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PURPOSE To generate and present survey results on important issues relevant to treatment and follow-up of localized and locally advanced, high-risk prostate cancer (PCa) focusing on developing countries. METHODS A panel of 99 PCa experts developed more than 300 survey questions of which 67 questions concern the main areas of interest of this article: treatment and follow-up of localized and locally advanced, high-risk PCa in developing countries. A larger panel of 99 international multidisciplinary cancer experts voted on these questions to create the recommendations for treatment and follow-up of localized and locally advanced, high-risk PCa in areas of limited resources discussed in this article. RESULTS The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion and not on a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations considered cost-effectiveness as well as the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. Results were tabulated in real time. CONCLUSION The voting results and recommendations presented in this article can guide physicians managing localized and locally advanced, high-risk PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for treatment of localized and locally advanced, high-risk PCa in developing countries have not been defined, this article will serve as a point of reference when confronted with this disease.

PURPOSE A group of international urology and medical oncology experts developed and completed a survey on prostate cancer (PCa) in developing countries. The results are reviewed and summarized, and recommendations on consensus statements for very low-, low-, and intermediate-risk PCa focused on developing countries were developed. METHODS A panel of experts developed more than 300 survey questions of which 66 questions concern the principal areas of interest of this paper: very low, low, and intermediate risk of PCa in developing countries. A larger panel of 99 international multidisciplinary cancer experts voted on these questions to create the recommendations for treatment and follow-up for very low-, low-, and intermediate-risk PCa in areas of limited resources discussed in this manuscript. RESULTS The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion not a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations consider cost-effectiveness and the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. The results were tabulated in real time. CONCLUSION The voting results and recommendations presented in this document can be used by physicians to support management for very low, low, and intermediate risk of PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for treatment for very low, low, and intermediate risk of PCa in developing countries have not been developed, this document will serve as a point of reference when confronted with this disease.

Background Active surveillance (AS) is the preferred treatment for patients with very low-and low-risk prostate cancer (PCa), but it is underperformed worldwide. This study aimed to report knowledge, attitudes, and practices (KAP) of AS for PCa among urologists in Brazil. Methods This cross-sectional study used a questionnaire with 50 questions divided into participant characteristics, knowledge regarding inclusion criteria for AS, follow-up, intervention triggers, acceptance, and practice for an index patient. Data analysis comprises absolute and relative frequencies of the variables. After that, a logistic regression was performed in order to verify possible patterns of answers provided by the respondents in the index patient questionnaire. Results Questionnaires were sent through the SurveyMonkey® platform to 5,015 urologists using email addresses and through social media. A total of 600 (12%) questionnaires returned and 413 (8.2%) were completed and included in the analysis. Only 53% of urologists adopt AS for low- and very-low-risk PCa. Inclusion criteria were patients with age > 50 years (32.2%), prostate specific antigen (PSA) Conclusion There is significant variability in the KAP of AS in Brazil, which indicates the need to reinforce AS, its inclusion and follow-up criteria, and the benefits for physicians and the general population. Trial registration: Not applicable.

To evaluate the clinical dilemma of men with surgical indication due to benign prostatic enlargement (BPE) and concomitant elevated PSA, we analysed if multiparametric magnetic resonance imaging (mpMRI) could safely prescind the prostate biopsy. Forty men with surgical indication due to BPE and concomitantly elevated PSA levels were prospectively enrolled and retrospectively analysed. All patients underwent 1.5 Tesla mpMRI prior to TRUS-guided biopsies. In cases where mpMRI was PIRADS 3 with focal lesions, PIRADS 4 or PIRADS 5, additional fragments were obtained with the fusion guided technique. Biopsy histopathological results were used as the standard of reference. Two scenarios were evaluated: scenario 1, considering mpMRI PIRADS 1 and 2 as negative; and scenario 2, considering PIRADS 1, 2 and 3 as negative. Clinically significant prostate cancer (CsPCa) was defined as ISUP ≥ 2. Median age was 68 years, median PSA was 9.41 (6.40–19.54) and median prostatic volume was 116.5 cc (IQR 86.5–155). Scenario 1 mpMRI sensitivity, specificity, PPV, NPV and accuracy for any prostate cancer on prostate biopsy was 76.9%, 63%, 50%, 85% and 67.5%. For csPCa, they were 87.5%, 59.4%, 35%, 95% and 65%, respectively, for the same measures. Scenario 2 the sensitivity, specificity, PPV, NPV and accuracy of mpMRI for any prostate cancer on prostate biopsy was 53.8%, 96.3%, 87.5%, 81.3% and 82.5%. For csPCa, they were 75%, 93.8%, 75%, 93.8% and 90%, respectively, for the same measures. Prostate mpMRI may prevent unnecessary biopsies in patients with elevated PSA and surgical indications due to BPE, given its high negative predictive value.

