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1.
Lancet ; 397(10274): 581-591, 2021 02 13.
Artigo em Inglês | MEDLINE | ID: mdl-33581820

RESUMO

BACKGROUND: Androgen suppression is a central component of prostate cancer management but causes substantial long-term toxicity. Transdermal administration of oestradiol (tE2) circumvents first-pass hepatic metabolism and, therefore, should avoid the cardiovascular toxicity seen with oral oestrogen and the oestrogen-depletion effects seen with luteinising hormone releasing hormone agonists (LHRHa). We present long-term cardiovascular follow-up data from the Prostate Adenocarcinoma Transcutaneous Hormone (PATCH) trial programme. METHODS: PATCH is a seamless phase 2/3, randomised, multicentre trial programme at 52 study sites in the UK. Men with locally advanced or metastatic prostate cancer were randomly allocated (1:2 from August, 2007 then 1:1 from February, 2011) to either LHRHa according to local practice or tE2 patches (four 100 µg patches per 24 h, changed twice weekly, reducing to three patches twice weekly if castrate at 4 weeks [defined as testosterone ≤1·7 nmol/L]). Randomisation was done using a computer-based minimisation algorithm and was stratified by several factors, including disease stage, age, smoking status, and family history of cardiac disease. The primary outcome of this analysis was cardiovascular morbidity and mortality. Cardiovascular events, including heart failure, acute coronary syndrome, thromboembolic stroke, and other thromboembolic events, were confirmed using predefined criteria and source data. Sudden or unexpected deaths were attributed to a cardiovascular category if a confirmatory post-mortem report was available and as other relevant events if no post-mortem report was available. PATCH is registered with the ISRCTN registry, ISRCTN70406718; the study is ongoing and adaptive. FINDINGS: Between Aug 14, 2007, and July 30, 2019, 1694 men were randomly allocated either LHRHa (n=790) or tE2 patches (n=904). Overall, median follow-up was 3·9 (IQR 2·4-7·0) years. Respective castration rates at 1 month and 3 months were 65% and 93% among patients assigned LHRHa and 83% and 93% among those allocated tE2. 157 events from 145 men met predefined cardiovascular criteria, with a further ten sudden deaths with no post-mortem report (total 167 events in 153 men). 26 (2%) of 1694 patients had fatal cardiovascular events, 15 (2%) of 790 assigned LHRHa and 11 (1%) of 904 allocated tE2. The time to first cardiovascular event did not differ between treatments (hazard ratio 1·11, 95% CI 0·80-1·53; p=0·54 [including sudden deaths without post-mortem report]; 1·20, 0·86-1·68; p=0·29 [confirmed group only]). 30 (34%) of 89 cardiovascular events in patients assigned tE2 occurred more than 3 months after tE2 was stopped or changed to LHRHa. The most frequent adverse events were gynaecomastia (all grades), with 279 (38%) events in 730 patients who received LHRHa versus 690 (86%) in 807 patients who received tE2 (p<0·0001) and hot flushes (all grades) in 628 (86%) of those who received LHRHa versus 280 (35%) who received tE2 (p<0·0001). INTERPRETATION: Long-term data comparing tE2 patches with LHRHa show no evidence of a difference between treatments in cardiovascular mortality or morbidity. Oestrogens administered transdermally should be reconsidered for androgen suppression in the management of prostate cancer. FUNDING: Cancer Research UK, and Medical Research Council Clinical Trials Unit at University College London.


Assuntos
Síndrome Coronariana Aguda/epidemiologia , Adenocarcinoma/tratamento farmacológico , Antagonistas de Androgênios/administração & dosagem , Estradiol/administração & dosagem , Estrogênios/administração & dosagem , Insuficiência Cardíaca/epidemiologia , AVC Isquêmico/epidemiologia , Neoplasias da Próstata/tratamento farmacológico , Síndrome Coronariana Aguda/mortalidade , Adenocarcinoma/patologia , Idoso , Idoso de 80 Anos ou mais , AVC Embólico/epidemiologia , AVC Embólico/mortalidade , Hormônio Liberador de Gonadotropina/agonistas , Ginecomastia/induzido quimicamente , Insuficiência Cardíaca/mortalidade , Humanos , AVC Isquêmico/mortalidade , Masculino , Pessoa de Meia-Idade , Neoplasias da Próstata/patologia , AVC Trombótico/epidemiologia , AVC Trombótico/mortalidade , Adesivo Transdérmico , Reino Unido
2.
J Urol ; 207(3): 609-616, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34694141

RESUMO

PURPOSE: Our aim was to report the positive surgical margin (PSM) rate of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) in an unselected, real-life cohort of patients treated at a fellowship-training urological department. MATERIALS AND METHODS: Demographic, clinical and pathological data of 529 consecutive patients who underwent RS-RARP between January 2017 and December 2020 were collected prospectively and analyzed retrospectively in a hospital-approved audit in a European Association of Urology Robotic Urology Section (ERUS)-approved fellowship program. Overall PSM rates were reported for the entire cohort and for pT2 and pT3 patients separately. We defined clinically significant PSM as any length of >3 mm or multiple PSMs regardless of length. RESULTS: Median patient age was 64 years. More than 97% of the patients had intermediate or high-risk disease. The pathological stages were T2 (66.5%) and T3 (33.5%). Overall PSM was reported in 13.3% of pT2 patients and 28.9% of pT3 patients. Clinically significant PSM was reported in 43 patients (8.1%), and most of them (27 patients) had pT3 disease. Only 2.6% positive margins were reported at the apex and 0.7% on the anterior surface and bladder neck. Immediate continence (defined as no pads or 1 safety pad a day) rate was 65%. CONCLUSIONS: PSM rates of RS-RARP are acceptable and are higher in pT3 disease compared to pT2.


