Frederico R. Romero

Elective Laparoscopic Partial Nephrectomy in Patients with Tumors >4 cm

OBJECTIVES To assess the perioperative outcomes of elective laparoscopic partial nephrectomy to treat renal tumors in patients with tumor burdens > 4 cm compared with those with tumor burdens of < or = 4 cm. METHODS A retrospective review of medical records was performed for all patients who had undergone laparoscopic partial nephrectomy for renal tumors from January 2000 to March 2005. The preoperative risk factors (ie, sex, age, American Society for Anesthesiologists score), perioperative course (ie, operative time, estimated blood loss, warm ischemia time, intraoperative and postoperative complications, transfusion rate, intraoperative biopsy of surgical margins, length of hospitalization), and pathologic outcomes (ie, tumor stage, type, and grade) were collected and compared between the patients in the 2 cohorts. RESULTS Patients with larger tumors had significantly more complications (37.0% vs 21.8%, P = .039) and a significantly longer hospitalization (4.1 vs 3.0 days, P = .026). For those with malignant tumors > 4 cm compared with those with malignant tumors of < or = 4 cm, the complication rate was 33.3% and 11.6% (P = 0.006) and the length of hospitalization was 4.5 and 3.2 days (P = .055), respectively. No other differences were noted between the 2 groups stratified by tumor size. CONCLUSIONS Laparoscopic partial nephrectomy is an oncologically feasible option for tumor burdens > 4 cm in the greatest dimension to provide a nephron-sparing option for patients in whom individually selected lesions can be isolated.

Laparoscopic partial nephrectomy in obese and non-obese patients: comparison with open surgery.

OBJECTIVES The aim of this study was to compare the perioperative outcomes of open (OPN) and laparoscopic (LPN) partial nephrectomy in obese and non-obese patients. METHODS We analyzed records for a cohort of 56 patients (28 obese and 28 non-obese) who underwent OPN, as well as 112 (56 obese and 56 non-obese) who underwent LPN. RESULTS Obese patients undergoing OPN had increased operative time (285.9 +/- 69.7 versus 195.2 +/- 59.8 minutes), blood loss (484.5 +/- 272.1 versus 391.7 +/- 308.6 mL), clamp time (44.4 +/- 12.8 versus 28.2 +/- 10.5 minutes), intraoperative complications (14.3% versus 1.8%), postoperative complications (35.7% versus 17.9%), and hospital stay (6.4 +/- 2.8 versus 3.2 +/- 2.2 days) than those undergoing LPN. Comparison of obese versus non-obese patients who underwent LPN revealed similar perioperative outcomes, with the exception of a greater blood loss in the obese patient cohort (391.7 +/- 308.6 versus 280.9 +/- 202.1 mL). Finally, in comparing perioperative data among non-obese patients who underwent OPN versus LPN, those who underwent LPN were found to have improved operative times (248.9 +/- 45.0 versus 181.1 +/- 62.4 minutes), less blood loss (412.4 +/- 274.6 versus 280.9 +/- 202.1 mL), fewer intraoperative complications (21.4% versus 1.8%), and shorter length of hospital stay (6.3 +/- 2.8 versus 3.2 +/- 1.6 days). CONCLUSIONS Laparoscopic partial nephrectomy has significantly better perioperative outcomes than open partial nephrectomy in both the obese and non-obese populations.

Indications for percutaneous nephrostomy in patients with obstructive uropathy due to malignant urogenital neoplasias

INTRODUCTION Urogenital neoplasias frequently progress with obstructive uropathy due to local spreading or pelvic metastases. The urinary obstruction must be immediately relieved in order to avoid deterioration in these patients. The percutaneous nephrostomy is a safe and effective method for relief the obstruction; however the indications of such procedures have been questioned in patients with poor prognosis. MATERIALS AND METHODS A retrospective study was performed with 43 patients (29 female and 14 male) with urogenital neoplasias who were undergoing percutaneous nephrostomy during a 54-month period. The median age was 52 years. The primary tumoral site was the uterine cervix in 53.5% of patients, the bladder in 23.3%, the prostate in 11.6% and other sites in 11.6%. RESULTS Postoperative complications occurred in 42.3% of the patients. There was no procedure-related mortality. Thirty-nine per cent of the patients died during the hospitalization period due to advanced neoplasia. The mortality rate was higher in patients with prostate cancer (p = 0.006), in patients over 52 years of age (p = 0.03) and in those who required hemodialysis before the procedure (p = 0.02). Thirty-two per cent of the patients survived long enough to undergo some form of treatment focused on the primary tumor. The survival rate was 40% at 6 months and 24.2% at 12 months. The percentage of the lifetime spent in hospitalization was 17.7%. The survival rate was higher in patients with neoplasia of the uterine cervix (p = 0.007) and in patients with 52 years of age or less (p = 0.008). CONCLUSION Morbidity was high in this patient group; however, the majority of patients could be discharged from hospital and followed at home. Patients under 52 years of age and patients with neoplasia of the uterine cervix benefited most from the percutaneous nephrostomy when compared to patients with hormone therapy-refractory prostate cancer, bladder cancer or over 52 years of age.