Objective To evaluate the predictive value of positron emission computed tomography or magnetic resonance (PET-CT and PET-MRI) using gallium-68-labeled prostate-specific membrane antigen (68Ga-PSMA) in lymph node involvement in prostate cancer. Methods A retrospective study comprising 91 patients diagnosed with prostate cancer between 2016 to 2020, who underwent 68Ga-PSMA PET-CT or PET-MRI for staging before prostatectomy. The patients were divided into Group 1, with 65 patients with satisfactory pathological lymph node analysis, and Group 2, with 91 patients representing the sum of patients with pathological lymph node analysis and those with postoperative prostate-specific antigen within 60 days after surgery. Receiver Operating Characteristic curves were used to assess accuracy of predictive capacity of imaging exams for lymph node involvement. Results Regarding local clinical staging, the groups showed similar results, and 50% were classified as staging T2a. The accuracy of 68Ga-PSMA PET-CT for prostate cancer lymph node staging was 86.5% (95%CI 0.74-0.94; p=0.06), with a sensitivity of 58.3% and specificity of 95%. The accuracy of 68Ga-PSMA PET-MRI was 84.6% (95%CI 0.69-0.94; p=0.09), with a sensitivity of 40% and specificity of 100%. Considering both 68Ga-PSMA PET-CT and PET-MRI, the accuracy was 85.7% (95%CI 0.76-0.92; p=0.015), with sensitivity of 50% and specificity of 97%. Conclusion The imaging tests 68Ga-PSMA PET-CT and PET-MRI were highly accurate to detect preoperative lymph node involvement, and could be useful tools to indicate the need for extended lymph node dissection during radical prostatectomy.

Objective To analyze the characteristics of public health services related to radical prostatectomy, according to hospital volume of surgeries and stratified as academic and non-academic centers. Methods An ecological study was conducted using a database available in TabNet platform of the Unified Health System Department of Informatics. Number of surgeries, length of hospital stay, length of stay in intensive care unit, in-hospital mortality rate, and cost of hospitalization were evaluated. The hospitals were divided into three subgroups according to surgery volume (tercile), and results were compared. The same comparisons were made among academic and non-academic centers. We considered academic centers those providing Urology residency program. Results A total of 11,259 radical prostatectomies were performed in the city of São Paulo between 2008 and 2018. We observed a significant trend of increase in radical prostatectomies for treating prostate cancer over the years (p=0.007). The length of stay in intensive care unit, and number of deaths were not statistically different among centers with diverse surgery volume, nor between academic and non-academic centers. However, length of hospital stay was significantly shorter in academic centers (p=0.043), while cost of hospitalization was significantly higher in high-volume center compared to low- (p

Radical prostatectomy is a commonly adopted treatment for localized/locally advanced prostate cancer in men with a life expectancy of ten years or more. Robotic-assisted radical prostatectomy (RARP) is comparable to open radical prostatectomy on cancer control and complication rates; however, new evidence suggests that RARP may have better functional outcomes, especially with respect to urinary incontinence and erectile dysfunction. Some of the surgical steps of RARP are not adequately described in published literature and, as such, may have an impact on the final outcomes of the procedure. We organized a Brazilian experts' panel to evaluate best practices in RARP. The confection of the recommendations broadly involved: selection of the experts; establishment of working groups; systematic review of the literature and elaboration of a questionnaire; and construction of the final text with the approval of all participants. The participants reviewed the publications in English from December 2019 to February 2020. A one-round Delphi technique was employed in 188 questions. Five reviewers worked on the final recommendations using consensual and non-consensual questions. We found 59.9% of questions with greater than 70% agreement that were considered consensual. Non-consensual questions were reported according to the responses. The recommendations were based on evidence-based literature and individual perceptions adapted to the Brazilian reality, although some issues remain controversial. We believe that these recommendations may help urologists involved in RARP and hope that future discussions on this surgical procedure may evolve over the ensuing years.

