Incidencia de la disfunción sexual eréctil asociada a la prostatectomía radical abierta y laparoscópica

Introducción: la dificultad o imposibilidad de lograr una actividad sexual satisfactoria a pesar de estar presentes las condiciones adecuadas para su desarrollo exitoso, se conoce como disfunción sexual. Si la dificultad consiste en alcanzar y mantener la erección necesaria para una penetración se produce una disfunción eréctil. Objetivo: describir la disfunción eréctil en los pacientes con cáncer de próstata sometidos a prostatectomía radical por vía abierta vs. laparoscópica, en el Hospital Universitario Comandante Faustino Pérez Hernández, de Matanzas, entre enero de 2010 y enero de 2020. Materiales y métodos: se realizó un estudio longitudinal retrospectivo en los 40 pacientes que acudieron a la Consulta Provincial de Cáncer de Próstata y les fue realizado cirugía radical, entre enero de 2010 y enero de 2020. Resultados: el 52,5 % de los pacientes tienen un promedio de edad entre 65 y 74 años. Un índice de comorbilidad de Charlson de 3 a 5 puntos predominó en un 75 % de la muestra. En la vía laparoscópica, todos los casos presentaron disfunción eréctil, siendo severa en el 50 % de ellos. El 22,5 % del total no la tuvieron, representando un 30 % de los operados por cirugía abierta. Conclusiones: la prostatectomía radical continúa siendo considerada uno de los tratamientos de elección del cáncer de próstata órgano-confinado. La causa principal de la presencia de disfunción eréctil se atribuye al procedimiento quirúrgico; la edad avanzada puede contribuir a empeorar el pronóstico y las enfermedades coadyuvantes. Son heterogéneos los resultados en la esfera sexual de la prostatectomía radical laparoscópica y la prostatectomía radical abierta, comparados con la bibliografía internacional.

Introduction: the difficulty or impossibility of achieving a successful sexual activity despite being present the adequate conditions for its successful development is known as sexual dysfunction. If the difficulty consists in reaching and maintaining the erection necessary for a penetration, erectile dysfunction occurs. Objective: to describe the erectile dysfunction in patients with prostate cancer undergoing open vs. laparoscopic radical prostatectomy, in the Comandante Faustino Perez Hernandez University Hospital, of Matanzas, between January 2010 and January 2020. Materials and methods: a longitudinal retrospective study was carried out in the 40 patients who attended Prostate Cancer Provincial Consultation and underwent radical surgery between January 2010 and January 2020. Results: 52.5% of the patients were aged between 65 and 74 on average. A Charlson comorbidity index of 3 to 5 points prevailed in 75% of the sample. In the laparoscopic pathway all the cases presented erectile dysfunction, being severe in 50% of them. 22.5% of the total did not have it, representing 30% of those operated by open surgery. Conclusions: radical prostatectomy continues to be considered one of the treatments of choice for organ-confined prostate cancer. The main cause of the presence of erectile dysfunction is attributed to the surgical procedure; advanced age can contribute to a worse prognosis and adjuvant diseases. The results in the sexual sphere of laparoscopic radical prostatectomy and open radical prostatectomy are heterogeneous compared with the international bibliography.

S100B level and cognitive dysfunction after robotic-assisted laparoscopic radical prostatectomy procedures: a prospective observational study / Nível de S100B e disfunção cognitiva após prostatectomia radical laparoscópica assistida por robô: estudo observacional prospectivo

Abstract Background: The present study investigated the association between Postoperative Cognitive Dysfunction (POCD) and increased serum S100B level after Robotic-Assisted Laparoscopic Radical Prostatectomy (RALRP). Methods: The study included 82 consecutive patients who underwent RALRP. Serum S100B levels were determined preoperatively, after anesthesia induction, and at 30 minutes and 24 hours postoperatively. Cognitive function was assessed using neuropsychological testing preoperatively, and at 7 days and 3 months postoperatively. Results: Twenty four patients (29%) exhibited POCD 7 days after surgery, and 9 (11%) at 3 months after surgery. Serum S100B levels were significantly increased at postoperative 30 minutes and 24 hours in patients displaying POCD at postoperative 7 days (p = 0.0001 for both) and 3 months (p = 0.001 for both) compared to patients without POCD. Duration of anesthesia was also significantly longer in patients with POCD at 7 days and 3 months after surgery compared with patients without POCD (p = 0.012, p = 0.001, respectively), as was duration of Trendelenburg (p = 0.025, p = 0.002, respectively). Composite Z score in tests performed on day 7 were significantly correlated with duration of Trendelenburg and duration of anesthesia (p = 0.0001 for both). Conclusions: S100B increases after RALRP and this increase is associated with POCD development. Duration of Trendelenburg position and anesthesia contribute to the development of POCD. Trial Registry Number: Clinicaltrials.gov (N° NCT03018522).

