Second brazilian consensus on the treatment of advanced prostate cancer: a SBOC-SBU-SBRT panel review

ABSTRACT Prostate cancer is the second most common cancer and the fifth leading cause of cancer deaths. In Brazil, it is likewise the second most common cancer among men, second only to non-melanoma skin cancers. The aim of this consensus is to align different opinions and interpretations of the medical literature in a practical and patient-oriented approach. The first Brazilian Consensus on the Treatment of Advanced Prostate Cancer was published in 2017, with the goal of reducing the heterogeneity of therapeutic conduct in Brazilian patients with metastatic prostate cancer. We acknowledge that in Brazil the incorporation of different technologies is a big challenge, especially in the Sistema Único de Saúde (SUS), which allows for the disparity in the options available to patients treated in different institutions. In order to update the recommendations and to make them objective and easily accessible, once more a panel of specialists was formed in order to discuss and elaborate a new Brazilian Consensus on Advanced Prostate Cancer. This Consensus was written through a joint initiative of the Brazilian Society of Clinical Oncology (SBOC) and the Brazilian Society of Urology (SBU) to support the clinical decisions of physicians and other health professionals involved in the care of patients with prostate cancer.

Lower urinary tract symptoms and sexual dysfunction in men with multiple sclerosis

OBJECTIVES: To assess the prevalence and interrelationship between lower urinary tract symptoms and sexual dysfunction in men with multiple sclerosis (MS). METHODS: In a cross-sectional study, we evaluated 41 men (mean age 41.1±9.9 years) with MS from February 2011 to March 2013, who were invited to participate irrespective of the presence of lower urinary tract symptoms or sexual dysfunction. Neurological impairment was assessed with the Expanded Disability Status Scale; lower urinary tract symptoms were evaluated with the International Continence Society male short-form questionnaire, and sexual dysfunction was evaluated with the International Index of Erectile Function. All patients underwent transabdominal urinary tract sonography and urine culture. RESULTS: The mean disease duration was 10.5±7.3 years. Neurological evaluation showed a median Expanded Disability Status Scale score of 3 [2-6]. The median International Continence Society male short-form questionnaire score was 17 [10-25]. The median International Index of Erectile Function score was 29 [15-46]. Twenty-nine patients (74.4%) had sexual dysfunction as defined by an International Index of Erectile Function score <45. Voiding dysfunction and sexual dysfunction increased with the degree of neurological impairment (r=0.02 [0.02 to 0.36] p=0.03 and r=-0.41 [-0.65 to -0.11] p=0.008, respectively). Lower urinary tract symptoms and sexual dysfunction also displayed a significant correlation (r=-0.31 [-0.56 to -0.01] p=0.04). CONCLUSIONS: Most male patients with MS have lower urinary tract symptoms and sexual dysfunction. The severity of the neurological disease is a predictive factor for the occurrence of voiding and sexual dysfunctions.

Prostate cancer in Brazil and Latin America: epidemiology and screening

ABSTRACT Introduction: Prostate cancer is one of the tumors with higher incidence and mortality among men in the World. Epidemiological data are influenced by life expectancy of population, available diagnostic methods, correct collection of data and quality of health services. Screening of the disease is not standardized around the World. Up till now there is no consensus about the risks versus benefits of early detection. There are still missing data about this pathology in Latin America. Objective: to revise current epidemiologic situation and early diagnosis policies of prostate cancer in Brazil and Latin America. Materials and Methods: Medline, Cochrane Library and SciELO databases were reviewed on the subject of epidemiology and screening of prostate cancer. Screening research was performed in websites on national public health organizations and Latin America. Screening recommendations were obtained from those governmental organizations and from Latin American urological societies and compared to the most prominent regulatory agencies and societies of specialists and generalists from around the World. Results: Brazil and Latin America have a special position in relation to incidence and mortality of prostate cancer. In Brazil, it occupies the first position regarding incidence of cancer in men and the second cause of mortality. Central America has the highest rate of mortality of the continent with lower incidence/mortality ratios. Screening recommendations are very distinct, mainly among regulatory organs and urological societies. Conclusion: prostate cancer epidemiology is an important health public topic. Data collection related to incidence and mortality is still precarious, especially in less developed countries. It is necessary to follow-up long term screening studies results in order to conclude its benefits.

