Emerson Luis Zani

Bariatric Surgery Does not Interfere With Sperm Quality—A Preliminary Long-Term Study

Purpose: Positive impact of weight loss on sexual function and hormones has been demonstrated, and male fertility in this scenario is to be better defined. We evaluated the impact of lifestyle modifications and gastric bypass on sperm quality. Methods: We prospectively studied 20 morbidly obese men during 24 months, randomized for intervention: lifestyle modifications (exercise and diet) for 4 months and subsequently gastric bypass (n = 10); and control: follow-up (n = 10). All patients underwent International Index of Erectile Function (IIEF-5) questionnaire, serum estradiol, prolactin (PRL), luteinizing and follicle-stimulating hormones (LH and FSH), free and total testosterones (FT and TT) and semen analysis at baseline (time 0), surgery 4 months later baseline (time 1) and final evaluation 24 months (time 2). Results: Intervention group presented significant reduction in body mass index (BMI) at times 1 and 2, compared to control. There were no significant differences among sperm parameters between groups at times 0, 1, and 2 and among times 0, 1, and 2 in each group. Increases in IIEF-5 score (P = .0469), TT (P = .0349), and FSH (P = .0025) and reduction in PRL (P < .0001) were observed in the intervention group from times 0 to 2 and 1 to 2. Comparing groups at time 2, IIEF-5, TT, and FT increased significantly in the intervention group (P = .0224, P = .0043, and P = .0149, respectively). Conclusions: Surgery-induced massive weight loss does not interfere with sperm quality, while it increased the quality of sexual function, TT, FT and FSH and reduced PRL. Lifestyle modifications impacted merely the BMI. New studies are warranted, mostly considering birth rate as primary end point and including infertile men.

Assessment of Serum Chromogranin-A as Prognostic Factor in High-Risk Prostate Cancer

Purpose The presence of neuroendocrine differentiation may play a key role in androgen-independent tumor progression. The prognostic significance of plasma chromogranin-A (CgA) was assessed in a series of consecutive patients with high-risk prostate cancer (PCa). Patients and Methods Twenty-three patients presenting high-risk PCa and 8 healthy individuals, as control group, had their blood samples collected to evaluate CgA, free and total prostate specific antigen, and free and total testosterone in a pilot study. The correlations of serum CgA levels with PSA, testosterone, Gleason score, number of foci of hypercaptation in bone scan, age, and outcomes were evaluated at baseline and after 12 months. Results Patients with PCa had significantly higher levels of plasma CgA (mean, 8.7; range, 1.9-73) than healthy patients (mean, 3.45; range, 0.6-5.6), P = 0.02. Analyzing only the patients group through correlation of the ranks, it was observed that CgA has low, insignificant correlations with PSA (P = 0.07) and with metastatic extension (P = 0.09). No association was found between the plasma CgA levels and the Gleason score (P = 0.20), age (P = 0.15), or disease progression (P = 0.27). Conclusion The serum levels of CgA were significantly increased in the group with PCa compared with the healthy group. However, there were low correlations between serum CgA and known prognostic factors (such as total and free PSA, age, Gleason score, and bone metastases) or clinical deterioration. Although future studies are needed with larger samples and longer follow-up, the presented data envisage a limited role to serum CgA as high-risk PCa prognostic factor.

Litotricia extracorpórea en niños: Eficacia y evaluación a largo plazo de la lesión del parénquima renal mediante gammagrafía con DMSA-99mTc