Reasons why patients reject digital rectal examination when screening for prostate cancer

OBJECTIVE To evaluate the reasons why patients reject digital rectal examination (DRE) when screening for prostate cancer. METHODS Four hundred and fifty men were prospectively evaluated in a prostate cancer educational program consisting of lectures, PSA testing, and DRE. Patients rejecting DRE were compared with those accepting DRE in regard to epidemic, social and cultural variables. RESULTS DRE was rejected by 8.2% of patients. Refusal rate was not different when patients were stratified by age, prostate cancer family history, school level, family income, and PSA level. Patients with a prior history of DRE had a lower rejection rate than those undergoing DRE for the first time (4.4% vs. 10.4%, p = 0.038). Patients with mild or no lower urinary tract symptoms rejected DRE more frequently than those with moderate or severe symptoms (9.6% vs. 1.4%, p = 0.018). Misconceptions about prostate cancer screening were present in 84.4% of those rejecting DRE vs. 46.9% of controls (p = 0.002); 43.7% expected severe discomfort in the group that rejected DRE vs. 28. 1% in the control group (p = 0.090); fear of finding a cancer during DRE was present in 34.4% of patients that refused DRE vs. 46.9% of controls (p = 0. 121); and 53.1% of patients rejecting DRE responded it was a source of shame vs. 15.6% of patients in the control group (p = 0.019). CONCLUSIONS The main reasons patients reject DRE when attending prostate cancer screening are the lack of lower urinary tract symptoms, misconceptions about prostate cancer screening and shame, especially when undergoing screening for the first time.

The significance of biological, environmental, and social risk factors for prostate cancer in a cohort study in Brazil

PURPOSE To evaluate the significance of several risk factors for prostate cancer in a cohort of Brazilian men. SUBJECTS AND METHODS Men ≥ 40 years-old participating in a prostate cancer screening program between December 2006 and April 2011 in the city of Curitiba, Brazil, were evaluated to determine the prevalence, relative risk (RR) and 95 % CI of prostate cancer according to age, race, ethnicity, family history of prostate cancer, educational level, and history of vasectomy, increased blood pressure, diabetes mellitus, and urethritis. RESULTS In 2121 men included in this study, prostate cancer prevalence was 0.6 % for men between 40-49 years versus 2.0 % (adjusted RR = 2.58), 7.7 % (adjusted RR = 5.76), and 8.4 % (adjusted RR = 4.88) for men 50-59 years, 60-69 years, and ≥ 70 years, respectively (p < 0.05 to all). The prevalence of cancer was 5.1% in blacks versus 3.3 % in whites (adjusted RR = 1.56, p > 0.05); 6.1 % in African descendants, in comparison to 3.0 % in non-African descendants (adjusted RR = 3.17, p < 0.05); 5.1% in men with a positive family history, compared to 2.5 % in those with no family history (adjusted RR = 1.55, p > 0.05); and 4.8 % in participants with incomplete elementary school level or lower, compared to 2.2 % in men with complete elementary school level or higher education (adjusted RR = 1.85, p > 0.05). Men with/without history of vasectomy, increased blood pressure, diabetes, and urethritis had a prostate cancer prevalence of 0.8 %/3.0 % (adjusted RR = 0.23, p > 0.05), 3.8 %/2.2 % (adjusted RR = 1.16, p > 0.05), 3.7 %/2.6 % (adjusted RR = 1.39, p > 0.05), and 2.6 %/2.6 % (adjusted RR = 0.99, p > 0.05), respectively. CONCLUSIONS Risk factors associated with an increased prevalence of prostate cancer in this cohort included increasing age and African ethnicity.

Coexistence of prostate neoplasia in patients undergoing radical cystoprostatectomy due to vesical neoplasia