Argus T® versus advance® sling for postprostatectomy urinary incontinence: a randomized clinical trial

ABSTRACT Objective To compare the results of two slings, Argus T® and Advance®, for the treatment of postprostatectomy urinary incontinence (PPUI). Material and Methods: From December 2010 to December 2011, 22 patients with PPUI were randomized as follows: 11 (mean age 62.09(±5.30)) underwent treatment with Advance® and 11 (mean age 62.55(±8.54)) with Argus T®. All patients were evaluated preoperatively with urodynamic testing, quality of life questionnaire (ICIQ-SF), voiding diary and 24-hour pad test. Exclusion criteria were: neurological diseases, severe detrusor overactivity and urethral stenosis. Evaluation was performed at 6, 12 and 18 months after the surgery. After implantation of the Argus T® sling, patients who experienced urine leakage equal to or greater than the initial volume underwent adjustment of the sling tension. Results were statistically analyzed using the Fisher’s test, Kolmogorov-Smirnov test, Friedman’s non-parametric test or the Mann-Whitney test. Results Significant improvement of the 24-hour pad test was observed with the Argus T® sling (p=0.038) , With regard to the other parameters, there was no significant difference between the two groups. Removal of the Argus T® device due to perineal pain was performed in one patient (9%). Despite non uniform results, both devices were considered useful to improve quality of life (ICIQ-SF): Argus T® (p=0.018) and Advance® (p=0.017). Conclusions Better results were observed in the 24h pad test and in levels of satisfaction with the Argus T® device. Both slings contributed to improve quality of life (ICIQ-SF), with acceptable side effects.

Open suprapubic versus retropubic prostatectomy in the treatment of benign prostatic hyperplasia during resident's learning curve: a randomized controlled trial

ABSTRACT Purpose: This study compared the suprapubic (SP) versus retropubic (RP) prostatectomy for the treatment of large prostates and evaluated perioperative surgical morbidity and improvement of urinary symptoms. Materials and Methods: In this single centre, prospective, randomised study, 65 consecutive patients with LUTS and surgical indication with prostate volume greater than 75g underwent open prostatectomy to compare the RP (32 patients) versus SP (33 patients) technique. Results: The SP group exhibited a higher incidence of complications (p=0.002). Regarding voiding pattern analysis (IPSS and flowmetry), both were significantly effective compared to pre-treatment baseline. The RP group parameters were significantly better, with higher peak urinary flow (SP: 16.77 versus RP: 23.03mL/s, p=0.008) and a trend of lower IPSS score (SP: 6.67 versus RP 4.14, p=0.06). In a subgroup evaluation of patients with prostate volumes larger than 100g, blood loss was lower in those undergoing SP prostatectomy (p=0.003). Patients with prostates smaller than 100g in the SP group exhibited a higher incidence of low grade late complications (p=0.004). Conclusions: The SP technique was related to a higher incidence of minor complications in the late postoperative period. High volume prostates were associated with increased bleeding when the RP technique was utilized. The RP prostatectomy was associated with higher peak urinary flow and a trend of a lower IPSS Score.

Transanal Minimally Invasive Surgery (TAMIS) to Treat Vesicorectal Fistula: A New Approach

ABSTRACT Purpose: Vesicorectal fistula is one of the most devastating postoperative complications after radical prostatectomy. Definitive treatment is difficult due to morbidity and recurrence. Despite many options, there is not an unanimous accepted approach. This article aimed to report a new minimally invasive approach as an option to reconstructive surgery. Materials and Methods: We report on Transanal Minimally Invasive Surgery (TAMIS) with miniLap devices for instrumentation in a 65 year old patient presenting with vesicorectal fistula after radical prostatectomy. We used Alexis® device for transanal access and 3, 5 and 11 mm triangulated ports for the procedure. The surgical steps were as follows: cystoscopy and implant of guide wire through fistula; patient at jack-knife position; transanal access; Identification of the fistula; dissection; vesical wall closure; injection of fibrin glue in defect; rectal wall closure. Results: The operative time was 240 minutes, with 120 minutes for reconstruction. No perioperative complications or conversion were observed. Hospital stay was two days and catheters were removed at four weeks. No recurrence was observed. Conclusions: This approach has low morbidity and is feasible. The main difficulties consisted in maintaining luminal dilation, instrumental manipulation and suturing.

