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PURPOSE To generate and present the survey results on critical issues relevant to screening, diagnosis, and staging tools for prostate cancer (PCa) focused on developing countries. METHODS A total of 36 of 300 questions concern the main areas of interest of this paper: (1) screening, (2) diagnosis, and (3) staging for various risk levels of PCa in developing countries. A panel of 99 international multidisciplinary cancer experts voted on these questions to create recommendations for screening, diagnosing, and staging tools for 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 the screening, diagnosis, and staging of PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for screening, diagnosis, and staging of PCa in developing countries have not been developed, this document 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: Non-metastatic castration resistant prostate cancer (M0 CRPC) has seen important developments in drugs and diagnostic tools in the last two years. New hormonal agents have demonstrated improvement in metastasis free survival in M0 CRPC patients and have been approved by regulatory agencies in Brazil. Additionally, newer and more sensitive imaging tools are able to detect metastasis earlier than before, which will impact the percentage of patients staged as M0 CRPC. Based on the available international guidelines, a group of Brazilian urology and medical oncology experts developed and completed a survey on the diagnosis and treatment of M0 CRPC in Brazil. These results are reviewed and summarized and associated recommendations are provided. Objective: To present survey results on management of M0 CRPC in Brazil. Design, setting, and participants: A panel of six Brazilian prostate cancer experts determined 64 questions concerning the main areas of interest: 1) staging tools, 2) treatments, 3) side effects of systemic treatment/s, and 4) osteoclast-targeted therapy. A larger panel of 28 Brazilian prostate cancer experts answered these questions in order to create country-specific recommendations discussed in this manuscript. Outcome measurements and statistical analysis: The panel voted publicly but anonymously on the predefined questions. These answers are the panelists' opinions, not a literature review or meta-analysis. Therapies not yet approved in Brazil were excluded from answer options. Each question had five to seven relevant answers including two non-answers. Results were tabulated in real time. Conclusions: The results and recommendations presented can be used by Brazilian physicians to support the management of M0 CRPC patients. Individual clinical decision making should be supported by available data, however, for Brazil, guidelines for diagnosis and management of M0 CRPC patients have not been developed. This document will serve as a point of reference when confronting this disease stage.

Introduction: Recent data suggest that robotic platform has become the most accessible minimal invasive surgery even for surgeons without previous training in laparoscopy. Laparoscopic partial nephrectomy (LPN) is a well-stablished procedure, however, with high level of complexity and long learning curve that limit its use. Objective: To describe safety, efficiency and learning curve of a single surgeon without previous experience in LPN to reach “TRIFECTA” at robot-assisted partial nephrectomy (RAPN). Patients and Methods: This is a retrospective study, with prospective data collection of 101 patients submitted to RAPN by a single surgeon. In order to analyze the learning curve, sample was chronologically divided in two phases: first phase: P1: 50 first patients, second phase: P2: 51 subsequent patients. TRIFECTA was defined as: ischemia time lower than 25 minutes, negative surgical margin and absence of severe complications (Clavien >2). Results: Mean age of patients was 54 years (SD=11.85), median tumor size was 32mm (SD=17) and surgery was performed with zero ischemia time in 33.6% of patients (29.8% at P1 and 40.9% at P2). Demographic data of patients were similar between both groups, except tumor size (P1=27.5mm vs. P2=35.3mm; p=0.02) and body mass index (BMI) (P1=26.6kg/m2 vs. P2=29kg/m2; p=0.03). Rate of bleeding, surgical time, presence of positive margin and peri-operatory surgical complications were similar in both phases. TRIFECTA was higher in P2 in relation to P1 (P1: 58% vs. P2: 87.8%; p=0.002) and median time of hot ischemia was significantly lower at P2 (P1: 17.3 vs. P2: 11.7; p=0.02). At multivariate analysis independent factors related to TRIFECTA included: chronological phase (OR 10.74; 95% IC: 1.63-70.53; p=0.013) and tumor size (OR 0.95; 95% IC: 0.91-0.99; p=0.024). Conclusion: RAPN seems to be safe and efficient with good functional and oncological results (TRIFECTA) since the beginning. Experience improvement was related to treatment of larger tumors, higher proportion of patients with zero ischemia and higher rate of TRIFECTA.

