Eliney Ferreira Faria

Program for prostate cancer screening using a mobile unit: results from Brazil.

OBJECTIVES To evaluate the initial results of a prostate cancer screening program using mobile units in Brazil. METHODS Since 2004, we have conducted a program of prostate cancer screening using mobile units across 231 municipalities from 6 Brazilian states. RESULTS A total of 17 571 men were evaluated by clinical history, digital rectal examination (DRE), and serum free and total prostate-specific antigen (PSA) levels. The recommendations for biopsy were a PSA level of ≥ 4.0 ng/mL, DRE findings suspicious for cancer, or a PSA level of 2.5-4.0 ng/mL with a percent-free PSA level < 15%. The biopsy protocol included 12 biopsy cores from the peripheral zone, 2 from the transition zone, and additional sampling of suspicious areas. The cumulative cancer detection rate was 3.7%. The main indication for biopsy was a PSA level of ≥ 4.0 ng/mL (51.2%), with a positive predictive value (PPV) of 44.1%. Another 19.7% of biopsied men had suspicious DRE findings with a normal PSA level (PPV 23.5%). A percent-free PSA level of < 15% in men with a PSA level of 2.5-4.0 ng/mL and normal DRE findings yielded a PPV of 31.1%. The PPV was greater (70.9%) for the 7.1% of men with both suspicious DRE findings and a PSA level of ≥ 4.0 ng/mL. Most cancers were Stage T1-T2 (93.4%), and the percentage of Gleason score of ≥ 7 was 32.5%. The proportion of insignificant cancers according to Epsteins criteria was 13.5%. CONCLUSIONS A mobile prostate cancer screening unit enabled an underserved population to gain access to specialized care through the public healthcare system. The cancer detection rate in this population was similar to those from international studies.

Comparison of Clinical and Pathologic Findings of Prostate Cancers Detected Through Screening Versus Conventional Referral in Brazil

INTRODUCTION Data regarding prostate cancer screening in Brazil are limited. We compared features of prostate cancers detected through screening versus those referred for treatment in Brazil. PATIENTS AND METHODS Group I included 500 of 13,754 men whose cancers were detected through screening, and Group II included 2731 men referred for treatment through the habitual public health system. We used Mann-Whitney and χ(2) tests to compare clinical and pathologic findings, considering significant any P < 0.05. RESULTS Median prostate-specific antigen (PSA) was lower among screened patients (5.5 ng/mL versus 10.0 ng/mL; P < 0.001). Of the screened patients, 170 (34%) had biopsy Gleason score ≥ 7, compared with 1265 (46.3%) in the referred group (P < 0.001). Lymph node metastases were suspected in 8.6% of the referred versus 3.2% of the screened men (P = 0.002). Distant metastases were more common in the referred men (9.3% vs. 3.0%; P < 0.001). Only 6.0% of the screened cancers were locally advanced at diagnosis (T3 or T4) versus 26.5% of the referred (P < 0.001). Screened patients had a higher proportion of localized tumors after surgery (67.7% vs. 54.2%; P = 0.002). Pathology Gleason scores were also lower among screened men (P < 0.01). Lymphadenectomies were performed in 166/636 men (26.1%). No nodal metastases were found in screened cancers (0/28; 0.0%), while 6/138 referred cancers (4.3%) presented nodal involvement (P = 0.3). CONCLUSION Clinical and pathologic characteristics of screen-detected cancers are more favorable than those of tumors diagnosed through the Brazilian health system.

Radical Prostatectomy for Locally Advanced Prostate Cancer: Current Status.

In the past, prostate cancer (PC) could only be detected clinically, and delayed diagnosis of locally advanced or metastatic disease at presentation was common. Prostate-specific antigen testing and magnetic resonance imaging led to PC detection in a much earlier stage. However, controversy about the best treatment for locally advanced PC remains. Recent refinements in surgery and radiation therapy have improved outcomes, but no comparative study has yet conclusively determined superiority of one option over the other. In this review, we present the most recent evidence about the role of radical prostatectomy for locally advanced PC treatment from a surgeons perspective.

Use of low free to total PSA ratio in prostate cancer screening: detection rates, clinical and pathological findings in Brazilian men with serum PSA levels <4.0 ng/mL

Study Type – Diagnostic (inception cohort)

Cutaneous ureterostomy with definitive ureteral stent as urinary diversion option in unfit patients after radical cystectomy

PURPOSE: Simple diversions are underutilized, mostly for unfit, bedridden, and very self-limited patients requiring palliative surgical management due to life-threatening conditions. Experience with cutaneous ureterostomy (CU) as palliative urinary diversion option for unfit bladder cancer patients is reported. METHODS: We retrospectively reviewed clinical and operative parameters of 41 patients who underwent CU following RC in three specialized Cancer Centers from July/2005 to July/2010. Muscle-invasive disease (clinical Stage T2/worse), multifocal high-grade tumor, and carcinoma in situ refractory to intravesical immunotherapy were the main indications for RC. Double-J ureteral stents were used in all patients and replaced every 6 months indefinitly. Peri-operative morbidity and mortality were evaluated. RESULTS: Median age was 69 years (interquartile range - IQR 62, 76); 30 (73%) patients were men. Surgery in urgency setting was performed in 25 (61%) of patients, most due to severe bleeding associated with hemodynamic instability; 14 patients (34%) showed an American Society of Anesthesiologists score 4. Median operative time was 180 minutes (IQR 120, 180). Peri-operative complications occurred in 30 (73%) patients, most Clavien grade I and II (66.6 %). There was no per-operative death. Re-intervention was necessary in 7 (17%) patients. Overall survival was 24% after 9.4 months follow-up. CONCLUSIONS: CU with definitive ureteral stenting represents a simplified alternative for urinary diversion after palliative cystectomy in unfit patients. It can be performed quickly, with few early and late postoperative complications allowing RC in a group of patients otherwise limited to suboptimal alternatives. Future studies regarding the quality of life are warranted.

