Resumo em Inglês:

ABSTRACT 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.

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ABSTRACT Testicular cancer is considered a rare disease affecting approximately 1% to 2% of the male population. This neoplasm has a cure rate of over 95%; as a result, a major concern is the future of fertility of carriers from this disease. There are several histological subtypes of testicular tumors; however, the Testicular Germ Cell Tumors (TGCTs), comprising both seminoma and non-seminoma tumors, are considered the main subtypes of testicular neoplasms. TGCT are characterized by being a solid tumor that mostly affects young men aged between 15 and 40 years old. While TGCT subtypes may have an invasive potential, seminoma subtype does not affect other cells rather than germ cells, while non-seminomas have more invasive properties and can achieve somatic cells; thus, having a more aggressive nature. This research intends to review the literature regarding information about sperm parameters, correlating the data found in those studies to the subfertility and infertility of patients with TCGTs. Furthermore, it will also correlate the data to the non-seminoma and seminoma histological subtypes from pre- and post-cancer therapy. PubMed databases were used. Searched keywords included: seminoma AND non-seminoma; male infertility; germ cell tumor; chemotherapy AND radiotherapy. Only articles published in English were considered. Current studies demonstrate that both TGCT subtypes promote deleterious effects on semen quality resulting in decreased sperm concentration, declined sperm total motility and an increase in the morphology alterations. However, findings suggest that the non-seminoma subtype effects are more pronounced and deleterious. More studies will be necessary to clarify the behavior of seminoma and non-seminoma tumors implicating the reproductive health of male patients.

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ABSTRACT Purpose: Proteomic biomarkers have been emerging as alternative methods to the gold standard procedures of cystoscopy and urine cytology in the diagnosis and surveillance of bladder cancer (BC). This review aims to update the state of the art of proteomics research and diagnosis in BC. Materials and Methods: We reviewed the current literature related to BC research on urinary, tissue, blood and cell line proteomics, using the Pubmed database. Findings: Two urinary protein biomarkers are FDA-approved (NMP22® and BTA® tests), only if performed along with cystoscopy for surveillance after initial diagnosis, but not in the primary diagnostic setting due to high false-positive rates in case of infections, stones and hematuria. There are a great number of non-FDA approved proteins being studied, with good preliminary results; panels of proteins seem valuable tools to be refined in ongoing trials. Blood proteins are a bigger challenge, because of the complexity of the serum protein profile and the scarcity of blood proteomic studies in BC. Previous studies with the BC tissue proteome do not correlate well with the urinary proteome, likely due to the tumor heterogeneity. Cell line proteomic research helps in the understanding of basic mechanisms that drive BC development and progression; the main difficulty is culturing low-grade tumors in vitro, which represents the majority of BC tumors in clinical practice. Conclusion: Protein biomarkers have promising value in the diagnosis, surveillance and prognostic of BC. Urine is the most appropriate body fluid for biomarker research in BC due to its easiness of sampling, stability and enrichment of shed and secreted tumor-specific proteins. Panels of biomarkers may exhibit higher sensitivity than single proteins in the diagnosis of BC at larger populations due to clinical and tumor heterogeneity. Prospective clinical trials are warranted to validate the relevance of proteomic data in the clinical management of BC.