Context The first case of the new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), was identified in Wuhan, China, in late 2019. Since then, the coronavirus disease 2019 (COVID-19) outbreak was reclassified as a pandemic, and health systems around the world have faced an unprecedented challenge. Objective To summarize guidelines and recommendations on the urology standard of care during the COVID-19 pandemic. Evidence acquisition Guidelines and recommendations published between November 2019 and April 17, 2020 were retrieved using MEDLINE, EMBASE, and CINAHL. This was supplemented by searching the web pages of international urology societies. Our inclusion criteria were guidelines, recommendations, or best practice statements by international urology organizations and reference centers about urological care in different phases of the COVID-19 pandemic. Our systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Of 366 titles identified, 15 guidelines met our criteria. Evidence synthesis Of the 15 guidelines, 14 addressed emergency situations and 12 reported on assessment of elective uro-oncology procedures. There was consensus on postponing radical prostatectomy except for high-risk prostate cancer, and delaying treatment for low-grade bladder cancer, small renal masses up to T2, and stage I seminoma. According to nine guidelines that addressed endourology, obstructed or infected kidneys should be decompressed, whereas nonobstructing stones and stent removal should be rescheduled. Five guidelines/recommendations discussed laparoscopic and robotic surgery, while the remaining recommendations focused on outpatient procedures and consultations. All recommendations represented expert opinions, with three specifically endorsed by professional societies. Only the European Association of Urology guidelines provided evidence-based levels of evidence (mostly level 3 evidence). Conclusions To make informed decisions during the COVID-19 pandemic, there are multiple national and international guidelines and recommendations for urologists to prioritize the provision of care. Differences among the guidelines were minimal. Patient summary We performed a systematic review of published recommendations on urological practice during the coronavirus disease 2019 (COVID-19) pandemic, which provide guidance on prioritizing the timing for different types of urological care., Take Home Message We performed a systematic review of published recommendations on urological practice during the coronavirus disease 2019 (COVID-19) pandemic, which provides guidance on prioritizing the timing for different types of urological care.

This letter to the Editor aims to provide suggestions and recommendations for the management of urological conditions in times of COVID-19 crisis in Brazil and other low- and middle-income countries It is important to highlight that one of the main characteristics of this pandemic is the oversaturation of the health system capacity, mostly due to a high demand for personal protective equipment (PPE), Hospital/ICU beds, as well as ventilators In places with limited resources and where the health care systems are already saturated, such consideration is even more worrisome Therefore, most worldwide authorities are recommending to avoid, as much as possible, patient's elective visits to hospitals, as well as a judicious use of the operating room in order to mitigate the strain put on the health system While efforts should be directed to the care of COVID-19 patients, other conditions (especially urgencies and oncological cases) must continue to be assisted Thus, through a panel of experts, we have prepared a practical guide for urologists based on the recommendations from the main Urologic Associations, as well as data from the literature to support the suggested management We will try to follow the standard guideline recommendations from the American Urological Association (AUA) and European Association of Urology (EAU), with the aim of pursuing the best outcomes possible However, some recommendations were based on the consensus of the panel, taking into consideration the reality of developing countries and the unprecedented situation caused by the COVID-19 crisis Most importantly, all recommendations on this manuscript are based on the expectancy of a maximum 3-month duration of the crisis If this period shall extended, these recommendations will be revised and updated Available at https://www intbrazjurol com br/pdf/aop/COVID_19_Arie_et_al pdf

Purpose:We compared cancer detection rates in patients who underwent magnetic resonance imaging cognitive guided micro-ultrasound biopsy vs robotic ultrasound magnetic resonance imaging fusion biop...