Background The Expanded Prostate Index Composite for Clinical Practice (EPIC-CP) is a short version of the original EPIC, developed to facilitate the instrument’s use in routine care. This study aimed to validate the EPIC-CP Portuguese version, and evaluate its role in presenting early functional outcomes of surgically treated prostate cancer patients at a Latin American referral center. Methods The EPIC-CP was self-administered prospectively and individually by all localized prostate cancer patients, before and after robotic-assisted radical prostatectomy, from March 2017 to June 2018 at a single institution. For validation, we used the Cronbach’s alpha coefficient to evaluate internal consistency. The EPIC-CP domains were compared before surgery, and 6 months and 12 months after surgery. Statistical analyses were performed using the student’s t test, and Wilcoxon and Friedman tests, with p values Results One hundred and fifty two patients answered the EPIC-CP. The patients had a median age of 62.7 (± 8.5) years and prostate specific antigen level of 6.3 (± 4.6) ng/ml. The Cronbach’s alpha varied from 0.75 to 0.77 for all domains with good internal consistency, except for the “vitality/hormonal” domain, which had a score of 0.35. The domain evolution for the preoperative and 6-month postoperative groups revealed that the domains related to urinary continence and bowel worsened, and were increased during the first 6 months; however, this variation had no obvious clinical implications, and the irritative symptoms improved. Regarding the sexual domain, the scores worsened, and also increased over the first 6 months. The results of the confirmatory factor analysis were robust, with an explained variance of 0.951 and covariance of 0.929. Conclusions The Portuguese version of the EPIC-CP is a reliable and valid questionnaire for postoperative patients, and very useful to improve the knowledge of the early functional outcomes of men treated for prostate cancer.

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

Purpose: Ultrasound-magnetic resonance imaging (US-MRI) fusion biopsy (FB) improves the detection of clinically significant prostate cancer (PCa). We aimed to compare the Gleason upgrading (GU) rates and the concordance of the Gleason scores in the biopsy versus final pathology after surgery in patients who underwent transrectal ultrasound (TRUS) systematic random biopsies (SRB) versus US-MRI FB for PCa. Materials and Methods: A retrospective analysis of data that were collected prospectively from January 2011 to June 2016 from patients who underwent prostate biopsy and subsequent radical prostatectomy. The study cohort was divided into two groups: US-MRI FB (Group A) and TRUS SRB (Group B). US-MRI FB was performed in patients with a previous MRI with a focal lesion with a Likert score ≥3; otherwise, a TRUS SRB was performed. Results: In total, 73 men underwent US-MRI FB, and 89 underwent TRUS SRB. The GU rate was higher in Group B (31.5% vs. 16.4%; p=0.027). According to the Gleason grade pattern, GU was higher in Group B than in Group A (40.4% vs. 23.3%; p=0.020). Analyses of the Gleason grading patterns showed that Gleason scores 3+4 presented less GU in Group A (24.1% vs. 52.6%; p=0.043). The Bland-Altman plot analysis showed a higher bias in Group B than in Group A (-0.27 [-1.40 to 0.86] vs. −0.01 [-1.42 to 1.39]). In the multivariable logistic regression analysis, the only independent predictor of GU was the use of TRUS SRB (2.64 [1.11 – 6.28]; p=0.024). Conclusions: US-MRI FB appears to be related to a decrease in GU rate and an increase in concordance between biopsy and final pathology compared to TRUS SRB, suggesting that performing US-MRI FB leads to greater accuracy of diagnosis and better treatment decisions.

Objectives To describe the experience of our institution in image-guided renal nodules percutaneous cryoablation, evaluating demographic and technical aspects as well as efficacy, safety and follow up. Materials and methods Retrospective study approved by our institutional review board. Seventy-one renal tumors evaluated in 60 patients treated with image guided percutaneous renal cryoablation from January 2009 to December 2015. No patient was excluded from study, even those who were lost on follow up. All the procedures were guided both by ultrasound and tomography. An argon and helium based cryoablation machine was used for all treatments. Hydrodissection was performed when the bowel or ureters were within 1 cm (iodinated contrast media in dextrose solution). Complications were assessed by the terminology criteria of the National Institutes of Health (NIH). Patients were monitored and evaluated by ultrasound, tomography, MRI and/or PET-CT. Results In most procedures (91.9%) only one nodule was treated. Nodules had a median size of 1.6 cm. Most nodules (61,9%) were exophytic. Hydrodissection and retrograde warm pyeloperfusion were performed in most procedures. Among all variables evaluated in univariate analysis, nearness of nodule to collecting system and anterior/posterior location were significantly associated with PRCA complications. No other factor evaluated was significantly associated with complications. Conclusion PRCA is solid alternative to traditional surgical therapies for treatment of small renal tumors in wide subset of patients. Medium term evidence shows excellent long-term oncological results, similar to nephrectomy, with minimal risk of major complications.