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ABSTRACT Purpose: To evaluate the erectile function in patients who underwent partial penectomy and identify factors associated with penile functional status. Materials and Methods: We identified patients who underwent partial penectomy due to penile cancer between 2009 and 2014. Clinical and pathological characteristics included patient age at the time of diagnosis, obesity, hypertension, dyslipidemia, diabetes, smoking, metabolic syndrome, Eastern Cooperative Oncology Group (ECOG) status, penile shaft length, tumor size, primary tumor stage (pT), clinical nodal status, and local recurrence. Erectile function was assessed prospectively with the International Index of Erectile Function (IIEF-5) at least 3 months after partial penectomy. Results: A total of 81 patients met analysis criteria. At the diagnosis, the median age was 62 years (range from 30 to 88). Median follow-up was 17 months (IQR 7-36). Of total patients, 37 (45%) had T2 or higher disease. Clinically positive nodes were present in 16 (20%) patients and seven (8.6%) developed local recurrence. Fifty patients (62%) had erectile dysfunction (ED) after partial penectomy, 30% had moderate or severe erectile dysfunction scores. Patients with ED versus without ED were similar in baseline characteristics except for age, penile shaft length, and presence of inguinal adenopathy (p <0.05). Multivariate analysis using logistic regression confirmed that older patients, shorter penile shaft length, and clinically positive lymph node were significantly associated with ED. Conclusion: Partial penectomy due to penile cancer provides adequate local control of the disease, however, proper counselling is important especially in relation to ED consequences. Preservation of penile length yields to more optimal erectile recovery.

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ABSTRACT Objectives: Develop and validate a new and simplified score for evaluating the lower urinary tract symptoms in men. Materials and methods: We modified the existing visual prostate symptom score, including changes in the images, sequence, and new alternatives, resulting in a new visual score (LUTS visual score-LUTS-V). For the validation of the new tool, we used the International Prostatic Symptom Score as the gold-standard and the new LUTS-V to 306 men. The total IPSS score and the total LUTS-V score of each subject were evaluated to determine the agreement between the two instruments. ROC curve was used to evaluate the diagnostic accuracy and best cut-off of LUTS-V. Sensitivity, specificity, and diagnostic odds ratios were used to describe the diagnostic properties. Results: The mean age of the participants was 59 [52-87] years. There was a significant correlation between LUTS-V and IPSS. (r=0.72 (p <0.0001). The Bland-Altman analyzes demonstrate good agreement between the two questionnaires (bias=5.6%). LUTS-V demonstrated excellent diagnostic accuracy in detecting the most serious cases with an area under the ROC curve of 83% [78-87%] 95% CI. p <0.001). LUTS-V >4 was the best threshold, with a sensitivity of 74% and specificity of 78%. Conclusions: LUTS-V is a simple, self-administered tool with a significant discriminatory power to identify subjects with moderate to severe LUTS and may represent a useful instrument for the diagnosis and follow-up of men with urinary symptoms.

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ABSTRACT Introduction: Nocturnal enuresis is a highly incident chronic disorder that generates countless problems to the child and their parents. Bed-wetting has significant negative impacts on self-esteem and the performance of children. The aim of the current study is to assess the quality of life of enuretic children, as well as its association to sex and age. Patients and Methods: Thirty-nine enuretic children (23 boys) and 49 healthy children (27 boys) without any history of previous treatment for enuresis or voiding dysfunction were included. Age ranged between 6 and 11 years old. The “AUQEI” questionnaire was applied in a private environment to all children by the same researcher (psychologist) to evaluate quality of life. Results: Enuretic children displayed loss in quality of life when compared to non-enuretic (35.9% of enuretic x 16.3% of non-enuretic, p=0.035). They were mostly affected in their daily activities (p=0.02). No significant differences were found in the association of sex and gender with quality of life. These results suggest that, children with nocturnal enuresis have 2.87 times more chances of having loss in quality of life compared to non-enuretic. Conclusions: Enuresis has a great impact in quality of life of children. This impact is not related to the age or sex of the child.