We report oncologic outcomes in patients treated with focal therapy for prostate cancer.We retrospectively analyzed a single institution cohort of men with localized prostate cancer who received focal therapy using high intensity focused ultrasound or cryotherapy from 2009 to 2018. Focal therapy was offered for low or intermediate risk disease (prostate specific antigen less than 20 ng/ml, Gleason score 7 or less and clinical stage T2b or less). Patients with previous prostate cancer treatment or less than 6 months of followup were excluded from study. Failure was defined as local or systemic salvage treatment, a positive biopsy Gleason score of 7 or greater in-field or out-of-field in nontreated patients, prostate cancer metastasis or prostate cancer specific death. Cox regression analysis was done to identify independent predictors of failure after focal therapy.Of the 309 patients included in study 190 and 119 were treated with high intensity focused ultrasound and cryotherapy, respectively. Median followup was 45 months. At 1, 3 and 5 years the failure-free survival rate was 95%, 67% and 54%, and the radical treatment-free survival rate was 99%, 79% and 67%, respectively. The 5-year metastasis-free survival rate was 98% and no prostate cancer specific death was registered in this cohort. Before focal therapy a biopsy Gleason score of 7 (3 + 4) or greater (HR 2.4, p0.001) and nadir prostate specific antigen (HR 2.2, p0.001) were independently associated with failed focal therapy. In the salvage focal therapy setting in-field recurrence after primary focal therapy was associated with poorer failure-free survival (p=0.02).Almost half of the men were free of focal therapy failure 5 years after treatment. Still, a significant proportion experienced recurrence at the midterm followup. The preoperative biopsy Gleason score and nadir prostate specific antigen were significantly associated with treatment failure.

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.

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 Focal therapy (FT) for localized prostate cancer (PCa) treatment is raising interest. New technological mpMRI-US guided FT devices have never been compared with the previous generation of ultrasound-only guided devices. Materials and Methods We retrospectively analyzed prospectively recorded data of men undergoing FT for localized low- or intermediate-risk PCa with US- (Ablatherm®-2009 to 2014) or mpMRI-US (Focal One®-from 2014) guided HIFU. Follow-up visits and data were collected using internationally validated questionnaires at 1, 2, 3, 6 and 12 months. Results We included n=88 US-guided FT HIFU and n=52 mpMRI-US guided FT HIFU respectively. No major baseline differences were present except higher rates of Gleason 3+4 for the mpMRI-US group. No major differences were present in hospital stay (p=0.1), catheterization time (p=0.5) and complications (p=0.2) although these tended to be lower in the mpMRI-US group (6.8% versus 13.2% US FT group). At 3 months mpMRI-US guided HIFU had significantly lower urine leak (5.1% vs. 15.9%, p=0.04) and a lower drop in IIEF scores (2 vs. 4.2, p=0.07). Of those undergoing 12-months control biopsy in the mpMRI-US-guided HIFU group, 26% had residual cancer in the treated lobe. Conclusion HIFU FT guided by MRI-US fusion may allow improved functional outcomes and fewer complications compared to US- guided HIFU FT alone. Further analysis is needed to confirm benefits of mpMRI implementation at a longer follow-up and on a larger cohort of patients.

Background: The three-way indwelling urinary catheter (IUC) is used for continuous bladder irrigation and is considered the cornerstone for clinical treatment of patients with macroscopic hematuria. Although there seems to be a logical relationship between catheter size and efficacy of irrigation and drainage, we often observe relevant variations in these parameters between different brands of catheters available on the market. The aim of this study was to compare the mechanical properties of different models of latex and silicone three-way catheters in an in vitro setting that resembles clinical use. Methods: Three different three-way catheters were evaluated: Gold Silicone-Coated Rusch® (Model A), 100% Silicone Rusch® (Model B) and X-Flow Coloplast® (Model C). Irrigation channel, drainage channel, and overall cross-sectional areas were all digitally measured. Irrigation and drainage channel flow rates were measured and correlated with their corresponding catheter cross-sectional area values. Results: Different catheter models of the same caliber have different internal irrigation port diameters, internal drainage port diameters and internal cuff port diameters. The Model C IUC internal irrigation port diameter is significantly larger than models A and B. When flows were evaluated, we found that in the same model, the increase in caliber of the IUC was related to an increased drainage flow, but not to an increased irrigation flow. Conclusion: Precise measurements of the internal architecture of the three-way catheter, rather than relying on the caliber itself, could assist surgeons in choosing the best product for each specific patient, while minimizing complications.