Resumo Introdução: O presente estudo investigou a associação entre Disfunção Cognitiva Pós-Operatória (DCPO) e aumento do nível sérico de S100B após Prostatectomia Radical Laparoscópica Assistida por Robô (PRLAR). Métodos: O estudo incluiu 82 pacientes consecutivos submetidos à PRLAR. Os níveis séricos de S100B foram determinados: no pré-operatório, após indução anestésica, e aos 30 minutos e 24 horas do pós-operatório. A função cognitiva foi avaliada com testes neuropsicológicos no pré-operatório, no 7° dia pós-operatório (7 DPO) e aos 3 meses após a cirurgia (3 MPO). Resultados: Observamos 24 pacientes (29%) com DCPO no 7 DPO e 9 pacientes com DCPO (11%) após 3 meses da cirurgia. Quando comparados com os pacientes sem DCPO, os níveis séricos de S100B estavam significantemente aumentados aos 30 minutos e às 24 horas do pós-operatório nos pacientes que apresentaram DCPO no 7 DPO (p= 0,0001 para os dois momentos) e 3 meses após a cirurgia (p= 0,001 para os dois momentos) A duração anestésica também foi significantemente maior em pacientes com DCPO no 7 DPO e 3 MPO em comparação com pacientes sem DCPO (p= 0,012, p= 0,001, respectivamente), assim como a duração da posição de Trendelenburg (p= 0,025, p= 0,002, respectivamente). O escore Z composto nos testes realizados no 7 DPO foi significantemente correlacionado com a duração da posição de Trendelenburg e a duração da anestesia (p= 0,0001 para ambos). Conclusão: S100B aumenta após PRLAR e o aumento está associado ao desenvolvimento de DCPO. A duração anestésica e o tempo decorrido em posição de Trendelenburg contribuem para o desenvolvimento de DCPO. Número de registro do estudo: Clinicaltrials.gov (n° NCT03018522)

Análise da custo-efetividade do rastreamento e das modalidades terapêuticas do câncer de próstata / Cost-effectiveness analysis of prostate cancer screening and therapeutic modalities

O câncer de próstata é a segunda neoplasia maligna mais comum no mundo. Apesar do emprego do rastreamento populacional com o uso do PSA (Prostate specific antigen) ter proporcionado diminuição na mortalidade pela doença, sua validade tem sido questionada em alguns grandes estudos. A da falta de políticas de prevenção efetivas e de dados brasileiros sobre o comportamento do câncer de próstata desfavorecem a análise sobre a realidade dessa população. As opções terapêuticas curativas para o câncer de próstata em seus estágios iniciais incluem a prostatectomia radical, radioterapia, ablação prostática com ultrassom de alta frequência (HIFU), todas elas relacionadas a complicações e sequelas funcionais, as quais podem ser diminuídas com o uso de técnicas minimamente invasivas, porém acarretando impacto no aumento de custos das fontes pagadoras. O presente estudo analisa a relação custoefetividade de um programa de rastreamento populacional de câncer de próstata na cidade de São Paulo (SP ­ Brasil), bem como custo-efetividade das cirurgias (aberta e robótica); a relação de custo minimização entre radioterapia e terapia ablativa (HIFU), e os custos de hormonioterapia, quimioterapia e outras terapias sistêmicas paliativas realizadas no A.C.Camargo Cancer Center entre os anos de 2013 e 2018. A análise dos resultados demonstrou que o rastreamento populacional e a prostatectomia radical robótica são custo-efetivas em relação ao não rastreamento e à prostatectomia aberta, segundo os padrões de cálculo estabelecidos pela OMS (AU)