Giant prostatic hyperplasia: report of a previously asymptomatic man presenting with gross hematuria and hypovolemic shock / Hiperplasia prostática gigante: hematúria macroscópica com choque hipovolêmico em paciente previamente assintomático

Giant prostatic hyperplasia is a rare condition characterized by very high volume benign prostatic enlargement (>500g). Few cases have been reported so far and most of them are associated with severe lower urinary symptoms. We report the first case of asymptomatic giant prostatic hyperplasia in an elderly man who had a 720g prostate adenoma, sudden gross hematuria and hypovolemic shock. The patient was successfully treated with open transvesical prostatectomy and had an uneventful postoperative recovery.

A hiperplasia prostática gigante é uma condição rara caracterizada por aumento benigno prostático significativo, com volume maior que 500g. Existem poucos casos relatados e, em sua maioria deles está associada a sintomas graves do trato urinário inferior. Relatamos aqui o primeiro caso de hiperplasia prostática benigna assintomática em paciente idoso com próstata de 720g, hematúria macroscópica de início súbito e choque hipovolêmico. O paciente foi submetido com sucesso à prostatectomia suprapúbica, sem intercorrências no intra e pós-operatório.

Comparison beetwen open and laparoscopic radical cistectomy in a latin american reference center: perioperative and oncological results

ABSTRACTObjectives:To evaluate the differences of peri-operatory and oncological outcomes between Laparoscopic Radical Cystectomy and Open Radical Cystectomy in our center.Materials and Methods:Overall, 50 patients were included in this non randomized match-pair analysis: 25 patients who had undergone Laparoscopic Radical Cystectomy for invasive bladder cancer (Group-1) and 25 patients with similar characteristics who had undergone Open Radical Cystectomy (Group-2). The patients were operated from January 2005 to December 2012 in a single Institution.Results:Mean operative time for groups 1 and 2 were 350 and 280 minutes (p=0.03) respectively. Mean blood loss was 330 mL for group 1 and 580 mL for group 2 (p=0.04). Intraoperative transfusion rate was 0% and 36% for groups 1 and 2 respectively (p=0.005). Perioperative complication rate was similar between groups. Mean time to oral intake was 2 days for group 1 and 3 days for group 2 (p=0.08). Median hospital stay was 7 days for group 1 and 13 for group 2 (p=0.04). There were no differences in positive surgical margins and overall survival, between groups.Conclusions:In a reference center with pelvic laparoscopic expertise, Laparoscopic Radical Cystectomy may be considered a safe procedure with similar complication rate of Open Radical Cystectomy. Laparoscopic Radical Cystectomy is more time consuming, with reduced bleeding and transfusion rate. Hospital stay seems to be shorter. Oncologically no difference was observed in our mid-term follow-up.

Laparoscopic Treatment of Vesicovaginal Fistula

Introduction Vesicovaginal fistula is a rare disease with great impact for the patients. Laparoscopic repair can be an interesting option in selected cases with goods results but few experience is reported.Objectives Detailed demonstration of our laparoscopic vesicovaginal fistula repair technique. Initial results for ten patients are provided Methods: We treated all cases by the same technique. The surgical steps were: Patient positioning in Lloyd-Davis; Cystoscopy and implant of guide wire on fistula and ureteral catheters (that was removed after procedure); Transperitoneal access and 4 or 5 ports in V or W shape; Opening the bladder wall; Dissection between bladder and vagina for tension free repair; Fistula resection; Vagina repair with Vicryl 3-0; Bladder repair with Vicryl 3-0; Peritoneum/omentum interposition; Positioning 20 Fr urethral catheter.Results Mean age was 50 years. Mean number of fistulas was 1,2. The most common etiology was gynecologic surgery (7). Mean operative time was 2,5 (1,8-3,2) hours. Mean blood loss was 150 (100-200)mL. Complication rate was 10% (one case of urinary infection treated conservatively). Mean hospital stay was 1,2 (1-2) days. Mean return to normal and activities was 20 (15-30) days. For nine patients mean sexual intercourse time was 3 (1-6) months. Success rate after 1 year was 90% (one case of recurrence in patient with previous radiotherapy). Mean follow-up was 36 (12-60) months.Conclusions Laparoscopic repair is feasible, reproducible and present all advantages of minimally invasive surgical procedure. Long term results are similar to conventional open approaches.

