cutaneous ureterostomy after radical cystectomy for bladder cancer: a systematic review.

PURPOSE: A systematic review of the literature with available published literature to compare ileal conduit (IC) and cutaneous ureterostomy (CU) urinary diversions (UD) in terms of perioperative, functional, and oncological outcomes of high-risk elderly patients treated with radical cystectomy (RC). Protocol Registration: PROSPERO ID CRD42020168851. MATERIALS AND METHODS: A systematic review, according to the PRISMA Statement, was performed. Search through the Medline, Embase, Scopus, Scielo, Lilacs, and Cochrane Database until July 2020. RESULTS: The literature search yielded 2,883 citations and were selected eight studies, including 1096 patients. A total of 707 patients underwent IC and 389 CU. Surgical procedures and outcomes, complications, mortality, and quality of life were analyzed. CONCLUSIONS: CU seems to be a safe alternative for the elderly and more frail patients. It is associated with faster surgery, less blood loss, lower transfusion rates, a lower necessity of intensive care, and shorter hospital stay. According to most studies, complications are less frequent after CU, even though mortality rates are similar. Studies with long-term follow up are awaited.

Does acquired obstructive azoospermia have less impact than congenital azoospermia on ICSI results? Systematic review and meta-analysis.

An electronic-based search was performed with MEDLINE bases through PubMed, Cochrane through Central, and Embase until August 2020 for the purpose of evaluating the impact of the aetiology of obstructive azoospermia on ICSI cycles. In the final analysis, there were 15 cohort studies included, comparing a group of patients with acquired azoospermia and others due to congenital bilateral absence of the vas deferens submitted to ICSI. Those 15 articles within 4,480 couples were analysed, and similar fertilisation rate (65.1% vs. 65.3%; p = .38), pregnancy rate per cycle (40.0% vs. 43.1%; p = .06) and live birth rate (29.6% vs. 30.0%;p = .76) were found between groups. Comparing specifically post-vasectomy azoospermia and congenital groups, both presented a similar fertilisation rate (62.4% vs. 53.4%, respectively; OR 1.10; 95% CI, 0.79, 1.54; p = .56; I2  = 89%) and pregnancy rate per cycle (39.4% vs. 35.6%, respectively; OR 1.26; 95% CI, 0.96, 1.66; p = .09; I2  = 0%). However, a higher live birth rate was identified in the congenital group compared to vasectomy group (28.4% × 19.5%; OR 1.54; 95% CI, 1.11, 2.15; p = .01; I2  = 0%). The reasons for that are unclear and factors such as couple age and sperm DNA fragmentation should be considered.

The Role of the Low-Intensity Extracorporeal Shockwave Therapy on Penile Rehabilitation After Radical Prostatectomy: A Randomized Clinical Trial.

BACKGROUND: Erectile dysfunction (ED) after radical prostatectomy (RP) still represents a major issue. Considering the benefits recently described regarding the application of low-intensity extracorporeal shockwave therapy (LiESWT) in vasculogenic ED, questions arise about its role in the scenario of penile rehabilitation. AIM: To compare the early introduction of phosphodiesterase-5 inhibitor (PDE5i) with a combination therapy enrolling both early PDE5i use and LiESWT in patients submitted to RP. METHODS: This study is a randomized clinical trial, open-label, with 2 parallel arms and an allocation ratio of 1:1. The study was registered in ReBEC (ensaiosclinicos.gov.br) Trial: RBR-85HGCG. Both arms started tadalafil at a dose of 5 mg/day right after the removal of the transurethral catheter, and the experimental group received 2,400 shocks/session-week distributed on 4 different penile regions. The full treatment consisted of 19,200 impulses across 8 weeks. OUTCOMES: The primary clincal end point was ≥4-point difference favoring the experimental group considering the mean International Index of Erectile Function short form (IIEF-5) at last follow-up. Any statistical difference in the IIEF-5 score between the arms was stated as the primary statistical end point. RESULTS: Between September 25, 2017, and December 3, 2018, 92 men were enrolled in the study. At last follow-up, we assessed 77 patients, 41 in the control group and 36 in the intervention group. A difference between groups was detected when accessing the final median IIEF-5 score (12.0 vs 10.0; P = .006). However, the primary clinical endpoint considering a difference ≥4-point between the arms has not been reached. When performing an exploratory analysis comparing the proportion of those individuals with an IIEF-5 score ≥17, no difference between groups was noted (17.1% vs 22.2%; P = .57). CLINICAL IMPLICATIONS: So far, the benefits arising from LiESWT for penile rehabilitation after RP have been uncertain. STRENGTHS & LIMITATIONS: This is the first trial assessing the role of LiESWT on erectile function after RP. Our study protocol included only one session per week for the experimental group, raising a query if a more intensive application could achieve better results once a statistically significant difference was found between groups. We discontinue the PDE5i use at the last session, which may have interfered in the penile vascular rehabilitation, maybe compromising the results too. CONCLUSION: After therapy with 19,200 impulses therapy across 8 weeks, we found an improvement of the IIEF-5 score, but it was not enough to be considered clinically significant. More studies are warranted before any recommendation on this topic. Baccaglini W, Pazeto CL, Corrêa Barros EA, et al. The Role of the Low-Intensity Extracorporeal Shockwave Therapy on Penile Rehabilitation After Radical Prostatectomy: A Randomized Clinical Trial. J Sex Med 2020;17:688-694.