Objetivo: determinar la eficacia de la litotricia extracorporea por ondas de choque (LEOC) y los posibles efectos nocivos en el parenquima renal de ninos sometidos a tratamiento de la litiasis renal mediante gammagrafia renal con acido dimercaptosuccinico marcado con 99mTc (DMSA-99mTc). Pacientes y metodos: desde enero de 2004 a noviembre de 2007 se sometio a 18 ninos (de 3-10 anos) a LEOC (Philips-Dornier) por urolitiasis renal. A todos los pacientes se les realizo una evaluacion preoperatoria, que incluyo una exploracion fisica, cultivo de orina, pruebas de imagen y gammagrafia renal con DMSA-99mTc. La evaluacion tras el tratamiento consto de una exploracion clinica, determinacion de la presion arterial, cultivo de orina, ecografia renal y DMSA-99mTC, repetidas a los 3, 6 y 12 meses, que se compararon con las exploraciones obtenidas antes de la LEOC para determinar posibles cambios morfologicos o funcionales. Resultados: se fragmentaron con exito los calculos en todos los casos; en 9 pacientes (50%) con una sesion de LEOC, en 6 (33%) con dos sesiones y en tres pacientes (17 %) con tres sesiones de LEOC. Solo un paciente (5%) mostro un cambio de tamano del rinon derecho con descenso de la funcion tubular, sin hipertension ni otros cambios importantes despues de tres sesiones de LEOC y 6 meses de seguimiento. En los demas casos se comprobo la ausencia de hipertension hasta los 12 meses de seguimiento, de hematomas en la ecografia o de cicatrices renales importantes en las exploraciones gammagraficas. Conclusion: la LEOC es eficaz y segura para tratar la litiasis renal en ninos. Pueden aparecer lesiones del parenquima renal precozmente tras el tratamiento, pero estas lesiones son pasajeras y se resuelven espontaneamente en practicamente todos los casos. No existen generalmente lesiones renales irreversibles asociadas con la LEOC, ni siquiera despues del periodo de seguimiento con exploracion clinica y ecografica y gammagrafia con DMSA-99mTc.

Is the minimally invasive treatment as good as transurethral resection for benign prostatic hyperplasia

Despite the development of new technologies, transurethral resection of the prostate (TURP) is still considered the gold standard for surgical treatment of the benign prostate hyperplasia (BPH). In general, new minimally invasive treatments have not demonstrated better outcomes than TURP in evidence based medicine trials published to date, and should be reserved for patients who prefer to avoid surgery, who are unsuitable candidates for surgery or who no longer respond favorably to medication.TUMT and TUNA appears to be more effective than medical therapy but less effective than TURP. Both treatments can be given under topical anesthesia or local prostatic or perineal block.Efficacy of transurethral vaporization appears similar to TURP, but the studies are short-term and the glands operated on are relatively small. In patients with small prostates, the transurethral incision of the prostate can also be a good option, associated with less morbidity than TURP.Bipolar resection of the prostate is similar to TURP in effectiveness, but the data are inconclusive regarding blood loss, length of catheterization and hospital stay.Long-term comparative trials are needed to determine if the minimally invasive therapies are superior to standard TURP.

Extracorporeal lithotripsy in children. The efficacy and long-term evaluation of renal parenchyma damage by 99mTc-DMSA scintigraphy

Abstract Purpose To determine the effectiveness of extracorporeal shock-wave lithotripsy (ESWL) and possible deleterious effects on renal parenchyma of children subjected to treatment of renal lithiasis, using renal scintigraphy with 99mTc dimercapto-succunic acid (DMSA). Patients and methods From January 2004 to November 2007, 18 children (age 3–10 years) underwent ESWL (Philips-Dornier) for kidney urolithiasis. All patients underwent preoperative evaluation, including physical examination, urine culture, image exams and renal scintigraphy with 99mTC-DMSA. Evaluation after treatment consisted of a clinical examination, blood pressure measurement, urine culture, renal ultrasound and 99mTCDMSA, repeated at 3, 6 and 12 months, which were compared to the scans obtained before ESWL to determine possible morphological or functional changes. Results Success in the stones fragmentation was achieved in all cases – in 9 patients (50%) with one session of ESWL, in 6 (33%) with two sessions and in 3 patients (17%) with 3 sessions of ESWL. Only one patient (5%), after three sessions of ESWL and 6 months of follow-up showed change in size of right kidney with a decrease in tubular function, without hypertension or other major changes. In the other cases, there was absence of hypertension up to 12 months of follow-up, absence of renal hematomas detected by ultrasound or significant renal scars in scintigraphic examinations. Conclusion ESWL is effective and safe for treating renal lithiasis in children. Renal parenchyma lesions may occur early after treatment, but these lesions are transients and resolve spontaneously in virtually all cases; generally, there are no irreversible renal lesions associated with ESWL, even after the follow-up period with clinical examination, ultrasound examination and 99mTc-DMSA scintigraphy.