Long-term results of a clinical trial comparing isolated vaginal stimulation with combined treatment for women with stress incontinence / Resultados a longo prazo de um estudo clínico comparando estimulação vaginal isolada com tratamento combinado para mulheres com incontinência urinária de esforço

Objective To determine the efficacy of stress urinary incontinence treatments adding pelvic floor muscle training to vaginal electrical stimulation. Methods Forty-eight women with stress urinary incontinence were randomized into 2 groups: 24 underwent isolated vaginal electrical stimulation, and 24 vaginal electrical stimulation plus pelvic floor muscle training. History, physical examination, voiding diary, perineum strength test, and urodynamic study were assessed. Comparisons were made for adherence to treatment, muscle strength improvement, urinary symptoms, and degree of satisfaction immediately, 12 and 96 months after treatment. Results Patients’ degree of satisfaction on vaginal electrical stimulation, and on vaginal electrical stimulation plus pelvic floor muscle training immediately, 12 and 96 months post treatment, were, respectively: 88.2% versus 88.9% 64.7% versus 61.1% and 42.9% versus 28.6% (p>0.05). Conclusion Vaginal electrical stimulation associated to pelvic floor muscle training did not show better results than vaginal electrical stimulation alone. .

Objetivo Determinar a eficácia da eletroestimulação vaginal combinada com treinamento muscular do assoalho pélvico para o tratamento da incontinência urinária de esforço. Métodos Um total de 48 mulheres com incontinência urinária de esforço foi randomizado em 2 grupos, sendo 24 submetidas a eletroestimulação vaginal isolada e 24 a eletroestimulação vaginal e treinamento muscular do assoalho pélvico. Foram avaliados anamnese, exame físico, diário miccional, força perineal e urodinâmica. Compararam-se a adesão ao tratamento, a melhora da força muscular perineal e dos sintomas urinários, e o grau de satisfação imediatamente, 12 e 96 meses após o tratamento. Resultados O grau de satisfação das pacientes no grupo da eletroestimulação isolada e do segundo grupo, imediatamente, com 12 e com 96 meses foi, respectivamente, 88,2% versus 88,9% 64,7% versus 61,1% e 42,9% versus 28,6% (p>0,05). Conclusão A eletroestimulação vaginal associada ao treinamento muscular do assoalho pélvico não foi mais eficaz do que a eletroestimulação isolada. .

Laparoendoscopic single-site nephroureterectomy for morbid obese patients

Since the first laparoendoscopic single-site (LESS) surgery report in urology in 2007 (1) (Rane A e Cadeddu JA), the few reports of LESS extraperitoneal access in the literature were mainly described for less complex cases. The aim of this video is to demonstrate the feasibility of LESS extraperitoneal access in a morbid obese patient presenting a malignant tumor in the renal pelvis. The patient is positioned in 90-degree lateral decubitus. An incision is made below the abdominal skin crease on the left side of the patient and the anterior rectus fascia is vertically incised with manual dissection of the extra/retroperitoneal space. We use an Alexis® retractor to retract the skin maximizing the incision orifice. Three trocars (12, 10 and 5 mm) are inserted through a sigle-port. The pedicle was controlled “en bloc” with a vascular stapler and the bladder cuff treated by the conventional open approach through the same incision. Operative time was 126 minutes with minimal blood loss. The pathology reported high grade papillary urothelial carcinoma in the pelvis (pT3N0M0) and in the ureter (pTa). LESS extraperitoneal nephroureterectomy is feasible and safe, even in more complex cases. It is a good alternative for morbid obese patients and for patients with synchronous distal ureteral tumors for whom an open approach to the bladder cuff is proposed to avoid incisions in two compartments of the abdominal wall.