Prostate cancer is the second most common malignancy in the world. Despite of prostate specific antigen (PSA) based population screening had shown mortality reduction, its validity has been questioned in some large studies. The lack of effective Brazilian prevention policies and data on prostate cancer behavior undermine a population's reality analysis. Curative treatment options for initial prostate cancer include radical prostatectomy, radiotherapy and high frequency ultrasound prostate ablation (HIFU), all of them related to complications and functional sequelae, which can be diminished by using minimally invasive techniques, however, affecting the rising costs of paying sources. This study analyzes the cost-effectiveness of a prostate cancer population screening program in the city of São Paulo (SP - Brazil), as well as the cost-effectiveness of surgeries (open and robotic approaches); a minimized-cost relationship between radiotherapy and ablative therapy (HIFU), and general costs of hormone therapy, chemotherapy and other palliative systemic therapies performed at the A.C.Camargo Cancer Center between 2013 and 2018. Results demonstrated that PSA based population screening and Robotic radical prostatectomy are cost-effective compared to not-screening population and open prostatectomy, according to WHO calculation standards (AU)

¿Qué hacer ante un pT0 en cáncer de próstata? Revisión a propósito de un caso / What to do with a pT0 in Prostate Cancer? Review of the Literature and Case Report

Introducción y Objetivos El cáncer de próstata es la segunda causa de mortalidad por cáncer en hombres en Colombia y en el mundo. El efecto "vanishing" en cáncer de próstata, es un fenómeno poco frecuente que se define como la ausencia de tumor en el estudio histológico postquirúrgico de pacientes llevados a prostatectomía radical como manejo curativo diagnóstico previo confirmado por biopsia o RTUP. Su incidencia en diferentes series llega hasta el 0,86%, por lo cual existen pocos estudios aleatorizados al respecto y aún no es clara la conducta con ese tipo de tumores. Reportamos un caso de un paciente con cáncer de próstata pT0 y realizamos una revisión de la literatura respecto del seguimiento y manejo que se deberían seguir al enfrentarnos a ese tipo de tumor. Métodos y Materiales Revisión de la literatura y reporte de caso clínico. Reporte de Caso Hombre de 58 años sintomático urinario, con PSA elevado por lo que se realizó biopsia transrectal de próstata, con resultado de adenocarcinoma de próstata confirmado por inmunohistoquímica. Al realizarse la prostatectomía radical no se encuentra tumor en la patología. En la literatura se encuentran factores asociados con la presencia del tumor cuando hay RTUP previa y uso de hormonoterapia neoadyuvante en el contexto de tumores de bajo volumen. A pesar de no encontrarse tumor en la patología, está descrita la recaída bioquímica y progresión clínica de esos tumores, por lo que debe realizarse el seguimiento usual para esa patología. Conclusiones El hallazgo de pT0 en cáncer de próstata, aunque poco frecuente, demanda una guía de manejo Proponemos la revisión de la patología con el protocolo descrito para reducir los falsos positivos y el seguimiento usual con los pasos estandarizados en las guías internacionales.

Introduction and Objectives Prostate cancer is the second leading cause of death related with cancer in men in Colombia and the world. "Vanishing" phenomenon in prostate cáncer is a rare event, where the post-surgical histologic review in patiets that underwent radical prostatectomy is negative, all of them with previous diagnosis of CaP by biopsy or TUR. The incidence of CaP in different series reaches 0.86%, whereby there are few randomized studies and the management and follow up of this type of tumors is not clear. In this article we report a case of a pT0 prostate cancer patient. We perform a systematic review of the literature to determine the medical behavior and medical follow up in cases presenting with pT0 prostate cancer. Materials and Methods Review of the literature & case report. Results Patient of 58 years old with medical history of recent progressive LUTS and high PSA levels that underwent a trans-rectal prostate biopsy with report of adenocarcinoma, that were confirmed by immunohistochemistry. In the pathology report after the radical prostatectomy no tumor cells were found. In the literature, there is reference about factors associated with pT0 prostate cancer in patients with previous RTUP and that were taken to hormonal coadjutant therapy in lesser degree tumors. Despite the absent of cancer findings in the pathology, it is well described biochemistry relapses and clinical progression of this tumors; usual protocol follow up must be made. Conclusion In patients with pT0 prostate cancer, even though to be a rare finding, must be studied and follow up with the steps mentioned above with the aim to reduce the false positive cases. Also the follow-ups steps must fully meet the requirements of standardized protocols guidelines.