OBJECTIVE To assess the incidence of bladder carcinoma infiltrating the prostate and prostate adenocarcinoma in patients undergoing radical cystoprostatectomy due to bladder cancer, as well as to assess if the characteristics of the bladder neoplasia influence the prostatic involvement by this neoplasia. MATERIALS AND METHODS We retrospectively assessed 60 male patients, who underwent radical cystoprostatectomy between July 1997 and December 2003. Mean age was 66.7 years (40 and 93 years). The product of radical cystoprostatectomies was checked for involvement of urethra and prostate parenchyma by the primary neoplasia, and for the presence of associated prostate adenocarcinoma. Bladder neoplasia characteristics, such as localization, size, multifocality, association with in situ carcinoma and histological grade, were studied in order to assess the possibility of using such characteristics as predictive factors of prostate infiltration by bladder urothelial carcinoma. RESULTS We observed the presence of 20% of patients with bladder carcinoma infiltrating the prostatic urethra, 23.3% of patients with infiltration of the prostate parenchyma and 28.3% of patients with associate prostate adenocarcinoma, resulting in a total of 55% of patients with prostatic involvement (infiltrative bladder carcinoma and/or adenocarcinoma). We also observed a statistically significant correlation between tumor location in the trigone, the presence of in situ carcinoma and the histological grade of the bladder tumor with prostatic infiltration by the vesical neoplasia. CONCLUSION The coexistence of prostatic neoplasia in patients operated for bladder neoplasia was frequent in our sample (55%). We observed that the prostatic infiltration by bladder tumors occurs more frequently with tumors located in the trigone, with associated in situ carcinoma and with high histological grade. There was no correlation between neoplastic infiltration of prostate and multifocality or size of the bladder tumor in the studied sample.

Paratesticular Sarcomas in Brazil

Purpose: Paratesticular sarcomas are rare and frequently reported as isolated case reports. Studies evaluating the relative frequency of the paratesticular sarcomas are limited, and to the best of our knowledge, this is the first study of paratesticular sarcomas in the Brazilian population. Patients and Methods: Medical records of all patients undergoing treatment for paratesticular sarcomas between 1993 and 2006 were retrieved from the archives of our institution. Results: Complete data from 12 patients (39 ± 23 years, range 13–78) with paratesticular sarcomas were available, which represented 6.7% of all orchiectomies performed for testicular malignancies in the same period. At the time of diagnosis, 3 patients had retroperitoneal spread of the disease, all of which had elevated serum lactic dehydrogenase levels. The remaining 9 patients had normal serum markers. There were 6 rhabdomyosarcomas, 4 leiomyosarcomas, 1 liposarcoma and 1 undifferentiated sarcoma. Median follow-up was 31.4 months. Primary surgical excision by inguinal approach was performed in all cases (radical orchiectomy in 10 and preservation of the testis in 2). Retroperitoneal lymph node dissection was performed in 3 patients and excision of the hemiscrotum in 1. Eight patients received adjuvant chemotherapy. Mean overall survival time was 27.8 ± 6.2 months after orchiectomy. Conclusion: Patients with paratesticular sarcomas are at high risk of disease progression, and systemic relapse remains a significant problem, determining poor prognosis. The high risk of local recurrence demands long-term follow-up, and intraoperative frozen section analysis might be of benefit. Elevated lactic dehydrogenase might also be a marker of retroperitoneal disease and poor prognosis. Improvement in survival requires effective systemic adjuvant therapy.

Refining the laparoscopic retroperitoneal lymph node dissection for testicular cancer.

Since its initial description, the laparoscopic retroperitoneal lymph node dissection has evolved considerably, from a purely diagnostic tool performed to stage germ cell testicular cancer to a therapeutic operation that fully duplicates the open technique. Herein, we describe the current technique employed at our institution, along with illustrations of all surgical steps, and delineate the refinements of the technique over time.

Patient positioning during digital rectal examination of the prostate: preferences, tolerability, and results

PURPOSE To evaluate the preferred position used by Brazilian Urologists to perform DRE, the position that Brazilian patients prefer or think it is less embarrassing to have a DRE, and to evaluate the results of DRE with patients in left lateral decubitus, modified lithotomy, standing-up, or the physician will have them place their elbows on the table and squat down slightly. MATERIALS AND METHODS Brazilian Urologists were contacted by e-mail, and 200 patients answered a questionnaire while undergoing prostate cancer screening. RESULTS The preferred position was modified lithotomy position reported by 63.4% of Urologists, and left lateral position reported by 42.7% of the patients. Total DRE time was lower in the standing-up position. Pain and urinary urgency scores were similar regardless of the position used, and bowel urgency score was higher in patients squatting down. Patients were similar in terms of age and PSA level, but there was a significant difference between the standard deviations of estimated prostate weight in left lateral position. There were no differences in prostate asymmetry, positive DRE, or incomplete palpation of the prostate rates among different examination positions. CONCLUSIONS Despite individual subjective preferences, a faster examination time in the standing-up position, and higher bowel urgency scores in patients with their elbows placed on the table and squatting down slightly, there were similar rates of prostate asymmetry, positive DRE, and incomplete palpation of the prostate, and comparable patient tolerability among different examination techniques.

Metastatic Primitive Neuroectodermal Tumor to the Kidney

Primitive neuroectodermal tumors of the kidney are rare neoplasms that may mimic renal cell carcinoma, especially in the presence of locally advanced or metastatic disease. Although several cases have been identified as primary renal tumors, this is the first report of metastatic spread of a primitive neuroectodermal tumor to the kidney.