Extending boundaries in minimally invasive procedures with simultaneous bilateral video endoscopic inguinal lymphadenectomy (veil) for penile cancer: initial Denver health medical center and ABC school of medicine experience and surgical considerations

Purpose To report the surgical technique, procedural outcomes, and feasibility of simultaneous bilateral Video Endoscopic Inguinal Lymphadenectomy (VEIL) in the management of patients with indication for inguinal lymphadenectomy. Surgical Technique: VEIL was applied in all patients using the oncological landmarks (the adductor longus muscle medially, the sartorius muscle laterally and the inguinal ligament superiorly). A 1.5 cm incision was made 2 cm distally to the lower vertex of the femoral triangle. A second incision was made 2 cm proximally and 6 cm medially. Two 10 mm Hasson trocars were inserted in these incisions and the working space was insufflated with CO2 at 5-15 mmHg. The final trocar was placed 2 cm proximally and 6 cm laterally from the first port. Results: A total of 5 VEIL procedures in 3 patients were performed. Two patients underwent simultaneous bilateral VEIL while another underwent simultaneous bilateral surgery with VEIL on the right and open lymphadenectomy on the left side due to an enlarged node. All laparoscopic procedures were successfully performed without conversion and maintained the oncological templates. One lymphocele occurred in the patient who underwent the open procedure. None of the patients presented with skin necrosis after the procedure. Mean number of nodes retrieved was 6 from each side and 2 patients presented with positive inguinal nodes. After one year of follow-up no recurrences were observed. Conclusion: Simultaneous lymphadenectomy procedures are feasible. Improvement in operative and anesthesia time could decrease the morbidity associated with inguinal lymphadenectomy while maintaining the oncological principles. .

Circuncisão por motivos médicos no sistema público de saúde do Brasil: epidemiologia e tendências / Circumcisions for medical reasons in the Brazilian public health system: epidemiology and trends

OBJETIVO: Avaliar os fatores epidemiológicos associados à circuncisão por motivos médicos, tendo por base os dados do sistema público de saúde do Brasil. MÉTODOS: Utilizando os dados públicos do Sistema Único de Saúde de 1984 e 2010, foi realizada busca de admissões hospitalares associadas ao tratamento cirúrgico da fimose. Um total de 668.818 homens admitidos nos hospitais públicos e submetidos à circuncisão foram identificados e incluídos neste estudo. RESULTADOS: A média±desvio padrão de 47,8±13,4 circuncisões/100 mil homens por ano foi realizada no Sistema Único de Saúde por razões médicas. No período de 27 anos em que o procedimento foi avaliado, 1,3% da população masculina necessitou de circuncisão por indicação médica. O número total de circuncisões e a taxa de circuncisões aumentou na infância e decaiu progressivamente depois de 5 anos de idade, voltando a aumentar após a sexta década de vida. Nas regiões do país com melhor acesso aos serviços de saúde, 5,8% dos meninos de 1 a 9 anos de idade necessitaram de circuncisões. De 1992 a 2010, houve 63 mortes associadas à circuncisão, com taxa de mortalidade de 0,013%. CONCLUSÃO: Por meio do presente estudo, foi possível estimar as taxas de circuncisão anuais no Brasil, e uma taxa de mortalidade muito baixa foi associada a esses procedimentos. As circuncisões são realizadas mais frequentemente em crianças na primeira década de vida, e um segundo pico de incidência de doenças no prepúcio ocorre depois da sexta década de vida quando a circuncisão é progressivamente realizada novamente.