Alternative techniques to reduce warm ischemia time in laparoscopic partial nephrectomy.

PURPOSE Demonstrate two alternatives that permit a warm ischemia time reduction during laparoscopic partial nephrectomy. MATERIALS AND METHODS In this video, two cases of intermediate complexity renal tumors according to the RENAL nephrometry renal scoring system illustrating the techniques and our preliminary experience: a 65 year old man with a 4 cm right, posterior renal tumor. This patient underwent an early unclamping and parenchymal suturing using a greek bar continuous suture with hem-o-lock clips attached to the respective extremities of the suture; The second patient is a 49 year old man with a 3 cm renal tumor. The technique utilized was no clamping resection following the ABC Medical School technique: dissection of renal hilum for eventual clamping if necessary, a frontal 360 degrees visualization of tumor limits, pneumoperitoneum pressure elevated to 25mmHg during tumor resection, spiral excavation of normal parenchyma around the tumor and resection with negative margins. RESULTS We previously performed 15 cases utilizing the early unclamping technique. The mean clamp time was 15 minutes with a mean blood loss of 285 mL. Only 1 patient had focal positive surgical margins, without recurrence demonstrated at 30 months. Fifteen partial nephrectomies were previously performed with on demand clamping. In 3 cases, clamping was necessary with a mean ischemia time of 11 minutes. The mean blood loss was 390 mL and 2 cases required a perioperative blood transfusion. One case presented with a positive focal margin without recurrence demonstrated at 24 months of follow-up. Renal function was preserved in all cases regardless of the technique applied. CONCLUSION Warm ischemia time can be reduced and kidney function can be preserved during laparoscopic nephrectomy if either early unclamping or on demand clamping are selectively applied.

Correlation Between Testosterone and PSA Kinetics in Metastatic Prostate Cancer Patients Treated With Diverse Chemical Castrations

To assess total testosterone and prostatic-specific antigen (PSA) kinetics among diverse chemical castrations, advanced-stage prostate cancer patients were randomized into three groups of 20: Group 1, Leuprolide 3.75 mg; Group 2, Leuprolide 7.5 mg; and Group 3, Goserelin 3.6 mg. All groups were treated with monthly application of the respective drugs. The patients’ levels of serum total testosterone and PSA were evaluated at two time periods: before the treatment and 3 months after the treatment. Spearman’s rank correlation coefficient was utilized to verify the hypothesis of linear correlation between total testosterone and PSA levels. At the beginning the patients’ age, stage, grade, PSA, and total testosterone were similar within the three groups, with median age 72, 70, and 70 years in Groups 1, 2, and 3, respectively. Three months after the treatment, patients who received Leuprolide 7.5 mg presented significantly lower median total testosterone levels compared with Goserelin 3.6 mg and Leuprolide 3.75 mg (9.5 ng/dL vs. 20.0 ng/dL vs. 30.0 ng/dL, respectively; p = .0072), while those who received Goserelin 3.6 mg presented significantly lower PSA levels compared with Leuprolide 7.5 mg and Leuprolide 3.75 mg (0.67 vs. 1.86 vs. 2.57, respectively; p = .0067). There was no linear correlation between total testosterone and PSA levels. Overall, regarding castration levels of total testosterone, 28.77% of patients did not obtain levels ≤50 ng/dL and 47.80% did not obtain levels ≤20 ng/dL. There was no correlation between total testosterone and PSA kinetics and no equivalence among different pharmacological castrations.

Incremental value of MRI for preoperative penile cancer staging.

To evaluate the incremental value of magnetic resonance imaging (MRI), compared to clinical examination, for penile cancer (PC) local staging.

Laparoscopic Retroperitoneal Lymph Node Dissection as a Safe Procedure for Postchemotherapy Residual Mass in Testicular Cancer

BACKGROUND To evaluate the feasibility, clinical and perioperative outcomes of laparoscopic retroperitoneal lymph node dissection (L-RPLND) in the management of patients with germ cell tumors (GCT) and residual post-chemotherapy mass. METHODS We report our experience of 25 patients treated with L-RPLND between 2008 and 2015. All 25 patients were diagnosed with GCT by primary pathological evaluation of the specimens after orchiectomy. All patients received cisplatin-based chemotherapy. The technique consisted of L-RPLND excision of the residual mass using unilateral template dissection. We assessed perioperative data and histological findings. RESULTS Surgery was successfully completed in 24 (96%) patients, 1 patient required an open surgery due to intense adhesions of the mass to the inferior vena cava. Mean operation time was 213 minutes. Mean blood loss was 260 mL. Postoperative complications were upper limb osteomuscular pain in 2 patients and chylous ascites in 1 patient. Mean postoperative hospital stay was 2 days. The median residual mass diameter was 3.3 cm (range 1.1-6.6 cm). Histopathological findings were necrotic tissue in 9 patients, teratoma in 9 patients, viable tumor in 6 patients, and Castleman disease in 1 patient. The median follow-up was 30 months. Normal antegrade ejaculation was preserved in all patients. CONCLUSIONS Laparoscopic postchemotherapy RPLND is a feasible, safe, and highly oncologically efficient procedure, which has the benefits of minimally invasive surgery.

Primary proximal urethral adenocarcinoma: Case report and brief review

Primary urethral cancer in females is rare. It has a poor prognosis. The published data on this topic are limited, composed mostly of small case series. This paper presents a case of an advanced adenocarcinoma of the urethra, intestinal type, treated with anterior exenteration.