Prostatectomía radical y calidad de vida: resultados en un centro de alta complejidad / Radical Prostatectomy and Quality of Life: Results in a Center of High Complexity

La prostatectomía radical (PR), es el procedimiento quirúrgico de elección cuando se trata de dar manejo con intención curativa al cáncer de próstata localizado. Fue el primer tratamiento quirúrgico descrito para el cáncer de próstata y ha sido realizado por más de 100 años. Tiene como ventaja importante frente a la radioterapia el permitir la estadificación precisa con el estudio patológico del espécimen quirúrgico; sin embargo, tiene algunas desventajas como la necesidad de hospitalización y recuperación post operatoria intrahospitalaria, la posibilidad de una resección incompleta y el riesgo de incontinencia urinaria y de disfunción eréctil, entre otras.1­3 La frecuencia de complicaciones y secuelas descrita en la literatura es variable, con amplios rangos según las diferentes series y autores disponibles.

Radical prostatectomy (PR) is the surgical procedure of choice when it comes to managing localized prostate cancer with curative intent. It was the first surgical treatment described for prostate cancer and has been performed for over 100 years. However, it has some disadvantages such as the need for hospitalization and in-hospital post-operative recovery, the possibility of incomplete resection and the risk of urinary incontinence and erectile dysfunction, among others.1-3 The frequency of complications and sequelae described in the literature is variable, with wide ranges according to the different series and authors available.

Entrenamiento de la musculatura del piso pélvico como parte del tratamiento para la disfunción eréctil después de prostatectomía radical: serie de casos, experiencia en un centro médico de alta complejidad / Pelvic floor muscle training as treatment for erectile dysfunction after radical prostatectomy: Case series, and experience in a high complexity hospital

Introducción La disfunción eréctil se ha reconocido como una complicación de la prostatectomía radical. El entrenamiento de los músculos del piso pélvico puede ser una opción terapéutica, sin embargo, existe poca evidencia sobre el efecto del entrenamiento en la función eréctil. Objetivo Describir el efecto de la rehabilitación de la musculatura de piso pélvico en la función eréctil en hombres > 40 años con disfunción eréctil después de prostatectomía radical. Métodos Estudio retrospectivo basado en la revisión de historias clínicas de pacientes con disfunción eréctil después de prostatectomía radical, sometidos a un protocolo de rehabilitación con ejercicios de músculos de piso pélvico, biofeedback y electroestimulación. La función eréctil se evaluó por el índice internacional de la función eréctil (IIEF-5). La presión de los elevadores del ano se midió con el equipo Myomed134 y la fuerza muscular con la escala modificada de Oxford. Resultados Se incluyeron 13 hombres con edad promedio de 63,2 ± 8 años, sin historia de consumo de tabaco y con índice de masa corporal de 24,9 ± 2,6 kg/m2. Antes de la intervención, se encontraron 10 casos con disfunción severa y 3 de leve a moderada, según el cuestionario IIEF-5. Después de la intervención, se encontró mejoría en 11 pacientes en la función eréctil: 7 con mejoría completa, 4 con disfunción eréctil leve. En 2 casos no se presentó mejoría. Conclusión El estudio muestra que el efecto del entrenamiento de la musculatura de piso pélvico es beneficioso en la recuperación de la función eréctil después de prostatectomía radical.

Introduction Erectile dysfunction has been recognised as a complication of radical prostatectomy. The training of the pelvic floor muscles can be a therapeutic option for these patients; however, there is little evidence on the effect of this training in erectile function. Objective To describe the effect of physical rehabilitation of pelvic floor muscles in men over 40 years old with erectile dysfunction as a result of radical prostatectomy. Methods A retrospective study was conducted based on a review of medical records of patients with erectile dysfunction after radical prostatectomy and following a rehabilitation protocol including pelvic floor muscles exercises, biofeedback, and electrostimulation. Erectile function was assessed by the modified Oxford scale, the international index of erectile function (IIEF-5), and the pressure, in cmH2O, of the levator ani muscle. Results The study included 13 men with a mean age of 63.2 ± 8.0 years. None of them had a smoking history, and the mean body mass index was 24.9 ± 2.6. Before the intervention, there were 10 cases with severe dysfunction according to the IIEF-5, 3 cases with mild to moderate dysfunction. After the intervention, the erectile function improved in 11 patients (7 with complete improvement and 4 with mild erectile dysfunction). Two patients showed no improvement. Conclusion The study suggests that the effect of the pelvic floor muscles training is beneficial in the recovery of erectile function after radical prostatectomy.