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

Background To compare the results of magnetic resonance imaging (MRI) with and without contrast-enhanced sequences for the detection of clinically significant prostate cancer. The value of contrast in the MRI protocol for the detection of prostate tumors has been discussed in previous studies. Materials and Methods We performed an institutional review board-approved, retrospective study of patients who had undergone prostate MRI followed by fusion biopsy during a 16-month period. The patients had undergone MRI on a 3-Tesla scanner with a phased-array coil using a routine multiparametric protocol: T2-weighted, diffusion, and dynamic postcontrast enhancement sequences. The examination films were read independently by 2 readers in 2 sessions: first without contrast-enhanced images and second with contrast-enhanced images. The images were graded according to the suspicion of clinically significant prostate cancer (scale, 1-5). The kappa coefficient was used to compare the readings with and without contrast. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for both readers were calculated using the biopsy findings as a reference standard. The level for statistical significance was set at P Results A total of 118 patients were included, and clinically significant prostate cancer was found in 48 patients (40.7%). The MRI findings on both contrast-enhanced and noncontrast-enhanced images had no statistically significant differences for either reader (P > .05 for all levels of suspicion). The sensitivity ranged from 68.3% to 80.7%, specificity from 57.1% to 77.1%, positive predictive value from 29.9% to 38.8%, negative predictive value from 88.0% to 91.3%, and accuracy from 60.6% to 73.0%. Conclusion Our results show that contrast-enhanced sequences provide minimal or no increased value for the detection of clinically significant prostate cancer.

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

This study aims to evaluate safety and efficacy of different endoscopic enucleation of the prostate (EEP) techniques, by comparing laser (L-EEP) and non-laser (NL-EEP) procedures; and EEP versus other endoscopic non-enucleation (ENE) surgeries for benign prostatic enlargement (BPE). A systematic literature review was performed for randomized clinical trials (RCT) that compared different endoscopic treatments for BPE, between 1982 and 2018. Two analyses were performed: (1) EEP versus ENE; and (2) L-EEP versus NL-EEP. Efficacy was assessed using perioperative data (removed tissue volume, operation time (OT), catheterization time, length of hospital stay); and functional outcomes [IPSS, IIEF-5, maximum flow rate (Qmax), postvoid residual volume (PVR), quality of life (QoL)]. Safety was assessed through complications (Hb and sodium decrease, transfusion rate). Meta-analyses were performed using RevMan® 5.3. Out of 35 RCTs (4066 patients), 31 (3909 patients) evaluated EEP versus ENE, and 4 (327 patients) evaluated L-EEP versus NL-EEP. EEP presented greater Qmax. Also, EEP presented less catheterization time, length of hospital stay, Hb decrease, transfusion rate. OT and bladder injury were greater with EEP. There were no significant differences between other items. L-EEP removed more tissue volume, with a smaller drop in serum Hb. There were no significant differences in other perioperative data, functional outcomes, complications. EEP and ENE are effective and safe for treating BPE. Perioperative data favors EEP. Statistical differences, with questionable clinical significance in functional outcomes and complication rates were encountered. L-EEP provides greater tissue removal and smaller Hb decrease then NL-EEP, with similar functional profiles.

Objective: To evaluate the diagnostic efficacy of transrectal ultrasonography (US) biopsy with imaging fusion using multiparametric (mp) magnetic resonance imaging (MRI) in patients with suspicion of prostate cancer (PCa), with an emphasis on clinically significant tumors according to histological criteria. Materials and Methods: A total of 189 consecutive US/MRI fusion biopsies were performed obtaining systematic and guided samples of suspicious areas on mpMRI using a 3 Tesla magnet without endorectal coil. Clinical significance for prostate cancer was established based on Epstein criteria. Results: In our casuistic, the average Gleason score was 7 and the average PSA was 5.0ng/mL. Of the 189 patients that received US/MRI biopsies, 110 (58.2%) were positive for PCa. Of those cases, 88 (80%) were clinically significant, accounting for 46.6% of all patients. We divided the MRI findings into 5 Likert scales of probability of having clinically significant PCa. The positivity of US/MRI biopsy for clinically significant PCa was 0%, 17.6% 23.5%, 53.4% and 84.4% for Likert scores 1, 2, 3, 4 and 5, respectively. There was a statistically significant difference in terms of biopsy results between different levels of suspicion on mpMRI and also when biopsy results were divided into groups of clinically non-significant versus clinically significant between different levels of suspicion on mpMRI (p-value