Assuntos
Margens de Excisão , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Biomarcadores Tumorais/sangue , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/patologia , Estudos Retrospectivos
3.
World J Urol ; 39(1): 143-148, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32219512

RESUMO

OBJECTIVE: To evaluate predictive factors of urinary incontinence (UI) after holmium laser enucleation of the prostate (HoLEP). METHODS: Patients (n = 2346) were included in a retrospective multicentric study from April 2012 to November 2017. Patients' characteristics (age, BMI, percentage with diabetes), preoperative data (IPSS score, whole gland volume, urinary drainage), operative data (enucleation time, enucleation efficiency, tissue enucleated weight, total delivered energy) and postoperative data were recorded. Absence of UI was defined as no pads at 3 and 6 months. Surgeon experience was stratified in three categories: beginners (< 21 cases), intermediate (21-40 cases) and experienced (> 40 cases). Multivariate logistic regression analysis was performed. RESULTS: UI was observed in 14.5% of patients (340/2346) at 3 months (95%CI 13-16%) and in 4.2% (98/2346) at 6 months (95%CI 3-5%). On multivariate analysis at 3 months, increasing age (OR per SD = 1.3 [1.14-1.48]), elevated BMI (OR per SD = 1.23 [1.09-1.38]), preoperative urinary drainage (OR = 0.62 [0.45-0.85]), increasing enucleated tissue weight (OR per SD = 1.29 [1.16-1.45]) and experienced surgeon with at least 40 cases (OR = 0.56 [0.42-0.75]) were significantly associated with UI. At 6 months, increasing age (OR per SD = 1.25 [1.01-1.53]), elevated BMI (OR per SD = 1.25 [1.03-1.5]), increasing whole gland volume (OR per one SD log = 1.24 [1.01-1.53]) and diabetes disorder (OR = 1.7 [1.03-2.78]) were significantly associated with UI. CONCLUSION: UI after HoLEP was observed in 14.5% of patients at 3 months and 4.2% at 6 months, with stress UI in half of the cases. Surgeon experience with at least 40 cases was the main predictive factor of 3 months UI after HoLEP and diabetes disorder of persistent UI at 6 months.


Assuntos
Lasers de Estado Sólido/uso terapêutico , Complicações Pós-Operatórias/epidemiologia , Prostatectomia/métodos , Hiperplasia Prostática/cirurgia , Incontinência Urinária/epidemiologia , Idoso , Estudos de Coortes , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
4.
Int Braz J Urol ; 44(1): 45-52, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29064650

RESUMO

INTRODUCTION: Carcinosarcoma of the bladder is a very rare neoplasm. The pathogenesis of carcinosarcomas is not clearly understood and remains a subject of debate. Whilst there is some research conceptualizing the histopathological findings of bladder carcinosarcomas, the demographic features, clinical outcomes, prognosis and treatment options remain unclear. MATERIALS AND METHODS: We analyzed 12 consecutive cases of patients with sarcoma-toid bladder cancer who were treated surgically at a single Urology Department be-tween 1999 and 2015. Radiology, pathology and surgical reports were reviewed to determine the pathological staging at the time of cystectomy. These were directly compared with 230 patients having cystectomies for urothelial cell carcinoma. The sarcomatoid patients, were compared to patients with urothelial cell cancers. The other histological sub types, squamous cell (17), neuroendocrine (9), metastatic (7), mixed (4), adenocarcinoma (3), were not included. RESULTS AND CONCLUSION: Carcinosarcoma of the urinary bladder is often described in the literature as a highly malignant neoplasm that is rapidly lethal. We found that the sarcoma does not offer a worse prognosis than conventional high-grade urothelial car-cinoma. There is no significant difference in grade, stage, positive surgical margin rate, nodal involvement, associated prostate cancer or incidence rates of progression, all cause or disease specific mortality. There was a barely significant difference in carcinoma in-situ. However, carcinosarcomas are three times the volume of urothelial cell tumors which may contribute to its reputation as an aggressive tumour (44cc v 14cc). Sarcomatous elements do not appear, from our small study, to bestow a worse prognosis.


