José Cury

Retroperitoneal schwannoma: case series and literature review

A 59-year-old white man presented with a long-term his-tory of vague left flank pain. On examination, he had a pal-pable mass and mild tenderness in left flank. Ultrasonogra-phy revealed a 12-cm heterogenous mass in the left adrenaltopography, with cystic and necrotic areas. (Figure 1- A). Acomputed tomography scan confirmed a 10.5 x 11.5 x 9.0-cm enhancing mass with cystic and necrotic central areas dis-placing the left kidney inferolaterally (Figure 1- B). The pa-tient was initially diagnosed as having a left adrenal tumorand underwent a mass excision through a left flank incision,between the 11

Upgrading the Gleason Score in Extended Prostate Biopsy: Implications for Treatment Choice

PURPOSE To determine the incidence of overestimation of Gleason score (GS) in extended prostate biopsy, and consequently circumventing unnecessary aggressive treatment. METHODS AND MATERIALS This is a retrospective study of 464 patients who underwent prostate biopsy and radical prostatectomy between January 2001 and November 2007. The GS from biopsy and radical prostatectomy were compared. The incidence of overestimation of GS in biopsies and tumor volume were studied. Multivariate analysis was applied to find parameters that predict upgrading the GS in prostate biopsy. RESULTS The exact agreement of GS between prostate biopsy and radical prostatectomy occurred in 56.9% of cases. In 29.1% cases it was underestimated, and it was overestimated in 14%. One hundred and six (22.8%) patients received a diagnosis of high GS (8, 9, or 10) in a prostate biopsy. In 29.2% of cases, the definitive Gleason Score was 7 or lower. In cases in which GS was overestimated in the biopsy, tumors were significantly smaller. In multivariate analysis, the total percentage of tumor was the only independent factor in overestimation of GS. Tumors occupying less than 33% of cores had a 5.6-fold greater chance of being overestimated. CONCLUSION In the extended biopsy era and after the International Society of Urological Pathology consensus on GS, almost one third of tumors considered to have high GS at the biopsy may be intermediate-risk cancers. In that condition, tumors are smaller in biopsy. This should be remembered by professionals involved with prostate cancer to avoid overtreatment and undesirable side effects.

Association between integrin expression and prognosis in localized prostate cancer

Integrins and other adhesion molecules are essential for maintaining the epithelial phenotype. Some studies have reported correlations between abnormalities in their expression and carcinogenesis, but their role in prostate cancer is unclear. Our aim was to study the expression profile of integrins in surgical specimens of prostate cancer and associate their expression patterns with patient outcomes.

Analysis of the risk factors for incidental carcinoma of the prostate in patients with benign prostatic hyperplasia

PURPOSE To determine the occurrence of incidental carcinoma of the prostate, its characteristics, and the risk factors for this diagnosis in a group of patients surgically treated for benign prostatic hyperplasia. METHODS The study comprised a retrospective analysis of 218 patients. After surgical treatment, patients with the finding of incidental carcinoma of the prostate were compared to those without this finding. The preoperative variables analyzed were patient age, digital rectal examination, PSA, PSA density, prostate volume, and preoperative prostate biopsy. We also determined the sensitivity, specificity, positive predictive value, and negative predictive value of digital rectal examination and PSA for the finding of incidental carcinoma of the prostate at surgical specimen analysis. RESULTS Thirteen (6.2%) out of the 218 patients presented incidental carcinoma of the prostate. Eight (61.5%) of these tumors were classified as T1a and 5 (38.5%) as T1b. Only advanced age (P = 0.003) and the presence of a suspect digital rectal examination (P = 0. 016) were statistically related to the findings of the surgical specimen analysis. The sensitivity, specificity, positive predictive value, and negative predictive value for the diagnosis of incidental carcinoma were 23.0%, 96.6%, 30.0%, and 95.2% for a suspect digital rectal examination and 85.0%, 34.1%, 7.5%, and 97.2% for a PSA greater than 4.0 ng/mL. The accuracy for these methods was 92.2% and 37.1%, respectively. CONCLUSIONS Advanced age and the presence of a suspect digital rectal examination represent the most important risk factors for the diagnosis of an incidental carcinoma of the prostate. However, the low positive predictive values reflect the weak correlations among these variables.