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

Background: Dynamic-contrast enhanced (DCE) sequence is used to increase detection of small lesions, based on increased vascularization. However, literature is controversy about the real incremental value of DCE in detection of clinically significant (CS) prostate cancer (PCa), since absence of enhancement does not exclude cancer, and enhancement alone is not definitive for tumor. Purpose: To test the hypothesis that DCE images do not increase CS PCa detection on MRI prior to biopsy, comparing exams without and with contrast sequences. Material and Materials and Methods: All men who come to our institution to perform MRI on a 3T scanner without a prior diagnosis of CS PCa were invited to participate in this study. Reference standard was transrectal prostate US with systematic biopsy and MRI/US fusion biopsy of suspicious areas. Radiologists read the MRI images prospectively and independently (first only sequences without contrast, and subsequently the entire exam) and graded them on 5-points scale of cancer suspicion. Results: 102 patients were included. Overall detection on biopsy showed CS cancer in 43 patients (42.2%), clinically non-significant cancer in 11 (10.8%) and negative results in 48 patients (47%). Positivities for CS PCa ranged from 8.9% to 9.8% for low suspicion and 75.0% to 88.9% for very high suspicion. There was no statistical difference regarding detection of CS PCa (no statistical difference was found when compared accuracies, sensitivities, specificities, PPV and NPV in both types of exams). Inter-reader agreement was 0.59. Conclusion: Exams with and without contrast-enhanced sequences were similar for detection of CS PCa on MRI.

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.

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

Objective: To describe the imaging findings of prostatic tumors nonadenocarcinoma on multiparametric magnetic resonance imaging. Methods: A total of 200 patients underwented multiparametric magnetic resonance imaging of the prostate for screening for prostate cancer, from August 2013 to September 2014, followed by biopsy with ultrasound/magnetic resonance imaging fusion. Results: We found three pathologic proved cases of prostatic pure leiomyomas (0.02%) in our series and described the multiparametric magnetic resonance imaging features of these prostatic leiomyomas. The imaging findings had similar features to lesions with moderate or high suspicion for significant cancer (Likert 4 or 5) when localized both in the transitional zone or in the peripheral zone of the gland. Conclusion: Pure prostatic leiomyomas had imaging findings on multiparametric magnetic resonance imaging that mimicked usual adenocarcinomas on this test. Radiologists, urologists and pathologists must be aware of this entity and its imaging features. RESUMO Objetivo: Descrever os achados de imagem de tumores prostáticos não adenocarcinoma na ressonância magnética multiparamétrica. Métodos: Realizaram ressonância magnética multiparamétrica da próstata para detecção de câncer de próstata 200 pacientes de agosto de 2013 a setembro de 2014, seguida por biópsia com fusão de imagens de ultrassonografia/ressonância magnética. Resultados: Encontramos três casos confirmados histologicamente de leiomiomas prostáticos puros (0,02%) em nossa casuística e descrevemos os achados da ressonância magnética multiparamétrica destes casos de leiomiomas. Os achados de imagem foram semelhantes aos de lesões com moderada ou alta suspeição para neoplasia clinicamente significante (Likert 4 ou 5) quando localizados na zona de transição ou zona periférica da próstata. Conclusão: Leiomiomas puros da próstata tiveram achados de imagem na ressonância magnética multiparamétrica que mimetizaram adenocarcinomas. Radiologistas, urologistas e patologistas devem estar cientes destas entidades e seus achados de imagem.

To determine the incremental diagnostic value of targeted biopsies added to an extended sextant biopsy scheme on a per-patient, risk-stratified basis in 2 academic centers using different multiparametric magnetic resonance imaging (MRI) protocols, a large group of radiologists, multiple biopsy systems, and different biopsy operators.All patients with suspected prostate cancer (PCa) who underwent multiparametric MRI of the prostate in 2 academic centers between February 2013 and January 2015 followed by systematic and targeted MRI-transrectal ultrasound fusion biopsy were reviewed. Risk-stratified detection rate using systematic biopsies was compared with targeted biopsies on a per-patient basis. The McNemar test was used to compare diagnostic performance of the 2 approaches.A total of 389 men met eligibility criteria. PCa was diagnosed in 47% (182/389), 52%(202/389), and 60%(235/389) of patients using the targeted, systematic, and combined (targeted plus systematic) approach, respectively. Compared with systematic biopsy, targeted biopsy diagnosed 11% (37 vs. 26) more intermediate-to-high risk (P0.0001) and 16% (10 vs. 16) fewer low-risk tumors (P0.0001). These results were replicated when data from each center, biopsy-naïve patients, and men with previous negative biopsies were analyzed separately.Targeted MRI-transrectal ultrasound fusion biopsy consistently improved the detection of clinically significant PCa in a large patient cohort with diverse equipment, protocols, radiologists, and biopsy operators as can be encountered in clinical practice.