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.

We assessed the impact of focal therapy on perioperative, oncologic and functional outcomes in men who underwent salvage robotic assisted radical prostatectomy compared to primary robotic assisted radical prostatectomy.Focal therapy was performed in patients presenting with Gleason score 3 + 3 or 3 + 4, clinical stage cT2a or less, serum prostate specific antigen 15 ng/ml or less, unilateral positive biopsy, maximum length of any positive core less than 10 mm and life expectancy greater than 10 years. Focal therapy was defined as target ablation of the index lesion plus a 1 cm safety margin in the normal ipsilateral prostatic parenchyma. The salvage group included 22 men who underwent salvage prostatectomy after focal therapy failure. The primary group was defined using matched pair 1:2 selection of 44 of 2,750 patients treated with primary prostatectomy. The primary and secondary end points were the between group differences in functional and oncologic outcomes, respectively.Complication rates were comparable (p0.05). Pad-free probability was comparable between the groups at 1 and 2 years (p = 0.8). Recovery of erectile function was significantly lower after salvage robotic assisted radical prostatectomy (p = 0.008), which also showed a significantly lower probability of cumulative biochemical recurrence-free survival compared to primary robotic assisted radical prostatectomy (56.3% vs 92.4% at 2 years, p = 0.001). Salvage prostatectomy demonstrated a significantly increased risk of biochemical recurrence (HR 4.8, 95% CI 1.67-13.76, p = 0.004). Study limitations included the retrospective nature, the lack of randomization and the short followup.Salvage robotic assisted radical prostatectomy after focal therapy failure is feasible with acceptable complication rates. However, patients assigned to primary focal therapy should be advised about a poorer prognosis in terms of oncologic control and lower erectile recovery rates in case of a future salvage surgery.

Resumen Introduccion La reaccion inflamatoria local despues de una biopsia prostatica (BP) puede influir de manera negativa en los resultados globales posprostatectomia radical. No hay evidencia suficiente en la literatura respecto al impacto del numero de punciones en los resultados posquirurgicos. Objetivos Determinar el impacto del numero de punciones de la BP en las complicaciones posquirurgicas y en el estado de los margenes operatorios. Material y metodos Se registraron prospectivamente 2.054 pacientes sometidos a prostatectomia radical asistida por robot (PRAR) en nuestra institucion. Se formaron 2 grupos de pacientes, en relacion con el numero de punciones en la BP (G1 ≤ 12 punciones; G2 > 12 punciones). Se evaluo por medio del analisis multivariable (modelos de regresion logistica) el impacto del numero de punciones en las complicaciones posquirurgicas. Resultados Se incluyeron 1.042 pacientes en el grupo 1 (≤ 12 punciones) y 1.012 pacientes en el grupo 2 (> 12 punciones). La tasa de complicaciones perioperatorias se incremento a medida que aumentaba el numero de punciones. (G1 6,4 vs. G2 8,5%; p = 0,03); no obstante, las complicaciones mayores (Clavien 3-4) fueron similares (G1 1,4 vs. G2 2,2%; p = 0,16). No hubo diferencia estadisticamente significativa respecto a los margenes quirurgicos positivos en ambos grupos (G1 11,8 vs. 9,98%; p = 0,2). El analisis multivariable (regresion logistica) demostro que el grupo 2 tenia un porcentaje un 39% mayor de experimentar complicaciones post-PRAR (OR 0,645). Conclusion El mayor numero de punciones (> 12) en la BP podria estar relacionado con mayor sangrado y complicaciones posquirurgicas despues de PRAR. Una cuidadosa evaluacion preoperatoria de los pacientes que se sometieron a biopsias o protocolos de saturacion multiple es obligatoria. La aplicacion de intervalos mas largos (> 6 semanas) entre la biopsia y la cirugia puede ser recomendable para minimizar los potenciales riesgos de complicaciones quirurgicas en los pacientes que pueden beneficiarse de PRAR. Otros estudios son todavia necesarios para confirmar estos resultados.