Assuntos
Carcinossarcoma/cirurgia , Neoplasias da Bexiga Urinária/cirurgia , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células de Transição/cirurgia , Carcinossarcoma/mortalidade , Carcinossarcoma/patologia , Cistectomia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento , Neoplasias da Bexiga Urinária/mortalidade , Neoplasias da Bexiga Urinária/patologia
5.
BJU Int ; 119(5): 667-675, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-27753182

RESUMO

OBJECTIVES: To compare quality-of-life (QoL) outcomes at 6 months between men with advanced prostate cancer receiving either transdermal oestradiol (tE2) or luteinising hormone-releasing hormone agonists (LHRHa) for androgen-deprivation therapy (ADT). PATIENTS AND METHODS: Men with locally advanced or metastatic prostate cancer participating in an ongoing randomised, multicentre UK trial comparing tE2 versus LHRHa for ADT were enrolled into a QoL sub-study. tE2 was delivered via three or four transcutaneous patches containing oestradiol 100 µg/24 h. LHRHa was administered as per local practice. Patients completed questionnaires based on the European Organisation for Research and Treatment of Cancer quality of life questionnaire 30-item core (EORTC QLQ-C30) with prostate-specific module QLQ PR25. The primary outcome measure was global QoL score at 6 months, compared between randomised arms. RESULTS: In all, 727 men were enrolled between August 2007 and October 2015 (412 tE2, 315 LHRHa) with QoL questionnaires completed at both baseline and 6 months. Baseline clinical characteristics were similar between arms: median (interquartile range) age of 74 (68-79) years and PSA level of 44 (19-119) ng/mL, and 40% (294/727) had metastatic disease. At 6 months, patients on tE2 reported higher global QoL than those on LHRHa (mean difference +4.2, 95% confidence interval 1.2-7.1; P = 0.006), less fatigue, and improved physical function. Men in the tE2 arm were less likely to experience hot flushes (8% vs 46%), and report a lack of sexual interest (59% vs 74%) and sexual activity, but had higher rates of significant gynaecomastia (37% vs 5%). The higher incidence of hot flushes among LHRHa patients appear to account for both the reduced global QoL and increased fatigue in the LHRHa arm compared to the tE2 arm. CONCLUSION: Patients receiving tE2 for ADT had better 6-month self-reported QoL outcomes compared to those on LHRHa, but increased likelihood of gynaecomastia. The ongoing trial will evaluate clinical efficacy and longer term QoL. These findings are also potentially relevant for short-term neoadjuvant ADT.


Assuntos
Adenocarcinoma/tratamento farmacológico , Antagonistas de Androgênios/administração & dosagem , Estradiol/administração & dosagem , Hormônio Liberador de Gonadotropina/administração & dosagem , Neoplasias da Próstata/tratamento farmacológico , Qualidade de Vida , Administração Cutânea , Idoso , Idoso de 80 Anos ou mais , Humanos , Masculino , Adesivo Transdérmico , Resultado do Tratamento
6.
Int Braz J Urol ; 43(2): 230-238, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28328188

RESUMO

BACKGROUND: Prostate-specific antigen densities have limited success in diagnosing prostate cancer. We emphasise the importance of the peripheral zone when considered with its cellular constituents, the "prostatocrit". OBJECTIVE: Using zonal volumes and asymmetry of glandular acini, we generate a peripheral zone acinar volume and density. With the ratio to the whole gland, we can better predict high grade and all grade cancer. We can model the gland into its acinar and stromal elements. This new "prostatocrit" model could offer more accurate nomograms for biopsy. MATERIALS AND METHODS: 674 patients underwent TRUS and biopsy. Whole gland and zonal volumes were recorded. We compared ratio and acinar volumes when added to a "clinic" model using traditional PSA density. Univariate logistic regression was used to find significant predictors for all and high grade cancer. Backwards multiple logistic regression was used to generate ROC curves comparing the new model to conventional density and PSA alone. OUTCOME AND RESULTS: Prediction of all grades of prostate cancer: significant variables revealed four significant "prostatocrit" parameters: log peripheral zone acinar density; peripheral zone acinar volume/whole gland acinar volume; peripheral zone acinar density/whole gland volume; peripheral zone acinar density. Acinar model (AUC 0.774), clinic model (AUC 0.745) (P=0.0105). Prediction of high grade prostate cancer: peripheral zone acinar density ("prostatocrit") was the only significant density predictor. Acinar model (AUC 0.811), clinic model (AUC 0.769) (P=0.0005). CONCLUSION: There is renewed use for ratio and "prostatocrit" density of the peripheral zone in predicting cancer. This outperforms all traditional density measurements.


Assuntos
Células Acinares/patologia , Antígeno Prostático Específico/sangue , Próstata/patologia , Neoplasias da Próstata/sangue , Neoplasias da Próstata/patologia , Idoso , Biópsia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Valor Preditivo dos Testes , Curva ROC , Padrões de Referência , Reprodutibilidade dos Testes , Células Estromais
7.
BJUI Compass ; 5(10): 969-975, 2024 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-39416751

RESUMO

Objectives: The objective of this study is to report the pilot phase of the Targeted Prostate Health Check programme that aims to identify men in the Surrey and Sussex region who have prostate cancer and who failed to be detected during the Covid era. Subjects and methods: Men aged 50 to 70, or 45 to 70 if Black or with a family history of prostate cancer, were identified from participating general practitioner (GP) records. Short message service (SMS) texts invited men to visit www.talkprostate.co.uk for information on prostate cancer and give consent to prostate-specific antigen (PSA) checks coordinated by a third-party virtual healthcare provider. Elevated age-related PSA levels, or levels below age-related thresholds but at 3 ng/mL or more, triggered referral to a rapid access urology clinic. GPs were informed of the results. Results: From 1842 text messages inviting 1549 people, 544 men consented to a PSA check. From 500 phlebotomy appointments, 485 (30% of invited men) took the PSA test of whom 68 (14%) were referred with an elevated PSA. After clinical review with multiparametric magnetic resonance imaging (mp-MRI), 22 patients underwent transperineal biopsies, and prostate cancer was detected in 18 men of whom 17 (95%) had clinically significant cancer. Conclusion: Our Targeted Prostate Cancer Health Check system identifies men at risk without burdening primary care. Awareness on prostate cancer risk was raised in 1549 invited men, half of whom were further educated via the registration website. One third of invited men were checked in whom clinically significant prostate cancer was found in 3.5%.