mpMRI-targeted biopsy versus systematic biopsy for clinically significant prostate cancer diagnosis: a systematic review and metaanalysis.

PURPOSE OF REVIEW: We aimed to compare the accuracy of clinically significant prostate cancer (csPCa) diagnosis by magnetic resonance imaging-targeted biopsy (MRI-TB) versus systematic biopsy (SB) in men suspected of having prostate cancer (PCa). RECENT FINDINGS: In biopsy-naïve patients, MRI-TB was more accurate to identify csPCa than SB. However, when comparing specifically MRI-TB versus transperineal (SB), we did not find any difference. Furthermore, in a repeat biopsy scenario, MRI-TB found more csPCa than SB as well. Finally, postanalysis comparing combined biopsy (SB plus MRI-TB) suggests that the later alone may play a role in both scenarios for identifying csPCa. SUMMARY: MRI-TB found more csPCa than SB in patients with suspected PCa in both scenarios, naïve and repeat biopsies, but more studies comparing those methods are warranted before any recommendation on this topic.

Association between Basal Total Testosterone Levels and Prostate Cancer D'Amico Risk Classes.

OBJECTIVE: To test the hypothesis that basal total testosterone (TT) serum levels are associated with the D'Amico risk classification at diagnosis of prostate cancer (PCA). MATERIALS AND METHODS: From November 2014 to March 2018, preoperative basal levels of TT and prostate-specific antigen (PSA) were measured in 601 consecutive PCA patients who were not under androgen deprivation therapy or undergoing prior prostate surgery. Patients were classified into low (reference group), intermediate, and high risk classes according to biopsy findings. The association of TT and other clinical factors with risk classes was evaluated using a multivariate multinomial logistic regression model. RESULTS: According to the D'Amico classification, 124 patients (24%) were low risk, 316 (52.6%) were intermediate risk, and 141 (23.4%) were high risk. Median basal TT circulating levels were significantly increased along clinical risk classes. TT along with PSA, percentage of biopsy positive cores, and tumor clinical stage were independently associated with a high risk (OR = 1.002; p = 0.022) but not with an intermediate risk of PCA when compared to the low risk class. In the intermediate-risk group, endogenous TT together with PSA were independently associated with tumor grade groups 2 (OR = 1.003; p = 0.022) and 3 (OR = 1.003; p = 0.043) compared to grade group 1 cancers. CONCLUSIONS: Basal TT levels are positively associated with the D'Amico risk classification, but the association is significant for the high-risk group compared to the low-risk group.

Bladder cancer trends and mortality in the brazilian public health system.

INTRODUCTION: Considering the lack of data on BC trends in Brazilian population, mainly as a result of the difficulty on gathering data, the present manuscript provides an overview of bladder cancer incidence, hospitalization, mortality patterns and trends using the Brazilian Data Center for The Public Health System (DATASUS). MATERIALS AND METHODS: All hospital admissions associated with BC diagnosis (ICD-10 C67) between 2008 and 2017 were analyzed. Distributions according to year, gender, age group, ethnicity, death, length of hospital stay, and costs were evaluated. Demographic data was obtained from the last Brazilian national census. RESULTS: From 2008 to 2017 there were 119,058 public hospital admissions related to BC. Patients were mostly white males aged 60 to 79 years-old. Mortality rates for patients who have undergone surgery was 6.75% on average, being 7.38% for women and 6.49% for men. Mortality rates were higher when open surgeries were performed compared to endoscopic procedures (4.98% vs 1.18%). Considering only endoscopic procedures, mortality rates were three times higher after urgent surgeries compared to elective ones (2.6% vs 0.6%). Over the years the cystectomy/transurethral bladder resection (C/T) ratio significantly decreased in all Brazilian Regions. In 2008, the C/T ratio was 0.19, while in 2017 it reduced to 0.08. CONCLUSIONS: Despite BC relatively low incidence, it still represents a significant social economic burden in Brazil, as it presents with recurrent episodes that might require multiple hospitalizations and surgical treatment. The set of data collected might suggest that population access to health care has improved between 2008-2017.