Does the criterion for prostate biopsy indication impact its accuracy?: A prospective population-based outpatient clinical setting study

Abstract Introduction Prostate specific antigen (PSA) and digital rectal examination (DRE) are the main tests for initial prostate investigation; there is no consensus about the best criterion for prostate biopsies. We aim to check the accuracy of different criteria in this context including PSA derivatives to detect prostate cancer. Material and methods Four different criteria for indication of prostate biopsy were compared: (A) PSA-density (>15ng/mL/cc); (B) PSA>2.5ng/mL; (C) PSA-velocity (>0.7ng/mL/year); (D) free/total PSA ratio ( Results The study was performed on 180 consecutive biopsies with 37.7% overall cancer detection rate: 29 (16.1%) performed following criterion A, 42 (23.3%) criterion B, 65 (36.1%) criterion C and 44 (24.4%) criterion D. Based on PSA criteria alone, the predictive positive value (PPV) was 37.9% for criterion A, 33.3% for B, 32.3% for C and 50.0% for criterion D, respectively, (p>0.05). Associating positive DRE with changed PSA, the PPV increased to 50%, 50%, 43.9% and 68.2% for criteria A, B, C and D, respectively (p>0.05). In univariate analysis, DRE (positive versus negative), PSA level (>10ng/mL versus 15%) and age were associated with PC. In multivariate analysis only positive DRE was associated with prostate cancer. Conclusions All the criteria of PSA derivatives are complementary and useful predictors of cancer risk. However, a positive DRE increased the PPV of PSA derivatives. New tools are needed to improve the accuracy of prostate cancer detection.

Psicoterapia: una pieza que falta en el puzle de la rehabilitación de la disfunción eréctil tras prostatectomía radical

OBJECTIVES To measure the impact of psychotherapy associated to the use of Tadalafil in the improvement of erectile function after radical prostatectomy. METHODS From 132 patients surgically treated for prostate cancer, thirty sequential patients with bilateral nerve sparing, low risk controlled disease and post-surgery erectile dysfunction (ED) took Tadalafil 20mg and underwent psychotherapy sessions, both weekly for three months. Patients were interviewed to establish the quality of erection using the instrument IIEF-5 and to measure psychological features impacting erectile function, aspects related to function, dysfunction, physical and emotional discomfort were evaluated with the help of an intensity scale. RESULTS The average age was 62.5 (46 to 77 years), 96.7% had a stable relationship, 56.6% of the patients accepted the diagnosis and 43.2% exhibited defense mechanisms (3.3% negation, 6.6% revulsion, 33.3% concern). A positive correlation was observed between erectile function and time exposed to treatment (IIEF-5 - 9.7 to 13.3, p=0.0006), with increased satisfaction with life in general (2.1 to 2.7, P=.028) and sexual life (3.1 to 3.7, P=.028), added to facilitation of expressing feelings/emotions (1.8 to 3.0, P=.0008). Satisfaction with relationship and intimacy with partner did not present significant improve (P=.12 and P=.61, respectively). CONCLUSIONS A holistic patient care with more complete ED rehabilitation includes psychotherapy with a positive correlation between erectile function and treatment exposition. Psychotherapy allowed the identification of important spouse related factors in this scenario.

Higher Prostate Weight Is Inversely Associated with Gleason Score Upgrading in Radical Prostatectomy Specimens

Background. Protective factors against Gleason upgrading and its impact on outcomes after surgery warrant better definition. Patients and Methods. Consecutive 343 patients were categorized at biopsy (BGS) and prostatectomy (PGS) as Gleason score, ≤6, 7, and ≥8; 94 patients (27.4%) had PSA recurrence, mean followup 80.2 months (median 99). Independent predictors of Gleason upgrading (logistic regression) and disease-free survival (DFS) (Kaplan-Meier, log-rank) were determined. Results. Gleason discordance was 45.7% (37.32% upgrading and 8.45% downgrading). Upgrading risk decreased by 2.4% for each 1 g of prostate weight increment, while it increased by 10.2% for every 1 ng/mL of PSA, 72.0% for every 0.1 unity of PSA density and was 21 times higher for those with BGS 7. Gleason upgrading showed increased clinical stage (P = 0.019), higher tumor extent (P = 0.009), extraprostatic extension (P = 0.04), positive surgical margins (P < 0.001), seminal vesicle invasion (P = 0.003), less “insignificant” tumors (P < 0.001), and also worse DFS, χ 2 = 4.28, df = 1, P = 0.039. However, when setting the final Gleason score (BGS ≤6 to PGS 7 versus BGS 7 to PGS 7), avoiding allocation bias, DFS impact is not confirmed, χ 2 = 0.40, df = 1, P = 0.530.Conclusions. Gleason upgrading is substantial and confers worse outcomes. Prostate weight is inversely related to upgrading and its protective effect warrants further evaluation.