8.
BJU Int ; 111(1): 179-80, 2013 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-23323700

RESUMO

OBJECTIVE: To demonstrate an ergonomic fourth arm technique to oversew the dorsal vascular complex (DVC) during robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: Balloon of a Foley catheter inflated in the bulbar urethra. Fourth arm cranial traction via suture in the tip of the catheter. DVC oversewn under direct vision. RESULTS: Oversew of DVC with minimal patient-side surgical assistance. About a 50% reduction in apical positive margin rate. CONCLUSION: A useful, ergonomic method of oversewing the DVC during RALP.


Assuntos
Laparoscopia/métodos , Prostatectomia/métodos , Robótica/métodos , Técnicas de Sutura , Falha de Equipamento , Ergonomia , Humanos , Laparoscopia/instrumentação , Masculino , Prostatectomia/instrumentação , Robótica/instrumentação , Suturas , Cateterismo Urinário
9.
Eur Urol Oncol ; 3(3): 262-269, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31411968

RESUMO

BACKGROUND: Prostate biopsy guided by magnetic resonance imaging (MRI) is increasingly used to obtain tissue from men with suspected prostate cancer (PC). OBJECTIVE: To report a multicentre series of image-fusion transperineal prostate biopsies and compare the diagnostic yield of clinically significant PC (csPC) between targeted and nontargeted biopsies. DESIGN, SETTING, AND PARTICIPANTS: The study included 640 consecutive patients with elevated prostate specific antigen (PSA) presenting for first biopsy or following a previous negative transrectal biopsy under the care of 13 urologists in 11 centres in the UK (April 2014-June 2017). INTERVENTION: Multiparametric MRI was carried out in 61 approved prostate MRI centres with transperineal targeted alone (n=283) or targeted plus nontargeted (n=357) transperineal rigid image-fusion targeted biopsy (MIM-Symphony-DX). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Rates of csPC and insignificant cancer detection in targeted and nontargeted biopsies were measured using a number of thresholds to define clinical significance. The primary definition was Gleason≥4+3 or any grade ≥6mm. RESULTS AND LIMITATIONS: The mean age, median PSA, and median prostate volume for the cohort were 63.8yr (standard deviation [SD] 8.4), 6.3 ng/ml (SD 5.8), and 42.0cm3 (SD 24.7), respectively. Overall, 276/640 men (43.1%) were diagnosed with csPC. csPC was detected from targeted biopsies alone in 263/640 cases (41.1%). Of the 357 men who underwent nontargeted biopsies, three (0.8%) had csPC exclusively in nontargeted cores, with no evidence of cancer in targeted cores. Overall, 32/357 (9.0%) had csPC in nontargeted biopsies regardless of the targeted biopsy findings. Clinically insignificant disease in nontargeted biopsies was detected in 93/357 men (26.1%). Our findings were consistent across all other thresholds of clinical significance. Limitations include the lack of nontargeted biopsies in all men. CONCLUSIONS: In this large multicentre series, nontargeted prostate biopsy cores had a low yield of csPC and a high yield of clinically insignificant PC. An image-fusion targeted-biopsy-only approach maintains high detection for csPC and low detection of clinically insignificant cancers. PATIENT SUMMARY: In this report, we found that following prostate multiparametric magnetic resonance imaging and targeted transperineal biopsies of suspicious areas, the clinical value of performing additional extensive unguided biopsies of nonsuspicious areas is limited and can often find insignificant cancers that do not need treatment.


Assuntos
Biópsia Guiada por Imagem/métodos , Imagem por Ressonância Magnética Intervencionista , Imageamento por Ressonância Magnética Multiparamétrica , Próstata/patologia , Neoplasias da Próstata/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Humanos , Masculino , Pessoa de Meia-Idade , Períneo , Estudos Retrospectivos , Fatores de Risco
10.
Cent European J Urol ; 71(1): 84-91, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29732212