The literature on focal therapy is currently insufficient to recommend it as first-line treatment. We need information from both randomised controlled trials and prospective registries for every available energy. That said, important research is under way in this field, and the door should be kept open to an approach that has the potential to offer adequate cancer control with lower morbidity and better post-treatment quality of life in properly selected patients.

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.

We report a case of a 43-year-old man who underwent a radical prostatectomy 3 years before the procedure (June 2015) for a locally advanced Gleason 7(4 + 3) prostate adenocarcinoma (pT3aN0), with negative surgical margins, followed by salvage radiotherapy. He also underwent antiandrogen therapy for biochemical relapse (bicalutamide) from October 2016 through May 2017, but prostate-specific antigen continued to rise (2.5 ng/mL [December 2017] and 3.3 ng/mL [February 2018]). At this point, he underwent a Ga-prostate-specific membrane antigen PET/CT, and after multidisciplinary discussion, the therapeutic option chosen was image-guided salvage cryoablation.

INTRODUCTION AND OBJECTIVES:Failure and need of retreatment after focal therapy (FT) for prostate cancer (PCa) has been seen in more than one third of patients in mid-term follow-up. In this study,...

INTRODUCTION AND OBJECTIVES:Focal therapy (FT) for prostate cancer (PCa) presents non-negligible rates of disease recurrence. We aim to assess the outcomes of redoing FT (s-FT) after FT failure as ...

INTRODUCTION AND OBJECTIVES:A great variety of surgical treatments are available for benign prostatic enlargement (BPE). This study aims to evaluate the safety and efficacy profile of different met...

INTRODUCTION The aim of this study was to review the oncological and functional outcomes of new and established primary focal treatments (FT) for localized prostate cancer (PCa). EVIDENCE ACQUISITION We performed a systematic search of published studies on FT for localized PCa using electronic databases (Medline and Embase). These studies included reports on hemi-ablation, focal ablation and target-ablation. We excluded salvage focal therapy studies and limited the search to those with a minimum of 12 months of follow-up. EVIDENCE SYNTHESIS We selected 20 studies with a total of 2523 patients who were treated in the primary setting. The energy sources used were cryotherapy (8), high-intensity focused ultrasound (9), irreversible electroporation (1), photodynamic therapy (1) and focused laser ablation (1), with 65% hemiablation, 25% focal ablation and 10% target-ablation. The median follow-ups ranged from 6 to 44.4 months. Mean age was 60.4-70 years and mean prostate-specific antigen was 4.4

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.

To evaluate the transition from laparoscopic (LPN) to robotic partial nephrectomy (RPN) in our institution using ‘trifecta’ outcomes as surrogate marker of efficacy. We identified 347 patients (LPN = 303, RPN = 44) in our prospectively maintained PN database between 2000 and 2014. The patients were chronologically divided into G1—first 151 LPN cases, G2—subsequent 152 LPN cases and G3—all RPN patients. Trifecta outcomes were defined as warm ischemia time (WIT) ≤25 min, no positive surgical margin (PSM) and complications ≤Clavien 2. Multivariable logistic model was used to analyze the predictors of the trifecta outcomes. The tumor complexity significantly increased from G1 to G3. We achieved lower WIT and less high-grade complication (Clavien ≥ 3) from G1 to G2, and the trend continued even with transition to RPN. PSM was consistently low throughout the transition. Renal functional outcomes always showed a significant positive trend, and with RPN, we achieved improved recovery of renal function (44 vs 57 vs 82 %, p

Most biliary stone diseases need to be treated surgically. However, in special cases that traditional biliary tract endoscopic access is not allowed, a multidisciplinary approach using hybrid technique with urologic instrumental constitute a treatment option. We report a case of a patient with complex intrahepatic stones who previously underwent unsuccessful conventional approaches, and who symptoms resolved after treatment with hybrid technique using an endourologic technology. We conducted an extensive literature review until October 2012 of manuscripts indexed in PubMed on the treatment of complex gallstones with hybrid technique. The multidisciplinary approach with hybrid technique using endourologic instrumental represents a safe and effective treatment option for patients with complex biliary stone who cannot conduct treatment with conventional methods.

