Fernandes Denardi

Prostate Specific Antigen Decrease and Prostate Cancer Diagnosis: Antibiotic Versus Placebo Prospective Randomized Clinical Trial

PURPOSE Prostate inflammation can lead to an increase in serum prostate specific antigen concentration and confound the use of prostate specific antigen kinetics. Repeat prostate specific antigen measurements after a period of observation or a course of empirical antibiotics are controversial in terms of the optimal approach to reduce the confounding impact on prostate cancer screening. This issue was analyzed in patients with a diagnosis of type IV or asymptomatic prostatitis (National Institutes of Health classification) and high prostate specific antigen. MATERIALS AND METHODS We studied 200 men between 50 and 75 years old with a high prostate specific antigen (between 2.5 and 10 ng/dl). Of these patients 98 (49%) had a diagnosis of type IV prostatitis. In a prospective, double-blind trial they were randomized to receive placebo (49 patients, group 1) or 500 mg ciprofloxacin (49 patients, group 2) twice a day for 4 weeks. Prostate specific antigen was determined after treatment and all patients underwent transrectal ultrasound guided biopsy of the prostate. RESULTS In group 1, 29 (59.18%) patients presented with a decrease in prostate specific antigen and 9 (31%) had cancer on biopsy, while in group 2 there were 26 (53.06%) patients with a decrease in prostate specific antigen and 7 (26.9%) with prostate cancer. There was no statistical difference in either group in relation to prostate specific antigen decrease after treatment or the presence of tumor. CONCLUSIONS A considerable number of patients (49%) were diagnosed with type IV prostatitis and high prostate specific antigen in agreement with the current literature. Of the patients 26.9% to 31% presented with a decrease in prostate specific antigen after the use of antibiotic or placebo and harbor cancer as demonstrated on prostate biopsy. Prostate specific antigen decreases do not indicate the absence of prostate cancer.

Nephron‐sparing surgery for renal tumours using selective renal parenchymal clamping

To describe a technical modification that facilitates nephron‐sparing surgery (NSS) for renal tumours, without clamping the renal pedicle or promoting renal surface hypothermia.

Primary Invasive versus Progressive Invasive Transitional Cell Bladder Cancer: Multicentric Study of Overall Survival Rate

Introduction and Objective: When feasible, the treatment for all-invasive bladder cancer is radical cystectomy. The aim of the present study was to analyze the prognostic difference, disease-specific survival rate, of muscle-invasive transitional cell cancer of the bladder (TCCB) for progressive invasive TCCB. Patients and Methods: A retrospective multicentric analysis was performed studying a total of 242 patients who underwent radical cystectomy for invasive TCCB from 1993 to 2005. The patients were divided into two groups: group 1 included 57 patients with progressive invasive TCCB, and group 2 included 185 patients with primary invasive TCCB. Both groups were further divided according to the pathological findings in pT2/3 (muscle and/or perivesical fat invasion), pT4 (adjacent organs/structure invasion), N+ (positive lymphatic nodes) and M+ (distant organ metastasis). Several tests were employed for statistical analysis: χ2, Mann-Whitney, Kaplan-Meier method and Wilcoxon (Breslow) method were used to compare the possible survival curve differences of groups 1 and 2. Multivariated analysis determined by proportional risk regression excluded sex, age and disease stage interferences in the final results. Results: The average time for a superficial TCCB to become muscle-invasive was 37.4 months, and the average number of transurethral resections performed in each patient was 3. The average and median global survival rates were, respectively, 96 and 88 months in group 1 and 98 and 90 months in group 2, without a statistically significant difference (p = 0.0734). The 1-year survival rate was 84.32% in group 1 and 76.54% in group 2. After 3 years of follow-up the survival rate fell to 74.50% in group 1 and to 59.05% in group 2. Finally, the 5-year survival rate was 57.94% in group 1 and 52.24% in group 2. Conclusion: In the present study, patients with primary invasive and progressive invasive TCCB showed a similar 5-year disease-specific survival rate. Pathological stage (pTN, N and M) and patient demography did not interfere with the results.

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.