RESUMO

INTRODUCTION: There are limited studies evaluating the 3 Incontinence Questionnaire (3IQ) against urodynamics based diagnosis as a reference standard. The 3IQ has been proposed to be useful to evaluate women at the level of primary care. The aim of this study was to determine correlation between 3IQ and video-urodynamics (VUDS) in diagnosing types of urinary incontinence. MATERIAL AND METHODS: Prospective data was collected on 200 consecutive female patients referred by primary care physicians for urinary incontinence. The mean age was 55 years (range 15-83 years). The patients were evaluated using the 3IQ and video-urodynamics. The 3IQ-based diagnosis of type of female urinary incontinence was compared to VUDS-based results. Sensitivity, specificity, positive likelihood ratios and positive predictive values were calculated. RESULTS: On 3IQ based self-evaluation, 28% of patients were classified as having stress urinary incontinence, 20% with urge incontinence and 40% with mixed incontinence. On video-urodynamics, urodynamic stress urinary incontinence (UDSUI) was detected in 56% of patients, detrusor overactivity (DO) in 15% and mixed urinary incontinence (MUI) in 19%. The 3IQ had a sensitivity and specificity respectively of 43% and 92% for UDSUI, 57% and 86% for DO and 58% and 64% for MUI. The corresponding positive likelihood ratios (CI, 95%) were 5.4 (CI 2.6 to 11.3) for stress urinary incontinence, 4.0 (CI 2.5 to 6.5) for DO and 1.62 (1.2 to 2.3) for MUI. The respective positive predictive values were 87% (CI 75% to 95%), 42% (CI 26% to 58%) and 28% (18% to 39%). CONCLUSIONS: In our study population, stress urinary incontinence was reasonably well predicted by the 3IQ, but the questionnaire under-performed in the diagnoses of detrusor overactivity and mixed urinaryincontinence.

11.
Int Urol Nephrol ; 39(1): 185-8, 2007.
Artigo em Inglês | MEDLINE | ID: mdl-17268896

RESUMO

INTRODUCTION: TRUS-guided needle biopsy of the prostate is the standard technique in the diagnosis of prostate cancer. However the practice is highly variable across the United Kingdom. We survey the standard approaches to TRUS biopsy of prostate, highlighting the nationwide diversity of practice and training. METHODS: One hundred and eighty questionnaires were sent out to specialist registrars, investigating the number of prostate biopsy cores taken, the use of prophylactic antibiotics, rectal preparation and local analgesia in TRUS biopsy of the prostate. One hundred and fourteen trainees (63%) returned the questionnaires. Twenty-three percent reported sextant biopsy as standard, 36% taking eight-core and 26% taking 10 or more cores. There is no standard regime for antibiotic prophylaxis. Eighteen percent also reported rectal preparation as routine. Thirty-eight percent of the patients receive local anaesthesia prior to the biopsy. Overall, 42% of the TRUS biopsies are carried out by urologists, 29% by radiologists and 21% by both. Six percents have nurse practitioners' involvement. Fifty-six percent of trainees are involve in the TRUS biopsy, 68% do not think they received enough training to carry out the procedure. CONCLUSIONS: TRUS-guided needle biopsy of the prostate is the standard technique in the diagnosis of prostate cancer. Our survey highlights nationwide diversity in practice in the UK with respect of the number of cores taken, antibiotic prophylaxis and local anaesthesia utilisation. This raised the issue of standardising the practice. More urologists are also actively taking part in this procedure, making the structured training increasingly important.


Assuntos
Educação , Próstata/patologia , Ultrassom Focalizado Transretal de Alta Intensidade/métodos , Biópsia , Humanos , Masculino , Inquéritos e Questionários , Reino Unido
12.
Int J Med Robot ; 13(1)2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26948671

RESUMO

OBJECTIVE: The paper describes novel real-time 'in situ mapping' and 'sequential occlusion angiography' to facilitate selective ischaemia robotic partial nephrectomy (RPN) using intraoperative contrast enhanced ultrasound scan (CEUS). MATERIALS AND METHODS: Data were collected and assessed for 60 patients (61 tumours) between 2009 and 2013. 31 (50.8%) tumours underwent 'Global Ischaemia', 27 (44.3%) underwent 'Selective Ischaemia' and 3 (4.9%) were removed 'Off Clamp Zero Ischaemia'. Demographics, operative variables, complications, renal pathology and outcomes were assessed. RESULTS: Median PADUA score was 9 (range 7-10). The mean warm ischaemia time in selective ischaemia was less and statistically significant than in global ischaemia (17.1 and 21.4, respectively). Mean operative time was 163 min. Postoperative complications (n = 10) included three (5%) Clavien grade 3 or above. Malignancy was demonstrated in 47 (77%) with negative margin in 43 (91.5%) and positive margin in four (8.5%). Long-term decrease in eGFR post selective ischaemia robotic partial nephrectomy was less compared with global ischaemia (four and eight, respectively) but not statistically significant. CONCLUSIONS: This technique is safe, feasible and cost-effective with comparable perioperative outcomes. The technical aspects elucidate the role of intraoperative CEUS to facilitate and ascertain selective ischaemia. Further work is required to demonstrate long-term oncological outcomes. © 2016 The Authors. The International Journal of Medical Robotics and Computer Assisted Surgery published by John Wiley & Sons, Ltd.


Assuntos
Neoplasias Renais/cirurgia , Nefrectomia/métodos , Circulação Renal , Procedimentos Cirúrgicos Robóticos/métodos , Ultrassonografia , Adulto , Idoso , Angiografia , Constrição , Meios de Contraste/química , Feminino , Taxa de Filtração Glomerular , Humanos , Isquemia , Rim/diagnóstico por imagem , Rim/cirurgia , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Período Pós-Operatório , Reprodutibilidade dos Testes , Cirurgia Assistida por Computador , Tomografia Computadorizada por Raios X , Resultado do Tratamento
13.
Int Urol Nephrol ; 38(2): 281-5, 2006.
Artigo em Inglês | MEDLINE | ID: mdl-16868698