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ABSTRACT Introduction: When the vasectomy reversal (VR) fails, and the patient desires natural conception with his sperm, vasectomy re-reversal (VRR) is the only alternative. Purpose: To determine the VRR effectiveness and whether specific parameters can be associated with its success. Materials and Methods: We retrospectively evaluated 18 consecutive vasectomized patients, who had failed their VR through bilateral vasovasostomy, and posteriorly were submitted to VRR. The parameters of the study were: age of the patients, elapsed time between vasectomy and VRR (V-VRRt), elapsed time between VR and VRR (VR-VRRt), presence of spermatozoa in the proximal vas deferens fluid (SptzVDF) in the VRR and results of semen analysis after VRR (SA-VRR). Results: The mean of the age of the patients was 44.11±6.55 years (32.0-57.0), the mean of V-VRRt was 11.76±6.46 years (1.5-25.0) and the mean of VR-VRRt was 2.13±2.27 years (0.5-10.0). SptzVDF in the VRR were found bilaterally in 8 patients, unilaterally in 4 and absent in 6. SA-VRR demonstrated normozoospermia in 9 patients, oligozoospermia in 3 and azoospermia in 6, with patency rate of 66.67%. SA-VRR showed statistically significant dependence only with SptzVDF in the VRR (p <0.01). Conclusions: VRR was effective in restoring the obstruction in more than half of the patients. Furthermore, the presence of spermatozoa in the vas deferens fluid was the parameter associated with the VRR success.

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ABSTRACT Purpose: False-negative urodynamic findings may mislead or prevent planned treatments due to unmatched findings with the clinical presentation. We hypothesized that the absence of urodynamic demonstration of SUI or OAB on urodynamics would interfere with clinical outcomes. Materials and Methods: Materials and Methods: We prospectively studied 124 women with (94) or without (30) demonstrable SUI after sling operations. Similarly, 64 women with OAB syndrome with (38) or without (26) demonstrable DO were also compared after treatment with anticholinergic agents. Patients were assessed with the UDI-6 and IIQ-7 questionnaires 3 and 6 months after treatment. Results: Only 76% of SUI patients demonstrated urine leakage during urodynamics. The UDI-6 score was higher in the demonstrable-SUI and demonstrable-DO groups, while the IIQ-7 score was comparable within the incontinence or urgency/frequency groups. Demonstrable and non-demonstrable SUI-operated patients showed similar outcomes. Patients with urgency syndromes with or without demonstrable DO had a similar rate of improvement with anticholinergic therapy. Conclusions: Women with clinical complaints of SUI objectively demonstrated on urodynamics presented the same subjective clinical outcome as those with SUI lacking objective demonstration when measured by the UDI-6 and IIQ-7 questionnaires. Similarly, patients with OAB syndrome with or without demonstrable DO had similar clinical improvement when treated with anticholinergics and measured using the same questionnaires.

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ABSTRACT Purpose: Incidence and mortality of prostate cancer (PCa) are still increasing in developing countries. Limited access to the health system or more aggressive disease are potential reasons for this. Ethnic and social differences in developed countries seem to make inappropriate to extrapolate data from other centers. We aim to report the epidemiological profile of a PSA-screened population from a cancer center in Brazil. Materials and Methods: We retrospectively selected 9.692 men enrolled in a PCa prevention program, comprising total PSA level and digital rectal examination at the first appointment, associated with complementary tests when necessary. Men aged over 40 years-old were included after shared decision-making process. Prostate biopsy (TRUS) was performed when clinically suspected for PCa. After the diagnosis, patients underwent appropriate treatment. Results: TRUS was performed in 5.5% of men and PCa incidence was 2.6%. Overall ratio between number of patients who needed to be screened in order to diagnose one cancer was 38.9 patients, with 2.1 biopsies performed to diagnose a cancer. Positive predictive value (PPV) of TRUS biopsy in this strategy was 47.2%, varying from 38.5% (<50 years-old) to 60% (>80 years-old). We evidenced 70 patients (27.9%) classified as low risk tumors, 74 (29.5%) as intermediate risk, and 107 (42.6%) as high-risk disease. Conclusions: PSA-screening remains controversial in literature. In front of a huge miscegenated people and considering the big proportion of high-risk PCa, even in young men diagnosed with the disease, it is imperative to inform patients and health providers about these data particularities in Brazil.