We reviewed retrospectively 145 patients presenting ureteralcalculi above the iliac crest. According to the treatment three groups were established. Group I was represented by 24 patients submitted to posterior ureterolithotomy; group 2, 100 patients treated by endourologic procedures; and group 3, 21 patients treated by extracorporeal shock-wave lithotrispy (ESWL). Success rate considered as complete removal of all calculous material was 100 percent in the posterior ureterolithotomy group, 92 percent in the endourologic group, and 94.7 percent in the ESWL group. Hospitalization, anesthesia, and complication rates were minimal in patients submitted to ESWL. One may conclude that ESWL is the treatment of choice for lumbar ureteric calculi.

The authors present their experience in the management of a rare complication observed during long-term use of a ureteral catheter. The calcification along the entire surface of the catheter followed by incrustation can make its removal by means of cystoscopy difficult, thus becoming a great challenge to the urologist.The authors describe their experience in the management of this complication through the analysis of two illustrative cases.After failing to remove the catheter using extracorporeal lithotripsy, ureterolithotripsy was performed and the calcified ureteral catheter was successfully removed in both cases.Ureterolithotripsy proved to be an effective and safe method in the management of calcified double-J catheter.

Percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy (ESWL*) can be used in the treatment of lower pole caliceal calculi. In a retrospective analysis these 2 therapies were compared for treatment of solitary lower pole caliceal calculi to evaluate morbidity. During a 2-year period 23 patients treated with percutaneous nephrolithotomy and 24 who underwent ESWL with the Siemens Lithostar were analyzed in regard to the success rate, effectiveness quotient, complication rate, length of hospitalization and disability period. Followup consisted of ultrasound and/or a plain film of the kidneys, ureters and bladder 1 day and 1 to 3 months postoperatively. A nephrotomogram was included in the ESWL group. Complete removal of all stone fragments was achieved in 93.6% of the patients treated percutaneously without retreatment. In the ESWL group the success rate was 79.2% with a 41.6% retreatment rate. On the other hand, the ESWL group had a shorter hospitalization and an earlier return to normal physical activities. Among the patients who underwent a percutaneous operation 13% had complications compared to 4.1% in the ESWL group. The recurrence rate was higher in the former group (13% within a median of 18 months, compared to 8.3% within a median of 11 months in the ESWL group). The mean stone diameter was 1.42 cm. in the percutaneous group and 1.22 cm. in the ESWL group. Stone composition was similar in both groups. Since ESWL is an effective noninvasive procedure without the need for routine anesthesia and hospitalization, and with prompt return of the patient to a normal life it must be considered the method of choice for lower caliceal stones less than 2 cm. in diameter. However, percutaneous nephrolithotomy will continue to have a primary role in the management of larger stones.

Two therapeutic methods, endourology and extracorporeal shock wave lithotripsy (ESWL), can be used in the treatment of ureteral calculi. In a retrospective analysis during a 2-year period 236 patients treated with endourological procedures and 71 who underwent ESWL with a Siemens Lithostar were analyzed as to the success rate, effectiveness quotient, complication rate and hospitalization. The mean stone size was 1.12 cm. in the endourology group and 1.03 cm. in the ESWL group. Complete removal of all stone fragments was achieved in 93.6% of the patients treated endourologically and without retreatment. In the ESWL group success was obtained in 90.1%, with an 11.2% retreatment rate. The retreatment rate was higher (25.0%) for calculi in the mid ureter. The group treated endourologically had a better success rate and no retreatment was necessary. On the other hand, the group treated with ESWL had a shorter hospitalization and a lower complication rate. Followup ranged from 11 to 60 months (mean 48 months) in the endourology group and 7 to 29 months (mean 11 months) in the ESWL group. These observations showed that in situ ESWL therapy with the Siemens Lithostar device is the method of choice for upper ureteral stones. Lower ureteral calculi should be treated endoscopically. Mid ureteral stones larger than 1 cm. had better results with endoscopic procedures and those smaller than 1 cm. had better results with ESWL.