RESUMO

OBJECTIVE: We prospectively evaluate the safety, morbidity and characteristics of complications for transrectal ultrasound guided needle biopsy of prostate carried out solely by urologists in a single unit. This will help to counsel patient prior to the biopsy. PATIENTS AND METHODS: One hundred consecutive patients were recruited to complete questionnaires prospectively, 2 weeks and 3 months after TRUS and prostate biopsy. Haematospermia, haematuria and rectal bleeding characteristics were evaluated. Pain, analgesia requirement, infection and urinary retention rates were also assessed. RESULTS: Ninety-two patients (92%) returned questionnaires 2 weeks and 63 patients (63%) three months after the biopsy. At 2 weeks questionnaire, 58 patients (63%) experienced haematuria and 9 patients (10%) for more than 1 week. Eighty-five percent of the 58 patients who had haematuria described it as mild and intermittent. Twenty-three (25%) patients experienced a rectal bleed and none for more than four days. Only 1 patient experienced clots with the rectal bleeding. Twelve (13%) patients had difficulty passing urine but the symptoms resolved by day four. Acute urinary retention did not occur. Thirty-five (38%) patients had some degree of discomfort and only one patient had pain for more than three days. Twenty-five (27%) patients took analgesia between 1 and 8 days (Mean 3 days). Two patients had a urinary tract infection despite prophylactic antibiotics. At three months, 4 patients (6%) had experienced secondary haematuria 3 weeks after the biopsy. Two patients experienced more rectal bleeding 2 weeks after the biopsy and 1 patient had residual discomfort 2 weeks after the procedure. Thirteen patients (21%) had haematospermia between day 6 and 56 (Mean 21 days). CONCLUSIONS: Transrectal ultrasound guided biopsy of the prostate is generally well tolerated with minor pain and morbidity in our urologist-led service. Our data will assist counselling of patients prior to the procedure.


Assuntos
Biópsia por Agulha/efeitos adversos , Biópsia por Agulha/métodos , Próstata/patologia , Ultrassonografia de Intervenção/métodos , Urologia/métodos , Biópsia por Agulha/instrumentação , Hemorragia Gastrointestinal/etiologia , Hematúria/etiologia , Humanos , Masculino , Morbidade , Dor/etiologia , Estudos Prospectivos , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/patologia , Doenças Retais/etiologia , Inquéritos e Questionários , Retenção Urinária/etiologia , Infecções Urinárias/etiologia , Urologia/instrumentação
14.
Urology ; 81(1): e7-8, 2013 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-23146346

RESUMO

Crossed ectopia is a rare congenital anomaly. S-shaped (sigmoid) kidney is one of the varieties of crossed ectopia that is associated with absence of any renal tissue in the contralateral renal fossa. S-shaped malformation of an ipsilateral kidney with presence of the contralateral kidney is an extremely rare condition and, to our knowledge, has been described only once before in the literature. We present the case and discuss the hypothesis for this rare malformation.


Assuntos
Rim/anormalidades , Rim/diagnóstico por imagem , Adulto , Humanos , Imageamento Tridimensional , Masculino , Tomografia Computadorizada por Raios X
15.
Int. braz. j. urol ; 44(1): 45-52, Jan.-Feb. 2018. tab, graf
Artigo em Inglês | LILACS | ID: biblio-892943

RESUMO

ABSTRACT Introduction Carcinosarcoma of the bladder is a very rare neoplasm. The pathogenesis of carcinosarcomas is not clearly understood and remains a subject of debate. Whilst there is some research conceptualizing the histopathological findings of bladder carcinosarcomas, the demographic features, clinical outcomes, prognosis and treatment options remain unclear. Materials and Methods We analyzed 12 consecutive cases of patients with sarcoma-toid bladder cancer who were treated surgically at a single Urology Department be-tween 1999 and 2015. Radiology, pathology and surgical reports were reviewed to determine the pathological staging at the time of cystectomy. These were directly compared with 230 patients having cystectomies for urothelial cell carcinoma. The sarcomatoid patients, were compared to patients with urothelial cell cancers. The other histological sub types, squamous cell (17), neuroendocrine (9), metastatic (7), mixed (4), adenocarcinoma (3), were not included. Results and conclusion Carcinosarcoma of the urinary bladder is often described in the literature as a highly malignant neoplasm that is rapidly lethal. We found that the sarcoma does not offer a worse prognosis than conventional high-grade urothelial car-cinoma. There is no significant difference in grade, stage, positive surgical margin rate, nodal involvement, associated prostate cancer or incidence rates of progression, all cause or disease specific mortality. There was a barely significant difference in carcinoma in-situ. However, carcinosarcomas are three times the volume of urothelial cell tumors which may contribute to its reputation as an aggressive tumour (44cc v 14cc). Sarcomatous elements do not appear, from our small study, to bestow a worse prognosis.