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ABSTRACT Background: Tyrosine kinase inhibitors (TKI) and immunotherapy improved survival in metastatic renal cell carcinoma (mRCC). Disparities in treatment access are present in healthcare systems globally. The aim of this study was to analyze survival outcomes of mRCC patients treated with first-line TKIs in the public (PHS) and private (PrS) health system in a Brazilian Cancer Center. Materials and Methods: Records from all mRCC patients treated with first-line TKIs from 2007-2018 were reviewed retrospectively. Categorial variables were compared by Fisher's exact test. Survival was estimated by Kaplan-Maier method and survival curves were compared using the log-rank test. Prognostic factors were adjusted by Cox regression model. Results: Of the 171 eligible patients, 37 (21.6%) were PHS patients and 134 (78.4%) were PrS patients. There were no difference in age, gender, or sites of metastasis. PHS patients had worse performance status (ECOG ≥2, 35.1% vs. 13.5%, p=0.007), poorer risk score (IMDC poor risk, 32.4% vs. 16.4%, p=0.09), and less nephrectomies (73% vs. 92.5%, p=0.003) than PrS patients. Median lines of therapy was one for PHS versus two for PrS patients (p=0.03). Median overall survival (OS) was 16.5 versus 26.5 months (p=0.002) and progression-free survival (PFS), 8.4 versus 11 months (p=0.01) for PHS and PrS patients, respectively. After adjusting for known prognostic factors on multivariate analysis, PHS patients still had a higher risk of death (HR: 1.61, 95% CI: 1.01-2.56, p=0.047). Conclusion: Patients with mRCC treated via the PHS had worse overall survival, possibly due to poorer prognosis at presentation and less drug access.

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ABSTRACT Purpose: To describe our experience in the management of retained encrusted ureteral stents using a single session combined endourological approach. Materials and Methods: Patients with retained encrusted ureteral stents who had been submitted to a single session combined endourological approach from June 2010 to June 2018 were prospectively evaluated. Patients were divided according to the Forgotten-Encrusted-Calcified (FECal) classification. The stone burden, surgical intervention, number of interventions until stone free status, operation time, hospital stay, complications, stone analysis, and stone-free rate were compared between groups. ANOVA was used to compare numerical variables, and the Mann-Whitney or Chi-square test to compare categorical variables between groups. Results: We evaluated 50 patients with a mean follow-up of 2.9±1.4 years (mean±SD). The groups were comparable in terms of age, sex, laterality, BMI, comorbidities, ASA, reason for stent passage, and indwelling time. The stone burden was higher for grades IV and V (p=0.027). Percutaneous nephrolithotomy was the most common procedure (p=0.004) for grades IV and V. The number of procedures until the patients were stone-free was 1.92±1.40, and the hospital stay (4.2±2.5 days), complications (22%), and stone analysis (66% calcium oxalate) were similar between groups. The stone-free rate was lower in grades III to V (60%, 54.5%, and 50%). Conclusions: The endoscopic combined approach in the supine position is a safe and feasible technique that allows removal of retained and encrusted stents in a single procedure. The FECal classification seems to be useful for surgical planning.

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ABSTRACT Introduction: The aim of the present prospective-randomized study was to compare perioperative outcomes and complications of bipolar and monopolar TURBT for lateral wall-located non-muscle invasive bladder cancers (NMIBC) under obturator nerve block (ONB). Patients and Methods: 80 patients who underwent TURBT for lateral wall-located primary bladder tumors under ONB from March, 2016 to November, 2019 were included in the present study. The patients were randomized equally into two groups; monopolar TUR (M-TURBT) and bipolar TUR (B-TURBT). The primary and secondary outcomes were safety (obturator jerk and bladder perforation) and efficacy (complete tumor resection and sampling of the deep muscle tissue). Results: Obturator jerk was detected in 2 patients (5%) in M-TURBT while obturator jerk was not observed during B-TURBT (p=0.494). Bladder perforation was not observed in both groups. All of the patients underwent complete tumor resection. There was no significant difference in muscle tissue sampling (67.5% vs. 72.5%, p=0.626) and thermal tissue damage rates (12.5% vs. 25%, p=0.201). The majority of complications were low-grade and the differences in Clavien grade 1-3 complications between groups were not statistically significant. Conclusion: In the treatment of lateral-wall located NMIBCs, either M-TURBT or B-TURBT can be safely and effectively performed by combining spinal anesthesia with ONB. Even so, it should be taken into consideration that low-grade postoperative hemorrhagic complications may occur in patients who undergo M-TURBT.