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

A recently published meta-analysis of randomized clinical trials (RCT) showed that androgen deprivation therapy (ADT) did not significantly increase cardiovascular mortality in prostate cancer patients. However, cardiovascular morbidity, which can impact quality of life, was not evaluated.To evaluate the risk of cardiovascular morbidity associated with ADT in patients with prostate cancer.We conducted a literature search from January 1960 to June 2012. RCT and large cohort studies that evaluated first-line endocrine therapy and ADT longer than 6 months were screened for inclusion.In total, 126,898 patients were included in four cohort studies, and 10,760 patients were included in nine RCTs. Analysis of the RCTs showed no differences in the development of acute myocardial infarction (AMI) (OR 1.23; 95 % CI 0.92-1.64; I (2): 0 %) among the patients receiving ADT or not. The analysis of randomized studies that reported other nonfatal cardiovascular events demonstrated a significant increase in such events in the group receiving ADT (OR 1.55; 95 % CI 1.09-2.20; I (2): 0 %). When the large cohort studies were included in the analysis, an increased risk of AMI among men with ADT was found (OR 2.01, 95 % CI 1.90-2.13; I (2): 91,3 %).The use of ADT in prostate cancer patients corresponded with a significant increase in cardiovascular morbidity associated with AMI and with nonfatal events. Therefore, ADT is linked to a significant negative impact on quality of life. Periodic cardiovascular evaluation is required for these patients.

Introduction: Renal ptosis is defined as the renal descent when there is a change from supine to orthostatic position, usually with a change of two vertebral bodies or more than five cm apart. Although rare, it is one of the causes of chronic flank pain or of upper abdomen. The typical patient of renal ptosis is young, female, thin, with complaint of pain when in an upright position (1, 2). Objective: Demonstrate a robot-assisted nephropexy technique in a young woman diagnosed with symptomatic renal ptosis on the right kidney, confirmed by imaging tests. Materials and Methods: A 29-year-old female patient with a history of chronic right-sided pain and palpable renal mobility on physical examination. The diagnosis of renal ptosis was confirmed by ultrasound imaging, excretory urography (Figure-1), and renal scintigraphy with 99mTc-DTPA (Figure-2). She was submitted to a robotic-assisted right nephropexy with a polypropylene mesh fixing the right kidney to the ipsilateral psoas muscle fascia. Result: We reported a 96-minute surgical time. The patient was discharged in the first postoperative day. At the one-month follow-up, there was an important improvement of the symptoms, with normality renal function and imaging tests describing adequate renal positioning. Conclusions: Robotic-assisted nephropexy is feasible and can be an excellent minimally invasive alternative technique for the proposed surgery. We reported a shorter hospital stay and a faster postoperative recovery compared with the opened procedure.

Background: Low-dose aspirin use has been correlated with an increased risk of bleeding and overall complications in surgical and invasive diagnostic procedures. In this review, our aim was to analyze the current literature on whether robot-assisted radical prostatectomy (RARP) is feasible and safe in patients taking low-dose aspirin perioperatively. Methods: A systematic review was performed identifying a total of 767 studies, published between January 2000 and September 2017, with five of these studies meeting the inclusion criteria for the meta-analysis, totalizing 1481 patients underwent RARP. Patients were divided into two groups: taking aspirin (group A) and those not taking aspirin (group B) perioperatively. Results: There were no significant differences between groups in the overall [group A 10.7% versus group B 15.7%, risk ratio (RR) 0.83; p = 0.45; I2 = 0%] or major complication rates (group A 1% versus group B 3%, RR 0.98; p = 0.98; I² = 0%), rate of cardiovascular events (group A 1.4% and group B 0.5%, RR 2.06; p = 0.24; I2 = 9%), blood loss (group A 278 ml versus group B 307 ml, SMD −0.12; p = 0.91; I2 = 96%), or hospital length of stay [group A 4 days (3–5) and group B 4 days (3–4), SMD −0.09; p = 0.52; I² = 0%]. There was a slightly higher blood-transfusion rate in group A (2.6%) versus group B (1.6%) (RR, 5.05; p = 0.04; I2 = 0%). Conclusion: Continued aspirin use in the perioperative period does not correlate with an increase in surgical morbidity, blood loss, or hospital length of stay. There was a slightly higher blood-transfusion rate in patients taking low-dose aspirin (group A) perioperatively.