Prostate cancer detection at rebiopsy after an initial benign diagnosis: results using sextant extended prostate biopsy

INTRODUCTION Sextant prostate biopsy remains the standard technique for the detection of prostate cancer. It is well known that after a diagnosis of small acinar proliferation (ASAP) or high grade prostate intraepithelial neoplasia (HGPIN), the possibility of finding cancer is approximately 40% and 30%, respectively. OBJECTIVE We aim to analyze follow-up biopsies on patients who initially received a benign diagnosis after exclusion of HGPIN and ASAP. METHODS From July 2000 to December 2003, 1177 patients were submitted to sextant extended prostate biopsy in our hospital. The mean patient age was 65.5 years old, and the median number of fragments collected at biopsy was 13. HGPIN and ASAP were excluded from our study. We only considered patients who had a diagnosis of benign at the first biopsy and were subjected to rebiopsies up until May 2005 because of a maintained suspicion of cancer. RESULTS Cancer was initially detected in 524 patients (44.5%), and the diagnosis was benign in 415 (35.3%). Rebiopsy was indicated for 76 of the latter patients (18.3%) because of a persistent suspicion of cancer. Eight cases of adenocarcinoma (10.5%) were detected, six (75%) at the first rebiopsy. Six patients were submitted to radical prostatectomy, and all tumors were considered clinically significant. CONCLUSION Our data indicate that in extended prostate biopsy, the first biopsy detects more cancer, and the first, second, and third rebiopsies after an initial benign diagnosis succeed in finding cancer in 7.9% (6/55), 5.9% (1/15) and 20% (1/4) of patients, respectively.

Long-term Treatment Outcomes Between Surgical Correction and Conservative Management for Penile Fracture: Retrospective Analysis

Purpose Early surgical management is the standard of care for penile fracture. Conservative treatment is an option with recent reports revealing lower success rates. We reviewed the data and long-term outcomes of patients with penile injury submitted to surgical or conservative treatment. Materials and Methods Between January 2004 and February 2012, 42 patients with penile blunt trauma on an erect penis were admitted to our center. We analyzed the following variables: age, etiology, symptoms and signs, diagnostic tests, treatment used, complications and erectile function during the follow-up. One patient was excluded due to missing information. Thirty-five patients underwent surgical repair and 6 patients were submitted to conservative management. Results Mean follow-up was 19.2 months (range, 7 days to 72 months). The mean elapsed time from trauma to surgery was 21.3±12.5 hours. Trauma during sexual relationship was the main cause (80.9%) of penile fracture. Urethral injury was present in five patients submitted to surgery. Dorsal vein injury occurred in three patients with false penile fracture and concomitant spongious corpus lesion was present in three patients. During follow-up, 31 cases (88.6%) of the surgical group and four cases (66.7%) of the conservative group reported sufficient erections for intercourse, with no voiding dysfunction and no penile curvature. However, the remaining two patients (33.3%) from the conservative group developed erectile dysfunction and three patients (50%) developed penile deviation. Conclusions Surgical approach provides excellent functional outcomes and lower complications. Early surgical management of penile fracture provides superior results and conservative approach should be avoided.