Rol de la cirugía en cáncer de próstata oligometastásico / Surgery in Oligometastatic Prostate Cancer

Es indudable que el cáncer de próstata es objeto de permanente investigación dada su alta prevalencia y morbimortalidad asociada. Sin embargo, el cáncer oligometastásico reconocido como una entidad aparte, es un tópico ha ido ganando interés durante los últimos años. Se ha propuesto que el cáncer oligometastásico podría ser considerado una etapa previa al cáncer metastásico avanzado, dada su evolución más indolente, permitiendo plantear nuevos cursos de tratamiento y nuevos enfrentamientos terapéuticos, que los utilizados en etapas más complejas. En este trabajo se realizó una revisión no-sistemática de la literatura actual respecto al rol de la cirugía en el cáncer oligometastásico, para esto se utilizaron las bases de datos Pubmed y MGH Treadwell Library, con limites dentro de los últimos 10 años además de publicaciones en las revistas Journal of Urology y European Urology. Se revisaron bases de datos chilenas reportadas en Datos Estadísticos e Información en Salud (DEIS). Históricamente, el tratamiento estándar para cáncer de próstata metastásico ha sido el tratamiento paliativo a largo plazo con terapia de deprivación de andrógenos (ADT). Sin embargo, basado en el comportamiento particular que presentaría el cáncer de próstata oligometastásico, se han realizado estudios en los que la cirugía cada vez juega un rol más protagónico. Los nuevos datos son altamente sugerentes que la cirugía podría representar una modalidad terapéutica útil en el manejo de cáncer de próstata oligometastásico. Sin embargo, aún es necesario definir protocolos respecto al manejo de esta entidad y se requieren mayores estudios para definir cuál sería la mejor forma de lograr resultados o si presentaría beneficio asociar el manejo quirúrgico a otras terapias complementarias. AU

There is no doubt that prostate cancer is subject of permanent research because of its high prevalence and associated morbidity and mortality. However, oligometastatic cancer as a particular entity, is a topic that has been gaining interest over the past few years. It has been proposed that oligometastatic cancer could be considered a stage prior to advanced metastatic cancer, given its more indolent course, allowing to consider if there would be benefits in new therapeutic approaches than those used in more advanced stages. In this paper, we performed a non-systematic review of the current literature regarding the role of surgery in oligometastatic cancer, using Pubmed and MGH Treadwell Library databases with limits within the last 10 years. And also, publications in journals as "European Urology" and "Journal of Urology". Chilean databases reported in "Datos Estadísticos e Información en Salud" (DEIS) were reviewed. Historically, the standard treatment for metastatic prostate cancer has been long-term palliative treatment with androgen deprivation therapy (ADT). However, based on the particular behavior of oligometastatic prostate cancer, studies have been performed in which surgical treatment is playing a more prominent role. The new data is highly suggestive that surgery could represent a useful therapeutic modality in the management of prostate cancer. However, it is still necessary to define protocols regarding the management of this entity and more studies are required to achieve this and define what would be the best way to accomplish results or whether it would be beneficial to associate surgical management with other complementary therapies.AU

Evidencia actual en prostatectomía radical robótica en pacientes con cirugía prostática previa / Current evidence in robot-assisted radical prostatectomy with previous prostate surgery

INTRODUCCIÓN: El cáncer de próstata es la segunda causa de muerte en hombres en Chile. La prostatectomía radical robo-asistida (RARP) se ha posicionado progresivamente como el tratamiento de elección en cáncer localizado pero se ha cuestionado tradicionalmente en pacientes con cirugía prostática previa, recomendación que pareciera no tener sustento en evidencia. OBJETIVO: Describir la evidencia actualmente disponible referente a resultados oncológicos y funcionales de prostatectomía radical robo-asistida en pacientes con cirugía prostática previa por hiperplasia prostática. Método: Revisión de la literatura publicada en la base de datos PUBMED entre el 1 de Enero del año 2008 hasta el 31 de Diciembre del año 2017. Se incluyen artículos que reporten resultados de pacientes con RARP tras cirugía prostática previa en cualquier modalidad sin límite de edad. RESULTADOS: Se encontraron un total de 1813 artículos. El total de estudios evaluados fue de 9 que en conjunto suman 297 pacientes. 7 artículos corresponden a series de casos y 2 a cohortes. Existen algunos artículos que informan mayor tiempo quirúrgico, sangrado intraoperatorio y porcentaje de márgenes positivos, sin embargo, el perfil de complicaciones perioperatorias y los resultados funcionales a largo plazo parecen no diferir de forma significativa respecto a los encontrados en pacientes sin cirugía prostática previa.