OBJECTIVE: To evaluate the epidemiological factors associated to medical circumcision, based on data from the Brazilian public health system. METHODS: Using the Unified Health System public database between 1984 and 2010, hospital admissions associated with surgical treatment of phimosis were searched. A total of 668,818 men admitted to public hospitals who underwent circumcision were identified and included in the present study. RESULTS: A mean±standard deviation of 47.8±13.4 circumcisions/100,000 men/year was performed through the Unified Health System for medical reasons. During the 27-year period evaluated, 1.3% of the male population required circumcision for medical reasons. Total number of circumcisions and circumcision rate increased in childhood, declined progressively after 5 years of age and rose again progressively after the sixth decade of life. In the regions of the country with better access to healthcare, 5.8% of boys aged 1 to 9 years old required circumcisions. From 1992 to 2010 there were 63 deaths associated with circumcisions (mortality rate of 0.013%). CONCLUSION: In conclusion, yearly circumcision rates could be estimated in Brazil, and a very low mortality rate was associated with this procedures. Circumcision is mostly performed in children in the first decade of life and a second peak of incidence of penile foreskin diseases occurs after the sixth decade of life, when circumcision is progressively performed again.

Influence of strict sperm morphology on the results of classic in vitro fertilization

OBJECTIVE: To determine the influence of the concentration of oval spermatozoa according to the strict morphology criterion in men with normal sperm concentration following the World Health Organization criteria on the results of classic IVF. MATERIALS AND METHODS: Based on review of patient charts, this study included infertile couples presenting with female causes for infertility or unexplained infertility, in whom men presented with normal spermogram values for sperm concentration, sperm motility, volume of ejaculate and total sperm count after semen processing greater than 20 million. Based on the value obtained in strict sperm morphology, patients were divided into three groups: in Group A, patients with values between 0% and 4%; in group B, between 5% and 14%, and in group C, patients with sperm morphology greater than 14%. The outcomes analyzed were oocyte fertilization rate, biochemical pregnancy rate, clinical pregnancy rate and rate of liveborns. RESULTS: A total of 244 cases met the inclusion criteria, 27 of them in group A, 165 in group B, and 52 in group C. The mean fertilization rate and the rate of liveborns were, respectively: 71.9% and 33.3% in group A; 80.9% and 24.2% in group B, and 78.8% and 28.8% in group C. There was no statistical difference among the groups in any of the outcomes analyzed. CONCLUSION: The values of strict sperm morphology, as proposed by Kruger and adopted by the World Health Organization, had no influence on the results of classic in vitro fertilization in the studied sample.

Testicular torsion and weather conditions: analysis of 21,289 cases in Brazil

PURPOSE: The hypothesis of association between testicular torsion and hyperactive cremasteric reflex, worsened by cold weather, has not been proved. Thirteen studies in the literature evaluated this issue, with inconclusive results. The aim of the present study was to evaluate the seasonality of testicular torsion in a large subset of patients surgically treated in Brazil, and additionally to estimate the incidence of testicular torsion. MATERIALS AND METHODS: Brazilian Public Health System Database was assessed from 1992-2010 to evaluate hospital admissions associated with treatment of testicular torsion. Average monthly temperature between 1992-2010 was calculated for each region. RESULTS: We identified 21,289 hospital admissions for treatment of testicular torsion. There was a higher number of testicular torsions during colder months (p = 0.002). To estimate the incidence of testicular torsion, we have related our findings to data from the last Brazilian census (2010). In 2010, testicular torsion occurred in 1.4:100,000 men in Brazil. CONCLUSIONS:Testicular torsion occurred at an annual incidence of approximately 1.4:100,000 men in Brazil in 2010. Seasonal variations do occur, with a significant increase of events during winter. Our findings support the theory of etiological role of cold weather to the occurrence of testicular torsion. Strategies to prevent these events can be based on these findings.

Steinstrasse predictive factors and outcomes after extracorporeal shockwave lithotripsy