Complications of robotic surgery in urological diseases: are we using standardized methodology to report complications?

PURPOSE OF REVIEW: The current data on complications reporting related to robot-assisted procedures (RAPs) in the urology literature are not comparable and do not use a validated classification. In this review, findings from various studies reporting positive and negative outcomes will be outlined. RECENT FINDINGS: Robotic procedures have outcomes similar to open and laparoscopic techniques but generally cause fewer adverse events. However, the lack of standards for presenting surgical morbidity related to RAP leads to underreporting of surgical complications, makes comparisons of surgical outcomes difficult and prevents adequate knowledge about the outcomes of procedures. SUMMARY: Although a reasonable number of positive outcomes of RAP have been reported in the literature, the extent of underreporting with this process is unknown. Further research and the development of a validated classification for reporting surgical complications will facilitate a better understanding of the actual outcomes.

HRQOL related to urinary diversion in Radical Cystectomy: a systematic review of recent literature.

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

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.

Alternative approach of a Fibroepithelial polyp.

A 41-year-old male presented at Emergency Department (ED) with right flank pain associated with hematuria for 3 days. Patient had a previous history of nephrolithiasis. The physical examination and blood tests were normal. Urine analyses showed haematuria > 1.000.000/µL. After clinical evaluation, a computer tomography (CT) showed right ureteral dilata¬tion caused by a 5 mm proximal stone and a distal intraluminal mass of 8 cm in length. In this setting, an ureteroscopic biopsy was performed and revealed a large polypoid lesion histologically suggestive of fibroepithelial polyp. Due to technical difficulties (intraluminal mass length and technical issue for the passage of guidewire) and after discussing all available minimally invasive options, we opted for a laparoscopic approach. Instead of ureterectomy of the affected segment of the ureter, as classically performed, we proceeded with an ureterotomy, blunt dissection of the tumor and ureterolithotomy, with complete removal of the mass. This approach did not require ureteral anastomosis and the ureteral dilatation facilitated its primary closure. No complications occurred, even after 3 years of follow-up.

Impact of local treatment on overall survival of patients with metastatic prostate cancer: systematic review and meta-analysis.

CONTEXT: Currently, standard treatment of metastatic prostatic cancer (MPCa) is androgen-deprivation therapy (ADT). Recent studies suggested that local treatment of MPCa is related to increase of survival of those patients, as observed in other tumors. OBJECTIVE: To evaluate the impact of local treatment on overall survival and cancer specific survival in 3 and 5 years in patients with MPCa. MATERIALS AND METHODS: Systematic review and meta-analysis of population studies published at PubMed, Scielo, Lilacs, Cochrane and EMBASE databases until June 2016. Several large cohorts and Post-Roc studies were included, that evaluated patients with MPCa submitted to local treatment (LT) using radiotherapy (RDT), surgery (RP) or brachytherapy (BCT) or not submitted to local treatment (NLT). RESULTS: 34.338 patients were analyzed in six included papers, 31.653 submitted to NLT and 2.685 to LT. Overall survival in three years was significantly higher in patients submitted to LT versus NLT (64.2% vs. 44.5%; RD 0.19, 95% CI, 0.17-0.21; p<0.00001; I²=0%), as well as in five years (51.9% vs. 23.6%; RD 0.30, 95% CI, 0.11-0.49; p<0.00001; I²=97%). Sensitive analysis according to type of local treatment showed that surgery (78.2% and 45.0%; RD 0.31, 95% CI, 0.26-0.35; p<0.00001; I²=50%) and radiotherapy (60.4% and 44.5%; RD 0.17, 95% CI, 0.12-0.22; p<0.00001; I²=67%) presented better outcomes. CONCLUSION: LT using RDT, RP or BCT seems to significantly improve overall survival and cancer-specific survival of patients with metastatic prostatic cancer. Prospective and randomized studies must be performed in order to confirm our results.