INTRODUCTION: Prostate cancer is the second leading cause of death in men in Chile. Robo-assisted radical prostatectomy has been progressively positioned as the treatment of choice in localized cancer but has been traditionally questioned in patients with previous prostate surgery, a recommendation that seems to have no support in evidence. OBJECTIVE: To describe the currently available evidence regarding oncological and functional results of robo-assisted radical prostatectomy in patients with previous prostatic surgery for prostatic benign hyperplasia. METHOD: Review of the literature published in the PUBMED database between January 1, 2008 and December 31, 2017. Articles that report results of patients with RARP after previous prostate surgery in any modality are included with no age limit. RESULTS: A total of 1813 articles were found. The total number of studies evaluated was 9, which together total 297 patients. 7 articles correspond to case series and 2 to cohorts. There are some articles that report longer surgical time, intraoperative bleeding and percentage of positive margins, however, the perioperative complications profile and longterm functional results do not seem to differ significantly from those found in patients without previous prostatic surgery

Processo de recuperação cirúrgica em pacientes submetidos à prostatectomia radical: estudo longitudinal de variáveis sociodemográficas, clínicas e psicológicas / Surgical recovery process in patients submitted to radical prostatectomy: longitudinal study of sociodemographic, clinical and psychological variables

O processo de recuperação cirúrgica pode ser precoce, esperado ou prejudicado, conforme estado de saúde do individuo e do próprio ato cirúrgico, que determinam a perspectiva de bem-estar e qualidade de vida, tendo neste período como parâmetro o alcance de condições superiores ou equivalentes as que os pacientes apresentavam no período pré-operatório. O objetivo deste estudo foi caracterizar variáveis sociodemográficas, clínicas e psicológicas e identificar os fatores preditivos para o bem-estar e qualidade de vida nos diferentes períodos de observação (0, 30, 90, 180 e 360 dias). Trata-se de um estudo longitudinal, de 120 participantes submetidos à prostatectomia radical, por período de até 12 meses. Foram utilizados questionários para caracterização do participante e para avaliação clínica e os instrumentos: Escala Visual Analógica de Dor, Inventário de Estratégias de Coping, Escala Hospitalar de Ansiedade e Depressão, Escala de Satisfação com o Suporte Social, Escala de Satisfação Conjugal, Escala de Bem-Estar Subjetivo e o Expanded Prostate Cancer Index. Os dados foram descritos por períodos e analisados pelo modelo linear de efeitos mistos. Os principais resultados na descrição dos dados apontaram que as médias dos escores de dor variaram de 0,63 a 2,42. As médias de enfrentamento focado no problema variaram de 1,20 a 1,67, sendo mais evidente em T0, T1, T2 e T3 em relação ao enfrentamento focado na emoção, que teve variação de 1,20 a 1,48. As médias de ansiedade variaram de 4,42 a 6,01 e a depressão de 3,59 a 4,24, sendo as de ansiedade ligeiramente superiores às de depressão na maioria dos períodos, exceto em T4. A satisfação com o suporte social variou com médias de 3,81 a 3,97. A satisfação conjugal variou de 1,73 a 1,99, de modo que, a maioria dos participantes não estava satisfeita com o relacionamento conjugal. Já o bem-estar subjetivo apresentou médias de 2,59 a 2,77, sendo a satisfação com a vida e o afeto positivo os principais domínios. Notou-se que o bem-estar subjetivo se apresentou estável nos períodos quando comparado com T0. Já a qualidade de vida variou com médias de 68,69 a 81,80. No período T0, os participantes apresentaram menores médias quanto à função sexual e incômodo urinário. Entretanto, nos períodos T1, T2, T3 e T4, as menores médias foram em relação à função sexual e incontinência urinária. Quando comparado com T0, a qualidade de vida foi inferior em todos os períodos no pós-operatório. Na análise de métodos mistos, o tempo de cirurgia, enfrentamento focado no problema, ansiedade e satisfação conjugal foram preditores de bem-estar subjetivo, entretanto, as variáveis idade, raça/cor, tempo de anestesia, dor, depressão e satisfação com o suporte social não foram preditoras para o bem-estar subjetivo. Já os preditores de qualidade de vida foram as variáveis dor, depressão, enfrentamento focado na emoção, ansiedade e satisfação conjugal, entretanto, a idade, raça/cor, tempo de anestesia e satisfação com o suporte social não foram preditoras para a qualidade de vida. Os resultados apresentados contribuem para a compreensão do processo de recuperação cirúrgica de participantes submetidos à prostatectomia radical