The Triple Clinicopathologic Features to Seminal Vesicle-Sparing Radical Prostatectomy

BACKGROUND AND PURPOSE With the widespread early detection programs for prostate cancer, there has been a downward stage migration and a marked decrease in the percentage of men with seminal vesicle invasion (SVI) compared with previous data. We evaluated clinicopathologic findings that are associated with SVI to select patients for potential seminal vesicle-sparing surgery. PATIENTS AND METHODS We reviewed our radical prostatectomy database from 1997 to 2006 to evaluate the incidence and clinical correlates of SVI. Variables analyzed included serum prostate-specific antigen (PSA) level, clinical stage, percentage of positive cores with cancer, Gleason score on biopsy, age, prostate weight, and urethral and vesical surgical margins. Statistical analysis included univariate and multivariate logistic regressions. RESULTS Of 267 patients, 32 (12%) had SVI. Preoperative PSA level, biopsy Gleason score, and percentage of positive cores were highly predictive of SVI on multivariate analysis. SVI was present in only 1/98 patients (1.02 %) with biopsy Gleason score ≤6, 0/23 patients (0%) with serum PSA level <4 ng/mL, and only 1 patient with ≤12.8% of positive cores on biopsy. In all cases of distal SVI, there was proximal involvement. CONCLUSION Serum PSA level, Gleason score, and percentage of positive cores on biopsy are statistically significant predictors of SVI on multivariate analysis. Seminal vesiculectomy does not benefit almost 99% of patients with biopsy Gleason score ≤6, PSA level <4 ng/mL, and with <12% cores with cancer. In cases of seminal vesicle-sparing surgery, frozen section of the proximal portion may be of adjunct usefulness for the triple.

Long-Term Results of Anderson–Hynes Pyeloplasty in Children: How Long Follow-Up Is Necessary?

PURPOSE After a successful pyeloplasty at 3 to 6 months, the question remains whether children need a long follow-up. METHODS The medical charts of patients with long-term follow-up (> 5 years), who underwent dismembered pyeloplasty for uretero-pelvic junction obstruction (UPJO) from May 1998 to May 2007, excluding those with bilateral UPJO, solitary kidney, associated vesicoureteral reflux or other abnormalities, and inconclusive renogram due to poor renal function, were retrospectively reviewed. Ultrasonography, differential renal function (DRF, DMSA), and renal drainage on diuretic renography (diethylene-triamine-pentaacetate technetium-99 or DTPA-Tc99) were performed at 3 and 6 months every year. RESULTS Complete data were available for 28 consecutive patients (28 renal unities) with 2 months to 12 years (mean age, 2.4 years) at surgery, of whom 21 (75%) were boys, 17 diagnosed prenatally (61%) and 18 unities (64.3%) were left, with median follow-up of 10.7 years. Images were graded according to the Society for Fetal Urology grading system: Grade III in 11 (49%) and grade IV in 17 (61%). All cases presented > 10% DRF (DMSA) and obstructed DTPA-Tc99. The T1/2 (the half-time of drainage) less than 20 minutes at 3 months was found in 21 cases (75%) and less than 25 minutes in 7 cases (25%). Renal function and patency were maintained during follow-up for all units with 8% maximum fluctuation of DRF. One index case (3.6%) of renal function deterioration presented DRF fluctuation > 8% at 3 months (from 23 to 32%) and progressive hydronephrosis and indeterminate DTPA at 6 months. CONCLUSIONS Satisfactory diuretic renogram at 3 to 6 months after pyeloplasty with maintained renal function and stable hydronephrosis suggests no need for further follow-up and indicates no functional loss with time. More than 8% DRF fluctuation might be a significant cutoff for further intervention aiming nephron preservation.