Assuntos
Humanos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Bexiga Urinária/cirurgia , Carcinossarcoma/cirurgia , Prognóstico , Neoplasias da Bexiga Urinária/mortalidade , Neoplasias da Bexiga Urinária/patologia , Carcinoma de Células de Transição/cirurgia , Carcinossarcoma/mortalidade , Carcinossarcoma/patologia , Cistectomia , Análise de Sobrevida , Estudos Retrospectivos , Resultado do Tratamento , Pessoa de Meia-Idade
16.
Eur Urol ; 63(5): 913-9, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23116657

RESUMO

BACKGROUND: Recent innovations in technology and operative techniques have enabled safe performance of robot-assisted zero-ischaemia partial nephrectomy (PN), thus preventing the deleterious effect of warm ischaemia time. OBJECTIVE: To describe a novel technique of occlusion angiography using intraoperative contrast-enhanced ultrasound scan (CEUS) for zero-ischaemia robot-assisted PN (RAPN). DESIGN, SETTING, AND PARTICIPANTS: We used a prospective cohort evaluation of five patients who had imaging suspicious of renal cell carcinoma (RCC) treated at a single centre. SURGICAL PROCEDURE: We used computed tomography with three-dimensional reconstruction to identify renal arterial anatomy and its relationship to the tumour. Then, RAPN was performed with selective clamping and demonstration of a nonperfused segment of kidney (occlusion angiography) using intraoperative CEUS. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We prospectively collected data on baseline, perioperative, and postoperative parameters. RESULTS AND LIMITATIONS: We describe the effects seen on ultrasound contrast administration. Contrast flare is seen in the segment of the kidney that is perfused. When selective clamping is performed, a watershed (line of demarcation) between the perfused and nonperfused segments of the kidney is clearly seen, allowing excision of the tumour in a relatively avascular plane and ensuring an adequate oncologic margin, when feasible. The mean age was 68.2 yr of age (range: 36-85), and the mean tumour size was 29.6mm (range: 20-42). The mean intraparenchymal extension of the tumour was 22.6mm (range: 12-30). Three tumours were located on the right kidney and two on the left. The mean blood loss was 420ml (range: 200-1000). The histology revealed clear cell RCC in two patients, oncocytoma in two patients, and type 1 papillary RCC in one patient. All the surgical specimens had negative surgical margins. The mean decrease in glomerular filtration rate was 8.4ml (range: 0-24). The mean follow-up was 6.4 mo (range: 5-8), with no evidence of recurrence in any patient. The only limitation in adopting this technique is the need for an intraoperative ultrasound probe with a CEUS mode. However, most specialists who perform minimally invasive surgery for small renal tumours believe that intraoperative ultrasound scan imaging is essential to achieving adequate resection margins. CONCLUSIONS: Intraoperative CEUS can be a useful adjunct in determining whether zero-ischaemia RAPN is feasible by delineating the area of nonperfusion. This technique has several advantages over the currently available techniques, such as indigo carmine green and Doppler probes.


Assuntos
Adenoma Oxífilo/irrigação sanguínea , Adenoma Oxífilo/cirurgia , Carcinoma de Células Renais/irrigação sanguínea , Carcinoma de Células Renais/cirurgia , Meios de Contraste , Neoplasias Renais/irrigação sanguínea , Neoplasias Renais/cirurgia , Nefrectomia/métodos , Fosfolipídeos , Robótica , Hexafluoreto de Enxofre , Cirurgia Assistida por Computador , Ultrassonografia de Intervenção , Adenoma Oxífilo/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Renais/diagnóstico por imagem , Constrição , Humanos , Imageamento Tridimensional , Neoplasias Renais/diagnóstico por imagem , Masculino , Valor Preditivo dos Testes , Estudos Prospectivos , Interpretação de Imagem Radiográfica Assistida por Computador , Circulação Renal , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Carga Tumoral
17.
Int. braz. j. urol ; 43(2): 230-238, Mar.-Apr. 2017. tab, graf
Artigo em Inglês | LILACS | ID: biblio-840830

RESUMO

ABSTRACT Background Prostate-specific antigen densities have limited success in diagnosing prostate cancer. We emphasise the importance of the peripheral zone when considered with its cellular constituents, the “prostatocrit”. Objective Using zonal volumes and asymmetry of glandular acini, we generate a peripheral zone acinar volume and density. With the ratio to the whole gland, we can better predict high grade and all grade cancer. We can model the gland into its acinar and stromal elements. This new “prostatocrit” model could offer more accurate nomograms for biopsy. Materials and Methods 674 patients underwent TRUS and biopsy. Whole gland and zonal volumes were recorded. We compared ratio and acinar volumes when added to a “clinic” model using traditional PSA density. Univariate logistic regression was used to find significant predictors for all and high grade cancer. Backwards multiple logistic regression was used to generate ROC curves comparing the new model to conventional density and PSA alone. Outcome and results Prediction of all grades of prostate cancer: significant variables revealed four significant “prostatocrit” parameters: log peripheral zone acinar density; peripheral zone acinar volume/whole gland acinar volume; peripheral zone acinar density/whole gland volume; peripheral zone acinar density. Acinar model (AUC 0.774), clinic model (AUC 0.745) (P=0.0105). Prediction of high grade prostate cancer: peripheral zone acinar density (“prostatocrit”) was the only significant density predictor. Acinar model (AUC 0.811), clinic model (AUC 0.769) (P=0.0005). Conclusion There is renewed use for ratio and “prostatocrit” density of the peripheral zone in predicting cancer. This outperforms all traditional density measurements.