EPIC-CP (Expanded Prostate Cancer Index Composite for Clinical Practice) is a short questionnaire that comprehensively measures patient reported health related quality of life at the point of care. We evaluated the feasibility of using EPIC-CP in the routine clinical care of patients with prostate cancer without research infrastructure. We compared longitudinal patient and practitioner reported prostate cancer outcomes.We reviewed health related quality of life outcomes in 482 patients who underwent radical prostatectomy at our institution from 2010 to 2014. EPIC-CP was administered and interpreted in routine clinical practice without research personnel. We compared practitioner documented rates of incontinence pad use and functional erections to patient reported rates using EPIC-CP.A total of 708 EPIC-CP questionnaires were completed. Mean urinary incontinence domain scores were significantly higher (worse) than baseline (mean ± SD 0.6 ± 0.2) 3 and 6 months after treatment (mean 3.1 ± 2.3 and 2.2 ± 2.1, respectively, each p0.05) but they returned to baseline at 12 months (mean 1.6 ± 1.7, p0.05). Mean sexual domain scores were significantly worse than baseline (mean 2.4 ± 2.8) at all posttreatment time points (each p0.05). Practitioners significantly overestimated incontinence pad-free rates at 3 months (48% vs 39%) and functional erection rates at 3 months (18% vs 12%), 6 months (38% vs 23%) and 12 months (45% vs 23%, each p0.05).EPIC-CP is feasible to use in the routine clinical care of patients with prostate cancer without requiring a research infrastructure. Using EPIC-CP in clinical practice may help practitioners objectively assess and appropriately manage posttreatment side effects in patients with prostate cancer.

Purpose: This study compared the suprapubic (SP) versus retropubic (RP) prostatectomy for the treatment of large prostates and evaluated perioperative surgical morbidity and improvement of urinary symptoms. Materials and Methods: In this single centre, prospective, randomised study, 65 consecutive patients with LUTS and surgical indication with prostate volume greater than 75g underwent open prostatectomy to compare the RP (32 patients) versus SP (33 patients) technique. Results: The SP group exhibited a higher incidence of complications (p=0.002). Regarding voiding pattern analysis (IPSS and flowmetry), both were significantly effective compared to pre-treatment baseline. The RP group parameters were significantly better, with higher peak urinary flow (SP: 16.77 versus RP: 23.03mL/s, p=0.008) and a trend of lower IPSS score (SP: 6.67 versus RP 4.14, p=0.06). In a subgroup evaluation of patients with prostate volumes larger than 100g, blood loss was lower in those undergoing SP prostatectomy (p=0.003). Patients with prostates smaller than 100g in the SP group exhibited a higher incidence of low grade late complications (p=0.004). Conclusions: The SP technique was related to a higher incidence of minor complications in the late postoperative period. High volume prostates were associated with increased bleeding when the RP technique was utilized. The RP prostatectomy was associated with higher peak urinary flow and a trend of a lower IPSS Score.

Introduction The local inflammatory process after prostate biopsies can have a negative impact on functional outcomes of radical prostatectomy. There is no evidence in literature demonstrating its impact on radical prostatectomy. Objectives To evaluate the impact of the number of TRUS core biopsies in the surgical morbidity and rate of positive margin on robot assisted radical prostatectomy (RARP). Material and methods A prospectively maintained database of 2054 RARPs in a single institution. Patients were further grouped into 2 groups based on the number of TRUS biopsy cores (G1 ≤ 12 cores; G2 > 12 cores). Multivariable logistic regression model was applied to analyze the impact of number of cores on complications. Results A total number of 1042 patients in the group 1 (≤12 cores) and 1012 patients in the group 2 (>12 cores) were included. The rate of perioperative complications increased with higher number of biopsies (G1 6.4 vs. G2 8.5%; p = 0.03), but high grade complication (Clavien 3–4) were similar (G1 1.4 vs. G2 2.2%; p = 0.16). Positive surgical margin rates were similar in both groups (G1 11.8 vs. 9.98%; p = 0.2). At the multivariable logistic regression analysis shown that G2 had a 39% (OR 0.645) higher rate to experience perioperative complications during RARP. Conclusion Higher number of TRUS biopsy cores (>12) is associated to higher blood loss and perioperative complications during RARP. Careful preoperative evaluation for those patients underwent multiple biopsies or saturation protocols is mandatory. Application of longer intervals (>6 weeks) between biopsy and surgery may be advisable to minimize potential risks of surgical complications in patients may benefit from RARP. Further studies are still necessary to confirm these results.