Patient's reactions to digital rectal examination of the prostate

OBJECTIVE In recent years, there has been a rise in the incidence of prostate cancer (PCa), and routine screening for the disease has become a well accepted clinical practice. Even with the recognized benefit of this approach, some men are still reluctant to undergo digital rectal examination (DRE). For this reason, we designed the present study in order to better understand mens reactions about this method of screening. The aim was to identify possible drawbacks that could be overcome to increase DRE. MATERIALS AND METHODS We randomly selected 269 patients that were enrolled in an institutional PCa screening program. They were first asked to answer a question regarding their preferred position to undergo the examination. Following this step, they answered a questionnaire in which physical and psychological reactions regarding the DRE were presented. Finally, we used a visual analogical scale (VAS) to analyze the perception of pain during DRE. RESULTS The supine position was preferred for most patients (53.9%). Before DRE, about 59.4% of patients felt that the exam would be acceptable. After DRE, this figure increased to 91.5% (p < 0.001). Mean VAS score during DRE was 1.69 on a scale with a range between 0 and 10 (0 = no pain; 10 = extreme pain). CONCLUSION Patient expectations about DRE were negative before examination and changed significantly following the exam. Pain during examination was negligible, contrary to the prevalent belief. These two findings must be clearly presented to patients in order to improve PCa screening acceptance.

An improved technique for controlling bleeding during simple retropubic prostatectomy: a randomized controlled study

To compare two techniques of open prostatic adenectomy (OPA) for controlling bleeding, as OPA is the most effective surgical method for alleviating obstructive symptoms related to benign prostatic hyperplasia (BPH) but there is always a risk of peri‐operative bleeding.

Is the ability to perform transurethral resection of the prostate influenced by the surgeon's previous experience?

PURPOSE To evaluate the influence of the urologist’s experience on the surgical results and complications of transurethral resection of the prostate (TURP). PATIENTS AND METHODS Sixty-seven patients undergoing transurethral resection of the prostate without the use of a video camera were randomly allocated into three groups according to the urologist’s experience: a urologist having done 25 transurethral resections of the prostate (Group I – 24 patients); a urologist having done 50 transurethral resections of the prostate (Group II – 24 patients); a senior urologist with vast transurethral resection of the prostate experience (Group III – 19 patients). The following were recorded: the weight of resected tissue, the duration of the resection procedure, the volume of irrigation used, the amount of irrigation absorbed and the hemoglobin and sodium levels in the serum during the procedure. RESULTS There were no differences between the groups in the amount of irrigation fluid used per operation, the amount of irrigation fluid absorbed or hematocrit and hemoglobin variation during the procedure. The weight of resected tissue per minute was approximately four times higher in group III than in groups I and II. The mean absorbed irrigation fluid was similar between the groups, with no statistical difference between them (p=0.24). Four patients (6%) presented with TUR syndrome, without a significant difference between the groups. CONCLUSION The senior urologist was capable of resecting four times more tissue per time unit than the more inexperienced surgeons. Therefore, a surgeon’s experience may be important to reduce the risk of secondary TURP due to recurring adenomas or adenomas that were incompletely resected. However, the incidence of complications was the same between the three groups.

The use of immunohistochemistry for diagnosis of prostate cancer

PURPOSE Atypical glands (ASAP) are diagnosed in 5.0% of prostate biopsies, and cancer identification in a rebiopsy is higher than 40.0%. The use of antibodies to mark basal cells is currently a common practice, in order to avoid rebiopsies. There has been no reported study that has reviewed characteristics of radical prostatectomies (RPs) when immunohistochemistry (IHC) was necessary for definitive diagnosis. MATERIALS AND METHODS Out of 4127 biopsies examined from 2004 to 2008, 144 (3.5%) were diagnosed with ASAP. IHC was performed using antibody anti-34ΒE12 and p63. The results of surgical specimens of 27 patients treated by RP after the diagnosis of prostate cancer (PC) was made using IHC (Group 1) were compared with 1040 patients where IHC was not necessary (Group 2). RESULTS IHC helped to diagnose PC in 103 patients (71.5%). Twenty-seven (26.2%) underwent RP. In Group 1, two (7.4%) adenocarcinomas were insignificant versus 29 (2.9%) for Group 2. Patients from Group 1 were younger (p = 0.039), had lower Gleason scores (GS) (p < 0.001), lower percentage of Gleason pattern 4 (p < 0.001), and smaller tumors (p < 0.001). CONCLUSION The use of IHC did not lead to diagnosis of insignificant tumors as illustrated by absence of differences in pathological stage or positive surgical margins in men submitted to RP. Therefore, our results suggest that this modality should be routinely used for a borderline biopsy and ASAP cases.