Assuntos
Humanos , Masculino , Idoso , Próstata/patologia , Neoplasias da Próstata/patologia , Neoplasias da Próstata/sangue , Antígeno Prostático Específico/sangue , Células Acinares/patologia , Padrões de Referência , Biópsia , Modelos Logísticos , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Curva ROC , Células Estromais , Gradação de Tumores , Pessoa de Meia-Idade
18.
N Z Med J ; 121(1287): 39-43, 2008 Dec 12.
Artigo em Inglês | MEDLINE | ID: mdl-19098966

RESUMO

OBJECTIVES: PSA testing has led to an increasing number of TRUS-guided biopsies being performed. These are well tolerated in the majority, but a minority of men find the procedure unacceptably painful. We have studied a cohort of men undergoing TRUS guided prostate biopsy to ascertain whether the biopsy strategy, or pain on probe insertion, can assist in predicting those who men most likely to suffer severe pain during prostate biopsy. METHODS: 162 men (screened and symptomatic) between 47 and 86 years of age (mean age 61.7 yrs) who attended for TRUS and biopsy were studied. The number of cores taken were governed by TRUS volume, less than and equal to or=40cc =12 cores. Each completed a 10-point visual analogue pain score (VAS) immediately after procedure. All men were asked to describe their pain, on insertion of the TRUS probe, followed by the first and the last biopsy. All biopsies were taken with an 18G spring-loaded Tru-cut disposable needle. Severe pain (score of 8-10) was deemed unacceptable. RESULTS: 22% (36/162) of the men biopsied experienced unacceptable pain in one or more of the three categories. There was a higher incidence of severe pain in those undergoing 12 cores compared to 7-11, or a standard sextant strategy (p=0.05, Chi-squared for linear trend). Severe pain was experienced by 6% (9/162) of men during probe insertion. Of this group 78% (7/9) also went on to find biopsies unacceptably painful, compared to 19% (29/152) of those who did not experience severe pain for probe insertion (p<0.0001, exact test for two independent proportions). CONCLUSIONS: Approximately 1 in 5 men experience unacceptable pain at some time during TRUS biopsy of the prostate. A high proportion of men (78%) in whom insertion of the TRUS probe was unacceptably painful, found subsequent biopsies equally painful. With trend towards saturation biopsies the need for predicting group of men who will need local/general anaesthesia is ever-increasing.


Assuntos
Biópsia por Agulha/métodos , Dor/etiologia , Próstata/patologia , Neoplasias da Próstata/patologia , Ultrassom Focalizado Transretal de Alta Intensidade , Idoso , Idoso de 80 Anos ou mais , Biópsia por Agulha/efeitos adversos , Distribuição de Qui-Quadrado , Detecção Precoce de Câncer , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Dor/epidemiologia , Medição da Dor , Estudos Prospectivos , Próstata/diagnóstico por imagem , Neoplasias da Próstata/diagnóstico por imagem , Ultrassonografia , Ultrassom Focalizado Transretal de Alta Intensidade/efeitos adversos
19.
N Z Med J ; 120(1252): U2496, 2007 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-17460746

RESUMO

The use of postoperative drains date back to Hippocrates. We report an iatrogenic case of migrated drain into the retroperitoneum. A novel technique using a rigid cystoscope for retrieval is described that prevented another laparotomy.


Assuntos
Drenagem/instrumentação , Migração de Corpo Estranho/etiologia , Migração de Corpo Estranho/cirurgia , Erros Médicos/efeitos adversos , Carcinoma de Células Renais/cirurgia , Cistoscópios , Cistoscopia/métodos , Migração de Corpo Estranho/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Nefrectomia/efeitos adversos , Radiografia , Espaço Retroperitoneal , Resultado do Tratamento
20.
BJU Int ; 100(2): 327-31, 2007 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-17617139

RESUMO

OBJECTIVE: To compare the incidence of acute and/or chronic intraprostatic inflammation (ACI) in men undergoing transurethral resection of the prostate (TURP) for urinary retention and lower urinary tract symptoms (LUTS), as recently a role was suggested for ACI in the pathogenesis and progression of BPH, and urinary retention is considered an endpoint in the natural history of this condition. PATIENTS AND METHODS: Details of TURPs done between January 2003 and December 2005 at one institution were obtained from the operating theatre database. Patients were divided by indication (retention/LUTS). Clinical data and histology reports were then reviewed and bivariate and logistic regression used to compare the pathological features between these groups. RESULTS: Of 406 patients, 374 had evaluable data; 70% of men with urinary retention had ACI, vs 45% of those with LUTS (P < 0.001). On logistic regression, the pathological factors associated with TURP for acute retention compared to that for LUTS were ACI, old age, and resection weight to a lesser degree. CONCLUSION: Inflammation appears to be important in the pathogenesis and progression of BPH. In this study, the risk of urinary retention due to BPH was significantly greater in men with ACI than in those without, and the association of TURP for retention with ACI was stronger than that with prostate weight. This finding might offer new avenues for the medical treatment of men with LUTS due to BPH.


Assuntos
Hiperplasia Prostática/complicações , Prostatismo/etiologia , Prostatite/complicações , Retenção Urinária/etiologia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Progressão da Doença , Humanos , Masculino , Pessoa de Meia-Idade , Hiperplasia Prostática/cirurgia , Prostatismo/cirurgia , Prostatite/cirurgia , Análise de Regressão , Estudos Retrospectivos , Ressecção Transuretral da Próstata , Retenção Urinária/cirurgia
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