Digital Rectal Examination Standardization for Inexperienced Hands: Teaching Medical Students

Objectives. To standardize digital rectal examination (DRE) and set how it correlates with the comprehensive evaluation of lower urinary tract symptoms (LUTS). Methods. After scaled standardization of DRE based on fingertips graphical schema: 10 cubic centimeters—cc for each fingertip prostate surface area on DRE, four randomly selected senior medical students examined 48 male patients presenting with LUTS in an outpatient clinical setting, totaling 12 DRE each. Standardized DRE, international prostate symptom score (IPSS), serum PSA, transabdominal ultrasound (US), urodynamic evaluation, and postvoid residue were compared. Results. The mean and median PVs were US—45 and 34.7 cc (5.5 to 155) and DRE—39 and 37.5 cc (15 to 80). Comparing DRE and US by simple linear regression: US PV = 11.93 + 0.85 × (DRE PV); P = 0.0009. Among patients classified as nonobstructed, inconclusive, and obstructed, the US PVs were 29.8, 43.2, and 53.6 cc (P = 0.033), and DRE PVs were 20, 35, and 60 cc (P = 0.026), respectively. Conclusion. This is the first attempt to DRE standardization focusing on teaching-learning process, establishing a linear correlation of DRE and US PVs with only 12 examinations by inexperienced hands, satisfactorily validated in an outpatient clinical setting.

Extra-anatomical transobturator bypass graft for femoral artery involvement by metastatic carcinoma of the penis: report of five patients

ObjectivesSquamous cell carcinoma (SCC) of the penis with inguinal lymph node involvement aggravates prognosis and can cause femoral artery bleeding, hemorrhagic shock and even death. The objective of this study is to describe the use of extra-anatomical transobturator bypass graft for femoral artery involvement by metastatic carcinoma of the penis.Casuistic and methodFive patients with SCC and inguinal lymphatic metastasis involving the femoral vessels, who underwent extra-anatomical arterial bypass through obturator foramen between 1999 and 2007, were reviewed. The surgical technique and the postoperative outcome were described.ResultsAfter extra-anatomical transobturator bypass, all patients presented distal pulses. The mean time of surgery was 6 h. In four patients, a knitted Dacron tube was used; and in one, the contralateral devalvulated greater saphenous vein was used. Concomitantly, two patients underwent mass resection and one patient underwent node dissection 2 weeks after bypass. Two patients chose not to undergo inguinal resection, opting for palliative chemotherapy after the vascular procedure. The average follow-up period was 12 months and four patients have died—three due to pulmonary metastasis, and one due to acute myocardial infarct. No prosthetic complication was identified and no patient presented femoral bleeding.ConclusionsThe use of the transobturator bypass can benefit patients presenting with penile SCC and inguinal lymph nodes metastasis involving the femoral vessels, allowing resection of extensive tumor lesions, as well as avoidance of local complications.

Análisis de satisfacción en varones que presentaban cáncer de próstata localizado tratados con prostatectomía radical o radioterapia: Aspectos Psicológicos y Sociales

Resumen Analisis de satisfaccion en varones que presentaban cancer de prostata localizado tratados con prostatectomia radical o radioterapia: Aspectos psicologicos y sociales Objetivos Analizar la satisfaccion y el impacto del tratamiento en pacientes con cancer de prostata localizado Metodos 180 pacientes con una edad media de 60 anos que fueron divididos en 3 grupos: grupo I – 100 pacientes que se habian sometido a prostatectomia radical retropubica (PRR), grupo II– 40 pacientes sometidos a radioterapia (RT), y grupo III – 40 hombres sanos. Se aplico un cuestionario a los grupos para valorar los cambios fisicos y psicologicos a los 18 meses tras el tratamiento. La herramienta de investigacion se baso en dos cuestionarios; primero: SF-36 (Short Form Health Survey), segundo: FACT-P (Functional Assessment Cancer Therapy) Resultados En el grupo I, el 70% nunca uso compresas, el 5% tuvo incontinencia urinaria total, y el 10% perdidas ocasionales de heces. En el grupo II, 85% no utilizo compresas y el 5% informo haber utilizado dos compresas al dia; 15% reportaron incontinencia fecal. La disfuncion sexual fue similar en ambos grupos: 75% del grupo de cirugia y el 72,5% del de radioterapia informaron de disfuncion erectil. En el grupo de control, 40% informaron de disfuncion erectil; 10% perdidas ocasionales de heces y ninguno tuvo cambios por lo que respecta a la satisfaccion global con el tratamiento. Setenta y ocho por ciento del grupo de PRR y el 77,5% del de RT informaron sentirse felices y satisfechos del tratamiento aceptado o elegido y afirmaron que lo elegirian de nuevo Conclusiones La valoracion de la satisfaccion relacionada con el tratamiento determina la tolerancia al mismo. Los resultados de este estudio no muestran cambios importantes en este aspecto entre ambas modalidades de tratamiento (p>0,05)