Initial experience of extracorporeal shock-wave lithotripsy (ESWL) using the Lithostar lithotriptor is reported; 193 patients underwent 248 treatments for 210 stones. A total of 139 renal calculi (126 patients) and 71 ureteral stones (67 patients) were analyzed. Treatments were performed without anesthesia in 65 calculi (27.6%), with intravenous sedation in 91 (42.5%), and under epidural anesthesia in 34 calculi (29.9%). A three-month follow-up showed a success rate of 88.0 percent for renal calculi and 95.5 percent for ureteral calculi treated in situ. Renal stone fragmentation was achieved with a mean of 4,890 shocks at 17.4 kV and ureteral calculi were fragmented with a mean number of 4,798 shocks at a mean of 18.3 kV. Auxiliary procedures after ESWL were required in 2 patients with renal stones and in 1 with ureteral calculi. A comparison between stone size and number of shock waves required to achieve stone fragmentation revealed a linear relationship. Hospitalization was not necessary in 84.4 percent of renal calculi and 89.6 percent of ureteral calculi. Retreatments were necessary in 22 (15.8%) of the renal calculi (18 had 2 sessions, 3 had 3 sessions, and 1 had 4 sessions). Of the ureteral calculi, 8 (11.3%) underwent retreatment (6 had 2 sessions, 1 had 3 sessions, and 1 had 4 sessions). The low morbidity with a large number of patients treated on an outpatient basis, minimizing the need for anesthesia, demonstrated a favorable initial successful experience with the Lithostar.

We reviewed our experience with in situ extracorporeal shock wave lithotripsy for ureteral stones in 30 patients. The Siemens Lithostar unit was used for stone disintegration and no attempts were made to manipulate the calculi back into the kidney. During the study period 15 patients presented with upper, 9 with mid and 6 with lower ureteral calculi. The mean stone size was 5 x 12 mm. The success rates in stone removal, hospitalization, anesthesia, average number of shocks and kilovolts used were analyzed. Complete removal of all calculous material was obtained in 86.6% of the patients after 3 months. Followup consisted of a plain film of the kidneys, ureters and bladder, and eventually renal ultrasound 1 day and 1 to 3 months postoperatively. Routinely, patients were treated without hospitalization, while 3 had persistent stone fragments and required hospitalization for auxiliary endourological procedures. The average hospital stay for these patients was 1.6 days. Of the 30 patients 13 (43.4%) were treated without anesthesia, 9 (30.0%) received intravenous sedation and 8 (26.6%) had epidural anesthesia. Patients received 3,000 to 6,000 shock waves per session (median 4,000) at 14.0 to 19.0 kv. (median 18.1 kv.), and in 76.9% the treatment was completed after 1 session. Patients who needed more than 1 session received 3,000 to 4,000 shock waves (median 3,000) at 15.0 to 19.0 kv. (median 17.8 kv.) per additional session. Minor complications, such as hematuria, were observed in 33.3% of the patients for less than 24 hours. A small erythematous area usually was present on the abdominal wall at the shock wave entrance site and temporary ileus was noted in 2 patients. In situ extracorporeal shock wave lithotripsy with the Siemens Lithostar device is an effective method for treatment of ureteral stones in all parts of the ureter due to the ease of patient positioning.

The lower calix is responsible for a significant number of kidneys with residual stone fragments after extracorporeal shock wave lithotripsy (ESWL*). To compare the effectiveness of controlled inversion therapy as an adjunctive method to the elimination of calculous fragments, 42 patients who had undergone treatment for lower caliceal stones with a Siemens Lithostar lithotriptor were reviewed. Of the patients 25 had no adjunctive therapy and 17 underwent controlled inversion therapy. The success rate, effectiveness quotient and complication rate were analyzed. Followup consisted of ultrasound and a nephrotomogram 1 day and 1 to 3 months postoperatively. Complete removal of all stone fragments was achieved in 84% of the patients without an adjunctive maneuver and in 64.7% of those treated with controlled inversion therapy. The effectiveness quotient was 72.4% and 35.5%, respectively. The group treated without adjunctive therapy had fewer retreatment sessions and a lower complication rate. There were no complications related to the controlled inversion therapy and patient acceptance was generally enthusiastic. We conclude that controlled inversion therapy did not improve the results of ESWL for lower pole caliceal calculi.

Congenital diverticulum of the male urethra is an uncommon condition. Urinary tract infection, urethral obstruction, and disturbances in micturition are the most common symptoms. Six cases of congenital diverticulum of the male urethra were studied with regard to diagnosis and treatment. Four patients underwent endoscopic treatment of the diverticulum. The procedure is simple and rapid, with low incidence of complications and high rates of success.