Purpose: Despite the increasing number of studies confirming the importance of neoadjuvant chemotherapy (NC) in patients before radical cystectomy (RC) for bladder cancer (BCa), NC remains underused. The aim of our study was to develop a nomogram predicting the cancer-specific mortality (CSM) of patients who underwent RC for transitional BCa, evaluating the available clinical information and the NC. Materials and methods: We identified 423 patients who underwent RC and pelvic lymph node dissection, treated or not with NC, in two European high-volume centers between 2007 and 2013. Chi-square and Student’s t tests were used to evaluate differences between groups. Kaplan–Meier curves were used to assess time to cancer-specific (CSS) and overall survival (OS). Uni- (UVA) and multivariable (MVA) Cox regression analyses were developed to address predictors of CSS and OS. A nomogram based on the Cox regression coefficient was developed to show the impact of NC on CSM. Results: Mean follow-up was 20.3Âmonths. Our population had mainly pT2 disease (77.1Â%), and 19.4Â% had preoperative cisplatinum-based NC. NC showed better CSS at UVA (pÂ=Â0.014) and MVA (odds ratio: 0.44; pÂ=Â0.043). Overall, the 3-year OS and the CSS rate were 69.3 and 79Â%, respectively. The nomogram developed to predict the 36-month CSM showed predictive accuracy of 67Â%. Conclusions: We developed the first nomogram predicting the 36-month CSM rate in patients with high-risk BCa according to the clinical data. Moreover, we demonstrate that preoperative cisplatinum-based chemotherapy is associated with better CSS.

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

e17068Background: The presence of prostate cancer (PCa) Gleason pattern 4 or 5 on biopsy is a major contraindication for active surveillance (AS). Limitations of anatomopathological morphological a...

Objective To evaluate the surgical morbidity and effectiveness in improving symptoms of benign prostatic hyperplasia (BPH), comparing ‘button-type’ bipolar plasma vaporisation (BTPV) vs transurethral resection of the prostate (TURP). Methods We conducted a literature search of published articles until November 2014. Only prospective and randomised studies with comparative data between BTPV and conventional TURP (mono- or bipolar) were included in this review. Results Six articles were selected for the analyses. In the 871 patients evaluated, 522 underwent TURP and 349 BTPV. There was a tendency for a higher transfusion rate in the TURP group, with two BTPV cases (0.006%) and 16 TURP cases (0.032%) requiring transfusions (P = 0.06). The number of complications was similar between the groups (odds ratio 0.33, 95% confidence interval [CI] 0.8–1.31; P = 0.12; I2 = 86%). When subdivided by severity, 10.7% (14/131) and 14.6% (52/355) of complications were classified as severe (Clavien 3 or 4) in patients who underwent BTPV and TURP, respectively (P = 0.02). The average duration of indwelling catheterisation was significantly less in patients who underwent BTPV (standardised mean difference [SMD] −0.84; 95% CI −1.54 to 0.14; P = 0.02; I2 = 81%). Both treatments significantly improved symptoms and the postoperative International Prostate Symptom Score was similar in both groups (SMD 0.09, 95% CI −1.56 to 1.73; P = 0.92). Conclusion BTPV is an effective and safe treatment for BPH. The improvement of urinary symptoms and overall complications are comparable to conventional TURP. However, BTVP appears to be associated with a lower rate of major complications and duration of indwelling catheterisation.