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ABSTRACT Background: Many medical therapies have been tested to deal with urinary stent-related symptoms (USRS). Several preventive and pharmaceutical methods have been already used for better compatibility of stents. However, the existing evidence for pharmacological treatment is still controversial. This study aims to evaluate the effects of pregabalin, solifenacin, and combination therapy on ureteral double-J stent-related symptoms following ureteroscopy and transureteral lithotripsy (TUL). Materials and methods: In a randomized controlled clinical trial, from November 2017 to March 2019, 256 patients who underwent ureteroscopy were enrolled. Patients were randomly divided into four groups including: group A received pregabalin 75mg BID (twice daily), group B received solifenacin 5mg orally once daily, group C received combination of pregabalin and solifenacin and the group D (control) given no drugs. Results: One hundred and fifty-one (58.9%) males and 101 (41.1%) females were enrolled in this study with a mean age of 43.47±7 (p=0.32, p=0.67). USSQ domains score such as urinary symptoms, pain, general condition, work performance, sexual matters and additional problems were significantly differenced during second and fourth week of follow-up among study groups (p <0.0001). In Tukey's multiple comparison test, urinary symptoms (p=0.735), pain (p=0.954) and sexual matters (p=0.080) in second week and work performance in forth week in group B was not significantly better than group D. Only group C in all indexes of USSQ showed significantly beneficial effects over group D (p <0.0001). Conclusion: Combination therapy of pregabalin and solifenacin has a significant effect on stent-related symptoms and is preferred over monotherapy of the respected medications.

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ABSTRACT We describe a step by step technique for open distal ureteroureterostomy (UU) in infants less than 6 months presenting with duplex collecting system and upper pole ectopic ureter in the absence of vesicoureteral reflux (VUR).

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ABSTRACT Objectives: To discuss the feasibility and efficacy of a laparoscopic vessel blocking forceps in laparoscopic inferior vena cava (IVC) thrombectomy (1–3). Materials and methods: The patient was secured in a left lateral decubitus position. The surgical field was built with 4-trocar. The laparoscopic vessel blocking forceps was used to block the IVC partially. With the help of the forceps, we completed a retroperitoneal laparoscopic radical nephrectomy and IVC thrombectomy. Results: The patient was a 73-year-old female. The tumor was located on the right side. Based on the preoperative radiology examination, the tumor thrombus extended from the right renal vein into the IVC, and the cephalic extent of tumor thrombus was 1.6cm above the renal vein. The preoperative stage was T3b, and the Mayo grade of the tumor thrombus was grade I. The operation was successfully completed without conversion to open surgery. The operation time was 159 minutes, and the estimated blood loss was about 50ml. No blood transfusion was needed. The postoperative hospital stay was 10 days. No operation related complication was observed. Postoperative pathology showed diffusely poor differentiated carcinoma, and the pathological stage was T3bN0. Conclusion: The laparoscopic vascular blocking forceps can clamp vessels without damaging the vessels. Vascular blocking forceps is suitable for laparoscopic surgical field. We recommend such a vascular blocking forceps for laparoscopic thrombectomy in patients with renal carcinoma and Mayo grade 0-I tumor thrombus. It may be used to clamp other blood vessels temporarily or control bleeding during laparoscopy in the future.