A total of 205 patients have undergone stone extraction surgery. Three groups were studied: in 70 patients the stones were removed by flank incision, in 20 patients by posterior incision and 80 patients were treated by percutaneous nephrolithotomy. Patients submitted to percutaneous nephrolithotomy had a shorter hospitalization, operative time and a significantly reduced period of recuperation, allowing earlier return to work and decreased disability. Narcotic drugs were demanded in a lower amount in the percutaneous nephrolithotomy group.

The isolated hypogastric artery aneurysm may give rise to urologic symptoms. This occurs as a consequence of extrinsic compression exerted by the aneurysm itself to the urinary tract or the involvement of the urinary tract by the perianeurysmatic fibrosis. We report 2 cases of isolated hypogastric artery aneurysm. One of the patients had unilateral ureteral obstruction while the other revealed a mass on rectal examination. In both cases surgery was performed and the urologic manifestations were relieved completely.

The records of 27 patients undergoing endoscopic treatment of ureteral calculi were reviewed. The percutaneous nephrostomy approach was used for calculi located above the iliac vessels, while the transurethral approach was used for those below the iliac vessels. The success rates achieved for these calculi were 82.3 and 90.0 per cent, respectively. Endoscopic treatment has proved to be safe and effective in patients with ureteral stones.

In a retrospective analysis classical radial nephrolithotomy, percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy for symptomatic small nonobstructive caliceal stones were compared to evaluate morbidity. Size (less than 1 cm.) and location of the stone (caliceal and nonobstructive) did not explain the severity of the symptoms nor would they have been an indication for an operation. In 8 patients treated by an open operation, 16 treated percutaneously and 6 who underwent extracorporeal shock wave lithotripsy the procedure time, success rate, complication rate and length of hospitalization were analyzed. Followup consisted of ultrasound and/or a plain film of the kidneys, ureters and bladder 1 day and 3 months postoperatively. A nephrotomogram was included in group 3 patients. Of 30 patients 3 had persistent stone fragments for more than 3 months: 2 underwent percutaneous nephrolithotomy and 1 was treated by extracorporeal shock wave lithotripsy. A total of 28 patients (93.3 per cent) achieved complete or significant relief of pain. In the percutaneous group both patients with persistent fragments were symptomatic in contrast with the extracorporeal shock wave lithotripsy group, in which 1 patient presented with stone fragments but was free of pain. The group treated percutaneously had a shorter procedure time (60 minutes) and the shock wave group had a shorter hospitalization. On the other hand, the open operation group had a better success rate as well as relief of pain. These observations showed that small, nonobstructive caliceal stones can be responsible for persistent, severe flank pain. Since extracorporeal shock wave lithotripsy is an effective noninvasive procedure that does not require routine anesthesia and hospitalization, with prompt return of the patient to normal life, it must be considered the method of choice in these particular patients.

Failure of the treatment of posterior urethral stenosis ranges from 10 to 30 per cent. Strictures secondary to pull-through or transpubic urethroplasty are difficult to manage. The management of these strictures is reviewed in 21 children and 84 adults. Of the 105 patients 69 had been treated previously by a perineal pull-through technique and 36 by transpubic urethroplasty. A total of 18 patients (10 in the transpubic and 8 in the pull-through groups) whose results were fair or poor underwent internal urethrotomy with the Sachse knife as a complementary treatment after posterior urethroplasty. Internal urethrotomy provided good results in 8 patients (80 per cent) in the transpubic group and 5 (62.5 per cent) in the pull-through group. None of the patients was incontinent and there was no symptomatic urinary infection postoperatively.

Oral administration of bacillus Calmette-Guerin was used to treat 10 patients with muscle invasive transitional cell carcinoma of the bladder. The treatment induced tumor regression in 7 patients (70 per cent), including 1 who died without evidence of recurrent tumor. Skin test reactivity was correlated with response to treatment. Only 1 patient had marked skin test reactivity at the time of tumor recurrence.Our data demonstrated that patients with invasive bladder cancer may derive benefit from immunotherapy.

We assigned 55 patients with superficial transitional cell carcinoma of the bladder by rotation to 1 of 3 treatment categories. Group 1 patients were treated by transurethral resection alone, group 2 by transurethral resection followed by topical thiotepa and group 3 by transurethral resection followed by orally administered bacillus Calmette-Guerin. Recurrent bladder tumors developed subsequently in 80 per cent of the patients in group 1, 42.9 per cent in group 2 and 6.2 per cent in group 3.