Tumor renal con trombo en la vena cava inferior: Manejo quirúrgico y pronóstico

Resumen Objetivos el objetivo del presente estudio fue evaluar las estrategias usadas para el manejo quirurgico del cancer de renal con extension de trombo a la vena cava inferior y evaluar el pronostico del paciente. Metodos Quince pacientes con cancer renal y trombo en la vena cava inferior fueron sometidos a una nefrectomia radical y trombectomia y fueron evaluados de forma retrospectiva. Los pacientes fueron seguidos desde 0 a 36 meses (media de 9,5 meses). La tomografia computada con reconstruccion tridimensional fue usada para definir el nivel del trombo. Resultados La edad media fue de 54 anos, con un rango de entre 16 y 79 anos. El trombo fue clasificado como de nivel I (13,5%), nivel II (40%), nivel III (26,5%) y nivel IV (20%). La cirugia fue llevada a cabo mediante by pass cardiopulmonar en seis casos, tres de los cuales sin esternotomia. Hubo una muerte intraoperatoria (13%) en un paciente que presentaba enfermedad metastasica con un trombo que alcanzaba la auricula derecha. Los pacientes con ganglios positivos o enfermedad metastasica como presentacion inicial tenian peor supervivencia global en la curva de Kaplan-Meier. Ambos, estadiaje tumoral (p = 0,380), y extension del trombo (p = 0,174) no tuvieron relacion con la supervivencia. Conclusiones A pesar de su morbilidad y mortalidad, la nefrectomia radical y la trombectomia deberian ser llevadas a cabo en casos de carcinoma renal con trombo tumoral, porque puede ofrecer la posibilidad de control local de la enfermedad. Los pacientes con ganglios linfaticos y enfermedad metastasica tienen peor pronostico.

Cáncer de próstata: práctica clínica basada en la evidencia

Objectives: Evidence-based medicine allows the best available external clinical evidence from systematic literature rese arch to be graded in order to determine the strength of its recommendation. This guideline aims to assist physicians and healthprofessionalsinclinicaldecisionsrelatedtoprostatecancertreatment,particularlyinurology,clinicaloncologyand radiotherapy. Methods: The publications used as information sources were obtained from structured data search in electronic databa ses, such as CENTRAL (Cochrane Central Register of Controlled Clinical Trials) and MEDLINE (online). Each item of this guideline derived from an original question which was distributed to the participants. Search strategies were prepared to select the studies presenting the best methodological quality, according to predefined levels of evidence. Results: All the recommendations were followed by a level of evidence (LE) and a degree of recommendation (DR). We used a formal ranking system to help the reader to judge the strength of the evidence behind the results published in support of each recommendation. Conclusions: The existing parameters should be viewed as guidelines of conduct. The final trial on which the clinical procedure or treatment plan is most suitable for a particular patient should be done by a physician, who should discuss the available treatment options with the patient according to the diagnosis.

Delivery of a urology online course using moodle versus didactic lectures methods

PURPOSE To subjectively and objectively compare an accessible interactive electronic library using Moodle with lectures for urology teaching of medical students. METHODS Forty consecutive fourth-year medical students and one urology teacher were exposed to two teaching methods (4 weeks each) in the form of problem-based learning: - lectures and - student-centered group discussion based on Moodle (modular object-oriented dynamic learning environment) full time online delivered (24/7) with video surgeries, electronic urology cases and additional basic principles of the disease process. RESULTS All 40 students completed the study. While 30% were moderately dissatisfied with their current knowledge base, online learning course delivery using Moodle was considered superior to the lectures by 86% of the students. The study found the following observations: (1) the increment in learning grades ranged from 7.0 to 9.7 for students in the online Moodle course compared to 4.0-9.6 to didactic lectures; (2) the self-reported student involvement in the online course was characterized as large by over 60%; (3) the teacher-student interaction was described as very frequent (50%) and moderately frequent (50%); and (4) more inquiries and requisitions by students as well as peer assisting were observed from the students using the Moodle platform. CONCLUSIONS The Moodle platform is feasible and effective, enthusing medical students to learn, improving immersion in the urology clinical rotation and encouraging the spontaneous peer assisted learning. Future studies should expand objective evaluations of knowledge acquisition and retention.