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ABSTRACT Introduction: To demonstrate the entire surgeon's point of view of a prone split-leg (PSL) endoscopic guided percutaneous nephrolithotomy (ePCNL) recorded with a GoPro® camera for standardization of the essential technical steps towards a successful procedure (1). Materials and methods: A 40y.o female patient presented with right flank pain for three years. She had previously been submitted to shock wave lithotripsy without success. Non-contrast computed tomography (NCCT) revealed a 2cm stone in the renal pelvis with 1400HU and stone-to-skin distance of 11cm (Guy's Stone Score 1). PCNL approach was chosen for providing higher chances of stone-free after a single procedure. Informed consent was obtained. The PSL ePCNL was uneventful with a single access in a mid-pole. The surgeon had a Full HD GoPro Hero 4® camera mounted on his head, controlled by the surgical staff with a remote control. All essential surgical steps were recorded. Results: Operative time was 90 minutes. Hemoglobin drop was 0.7g/dL. The post-operative NCCT scan was stone-free. The patient was discharged 24h after surgery. Kidney stent was left with a string and removed after 5days. The camera worked properly and didn't cause any kind of discomfort to the surgeon. The quality of the recorded movie was excellent. Conclusion: By recording the surgeon's perspective of an endoscopic urological procedure, we were able to provide a comprehensive understanding of the surgical technique by assembling the endoscopic, fluoroscopic, and operative field views. The GoPro® camera proved to be an interesting tool to document surgical procedures without compromising outcomes and has great potential for educational purposes.

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ABSTRACT Purpose: Enucleation of a large prostate is the best surgical choice for patients refractory to clinical treatment (1,2). Since the first robot-assisted simple prostatectomy (RASP) was described (3,4), some technical modifications (5–7) and different approaches to reach the adenoma have been proposed (8,9). The aim of this video is to demonstrate three different techniques of RASP. Materials and Methods: The first procedure begins with a transversal incision over the bladder neck, the second is a transvesical approach and the last one is a Retzius-sparing RASP. All techniques were performed with a vesico-urethral anastomosis. Results: Three patients underwent RASP, each one with a different approach. Patients presented mean age of 66±4.4 years, PSA baseline level of 7.8±3ng/mL, IPSS score of 17.7±4.5, maximum urine flow of 8.3±1.5mL/seg and 122.3±11.2cm3 of prostate volume. The mean operative time was 63±8 minutes, estimated blood loss of 106.7±11.5mL, prostate weight of the surgical specimen of 106.3±8 grams and 1 day of length of stay. No continuous bladder irrigation was required and there was no complication. The mean postoperative PSA and IPSS were 0.7±0.3ng/mL, 4.7±1.5. The maximum urine flow raised to 20±4.4mL/seg. Conclusions: RASP with vesico-urethral anastomosis allowed minimal blood loss, short length of stay and great functional outcomes. All the three approaches allowed to perform this technique in a safe way, while showing different alternatives to reach the adenoma.

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ABSTRACT Introduction: Vesico-vaginal fistula (VVF) is a rare event in Western countries and are mainly consequent to iatrogenic injuries (1, 2). When conservative management fails, surgical repair is needed, although timing and surgical approach (open or minimally invasive (3)) are still controversial (4, 5). Herein we present a step-by-step description of robot-assisted vesico-vaginal fistula repair. Material and Methods: From 2015 to 2018 six patients underwent robotic vesico-vaginal fistula repair. Pre-operative cystoscopy was performed to identify the fistulous tract. The ureters were stented. A small catheter was inserted in the fistula. A longitudinal cystotomy was performed, then a dissection of the posterior bladder from the anterior vaginal wall was performed and the fistolous tract was excised. The vagina was sutured horizontally. Four patients underwent omental flap and two pericolic fat interposition. The bladder was closed with a double-layer suture. Results: All the vesico-vaginal fistulas developed after previous gynaecological surgery. The median operative time was 160 minutes [interquartile range (IQR) (146-177)]. Intraoperative blood loss was 25 (IQR 0-50) mL. No post-operative complications were recorded. Ureteral stents were removed at 4th post-operative day. Catheter was removed 13 (IQR 11-15) days after surgery after cystography assessment. One patient had Clavien I complication (ileus). Surgical pathology report was negative. No fistula recurrence was reported during follow-up. Conclusions: In our experience, robot-assisted fistula repair is a feasible and safe procedure. It presents the advantages of minimally invasive approaches and seems to provide low morbidity and good outcomes. Compared to transvaginal approach, the robotics allows to manage more complex cases with high success rate (6).