PURPOSE: Urinary stone disease is a common medical problem. Extracorporeal shockwave lithotripsy (SWL) has been applied with high success and low complication rates. Steinstrasse (SS) is a possible complication after SWL. The aim of the present study was to prospectively evaluate the factors and outcomes associated with SS after SWL. MATERIALS AND METHODS: We have prospectively evaluated 265 SWL sessions (2005-2009). Two lithotriptors were used randomly: Siemens Lithostar and Dornier Compact S. All patients had imaging exams after 30 and 90 days or according to symptoms. RESULTS: SS was observed in 14 (5.3 percent) out of 265 SWL procedures (n = 175 patients, 51.5 percent women/48.5 percent men, mean ± SD age = 46.3 ± 15.5 years). SS was more common after SWL for pelviureteral calculi rather than caliceal stones (p = 0.036). There was a trend toward more occurrences of SS after SWL for larger stone area (> 200 mm², p = 0.072). Preoperative ureteral stent didn't prevent SS. SWL machine, intensity, number of pulses and frequency were not associated with SS formation. Post-SWL pain, fever and gravel elimination were factors associated with SS (p = 0.021; p = 0.011; p = 0.078). When SS occurred, treatment modalities included Medical Expulsive Therapy (MET), ureteroscopy and SWL. CONCLUSIONS: Steinstrasse is an uncommon event after SWL and seems to occur more frequently with larger pelviureteral stones. Impaction of stones is more frequent in the middle ureter. All patients should be followed after SWL, but SS should be specially suspected if there is macroscopic gravel elimination, flank pain and/or fever. When SS occurs, treatment should be promptly introduced, including medical expulsive therapy, surgical approach or SWL in selected cases. Further prospective studies are awaited to evaluated preventive measures for SS occurrence.

Por que os pacientes são encaminhados ao urologista?: análise crítica dos encaminhamentos no município de São Bernardo do Campo / Why are patients referred to urological consultation?: critical analysis of referrals in São Bernardo do Campo

Introdução: A elevada demanda por atendimento urológico em São Bernardo do Campo gera uma espera para que pacientes sejam atendidos pelo urologista, após terem sido encaminhados pelo clínico. Objetivos: Avaliar condições associadas a encaminhamentos aos ambulatórios de Urologia da Faculdade de Medicina do ABC, no município. Métodos: Foram avaliados 106 relatórios de encaminhamento de pacientes para consulta urológica em São Bernardo do Campo, entre dezembro de 2009 e março de 2010, e sua correlação com os dados obtidos em consulta urológica. Resultados: Os principais motivos para encaminhamento urológico foram o exame da próstata (29,2%) e a urolitíase (22,6%). Houve concordância entre o motivo referido e o diagnóstico após consulta urológica em 55,7% dos casos, discordância em 20,8% e ausência de menção do motivo da consulta em 23,6%. Observouse que 56,6% dos pacientes não levaram os exames mínimos necessários à consulta com o especialista. Dos encaminhamentos por disfunções sexuais, 17% referiam o real motivo para consulta. Houve concordância em 100% dos encaminhamentos de pacientes oncológicos. Médicos formados há mais de 30 anos encaminharam pacientes mais precisamente. Conclusão: A imprecisão no encaminhamento aos ambulatórios de Urologia e a inexistência de protocolos para tal contribuem para a morosidade do sistema. Propõe-se o uso de protocolos para solicitar exames, previamente ao encaminhamento ao urologista, e o reforço quanto à importância da precisão do encaminhamento junto aos médicos responsáveis pela atenção primária.

Introduction: High demand to urological care in São Bernardo do Campo leads to a delay from the primary care physician referral until urologist?sconsultation. Objetives: To evaluate conditions associated with referrals to the Urology outpatient clinic from Faculdade de Medicina do ABC in thismunicipality. Methods: We analyzed 106 urological referral reports of patients in São Bernardo do Campo, from December 2009 to March 2010, and compared to data obtained after urologic consultation. Results: The main reasons for urological referral were prostatic check-up (29.2%) and urolithiasis (22.6%). There was similarity between referral report and diagnoses after urological consultation in 55.7% of the cases, discordance in 20.8%, while no reason was informed in 23.6% of referral reports; 56.6% of the pacients did not bring their exams to specialist?s consultation. Referrals for sexual disfunction held the real reason for consultation in 17% of the cases, while concordance was found in every referral for oncologyc disease. Moreover, doctors graduated for more than 30 years usually referred pacients more precisely. Conclusion: The lack of accuracy in patient's referral to urological clinics and the absence of referral protocols contribute to the delay in the health care system. We recommend the adoption of guidelines to aid requesting subsidiary exams before referring patients to the urologist as well as the reinforcement towards the need of a proper referral by primary care physicians.