Testicular decompression and tunica vaginalis flap in human acute testicular torsion: modified step-by-step technique description and preliminary outcomes.

OBJECTIVE: To report the effects of a tunica vagina flap on testicular compartment syndrome. METHODS: This single-arm clinical trial was conducted from September 2020 to October 2021. Consecutive patients with suspected testicular torsion within 24 hours of pain onset were included. Patients with past testicular torsion, bilateral torsion, or previous atrophy were excluded. The tunica vaginalis was opened, and the intratesticular pressure was measured before testicular retrieval from the scrotum and detorsion (P1), after detorsion (P2), and after transverse incision (P3). A tunica vaginalis flap was performed and a new intratesticular pressure was recorded (P4). The contralateral testicular pressure was recorded before fixation (Pc). The minimum follow-up period was 6 months. RESULTS: Fifteen patients were recruited from September 2020 to October 2021. Nine patients completed the follow-up. The median age (range) was 15 years (9-19). The mean P1, P2, P3, P4, and Pc (range) were 43, 60, 23, 20, and 14mmHg, respectively. The atrophy rate was 66.3% and the viability was 88.9%. No major complications were observed. CONCLUSION: The modified tunica vaginalis flap in acute testicular torsion decreased intratesticular pressure. Furthermore, normal testicular pressure can improve testicular preservation. It can also decrease testicular pressure to normal levels and preserve the testicular parenchyma. Testicular torsion causes orchiectomy in more than 80% of the cases after 24 hours of pain onset. Testicular detorsion only (P1-P2) showed a small difference in intratesticular pressure (median 4mmHg). Testicular incision (P2-P3) only demonstrated a major pressure decrease (median, 45mmHg). The final pressure after TVR was similar to the non-twisted testicle pressure (median, 1mmHg). Testicular salvage (88.9%) and atrophy (66.3%) rates were slightly higher than the previous literature reports, perhaps the initial learning curve of this novel technique.

Premature ejaculation prevalence among young men who have sex with men: a cross-sectional study with internet users in the metropolitan region of São Paulo, Brazil.

Background: There are only a few studies about the prevalence and correlates of premature ejaculation (PE) among men who have sex with men (MSM). Aim: (1) To estimate PE prevalence according to 3 assessment methods: self-reported time from penetration to ejaculation (ejaculation latency time [ELT]); Premature Ejaculation Diagnostic Tool (PEDT); and a direct question about the self-perception of ejaculation as being normal, too early (premature), or retarded. (2) To assess the agreement of the 3 assessment methods and identify factors associated with PE according to each method and their combination. Methods: We evaluated data from 226 MSM who participated in a cross-sectional study about sexual behavior among men living in the metropolitan region of São Paulo, Brazil. They responded anonymously to an online survey between May 2019 and March 2020. We calculated the agreement of the 3 assessment methods and their association with other characteristics using logistic regression models. Outcomes: Outcomes included the prevalence of PE according to the assessment methods and the association measures (PE vs sociodemographic characteristics and sexual behavior). Results: The prevalence of PE among MSM was 21.2% (95% CI, 16.1%-27.1%) according to the PEDT, 17.3% (95% CI, 12.6%-22.8%) per self-report, and 6.2% (95% CI, 3.4%-10.2%) by estimated ELT ≤2 minutes. The agreement among the 3 assessments was fair (kappa, 0.31; 95% CI, 0.25-0.37; P < .001). Association with PE varied by assessment method: obesity and shorter time for ejaculation with anal sex vs masturbation were associated with PE according to the PEDT and ELT but not self-evaluation. Perception about ideal time to ejaculate ≤5 minutes increased the chance of PE based on ELT. Higher chances of self-reported PE were associated with trying to hold back ejaculation, and lower chances were associated with higher frequencies of masturbation. Clinical Implications: Combining tools to investigate PE allows the identification of characteristics associated with this condition and may result in improvement in the care of MSM. Strengths and Limitations: This anonymous online survey provided the privacy necessary for participants to respond freely about sensitive questions, with a low risk of social adequacy bias. However, as it was a secondary analysis of a larger study, it could not evaluate comorbidities (eg, erectile dysfunction, prostatitis, depression) and the use of condoms. Conclusion: The prevalence of PE among MSM is high and varies according to the instrument used for the assessment, and the agreement among the 3 assessments was only fair.