The surgical recovery process can be early, expected or impaired, according to the individual"s health condition and the surgery, which determine the perspectives of wellbeing and quality of life. In this period, the achievement of conditions higher or equivalent to what the patients presented in the preoperative period serves as the parameter. The objective in this study was to characterize sociodemographic, clinical and psychological variables and to identify the predictive factors of wellbeing and quality of life in the different observation periods (0, 30, 90, 180 and 360 days). A longitudinal study was undertaken of 120 participants submitted to radical prostatectomy over a 12-month period. Questionnaires were used to characterize and clinically assess the participants, as well as the following instruments: Visual Analogue Pain Scale, Ways of Coping, Hospital Anxiety and Depression Scale, Satisfaction with Social Support Scale, Scale of Marital Satisfaction, Subjective Wellbeing Scale and the Expanded Prostate Cancer Index. The data were described per period and analyzed using the linear mixed effects model. The main results in the description of the data appointed that the mean pain scores ranged between 0.63 and 2.42. The mean problemfocused coping scores varied between 1.20 and 1.67, being clearer in T0, T1, T2 and T3 than emotion-focused coping, which varied between 1.20 and 1.48. The mean anxiety scores ranged between 4.42 and 6.01 and depression between 3.59 and 4.24, the former slightly surpassing the latter in most periods, except in T4. The satisfaction with social support varied with averages between 3.81 and 3.97. Marital satisfaction ranged between 1.73 and 1.99, showing that most participants were not satisfied with the marital relationship. Subjective wellbeing presented mean scores between 2.59 and 2.77, the main domains being satisfaction with life and positive affect. As observed, subjective wellbeing was stable in the periods when compared to T0. Quality of life, then, varied with averages between 68.69 and 81.80. In period T0, the participants presented lower averaged for the sexual function and urinary discomfort. In periods T1, T2, T3 and T4, on the other hand, the lowest averages were related to the sexual function and urinary incontinence. When compared to T0, the quality of life was lower in all postoperative periods. In the mixed methods analysis, the length of surgery, problem-focused coping, anxiety and marital satisfaction were predictors of subjective wellbeing, while age, race/color, length of anesthesia, pain, depression and satisfaction with social support did not serve as predictors of subjective wellbeing. The predictors of quality of life were pain, depression, emotion-focused coping, anxiety and marital situation, while age, race/color, length of anesthesia and satisfaction with social support did not serve as predictors for quality of life. The results presented contribute to understand the surgical recovery process of participants submitted to radical prostatectomy

Avaliação prospectiva de curva de aprendizado da prostatectomia radical laparoscópica assistida por robótica / Prospective evaluation of the learning curve for robotic assisted laparoscopic radical prostatectomy

INTRODUÇÃO: O câncer de próstata é responsável por 15% dos casos novos de câncer que acometem os homens e pela 5ª causa de morte. As técnicas minimamente invasivas, sobretudo a cirurgia robótica tornou-se a técnica comumente empregada nos Estados Unidos. Muitos artigos tentam demonstrar a curva de aprendizado necessária para a estabilização dos resultados, mas a implementação de novas tecnologias passa por diversos desafios, além da avaliação de seus resultados e dos custos, o que em países em desenvolvimento pode ter um importante impacto no sistema de saúde. OBJETIVO: Avaliar a curva de aprendizado da prostatectomia radical laparoscópica robótica assistida (PRRA) para o tratamento do câncer de próstata, de acordo com a continência urinária, a potência sexual, o tempo cirúrgico e o controle oncológico. MÉTODOS: Duzentos pacientes com neoplasia de próstata localizada submetidos à PRRA por um único cirurgião foram divididos em quatro grupos de acordo com a sequência das cirurgias. Foram avaliados os dados intra-operatórios, como: tempo cirúrgico, perda sanguínea estimada e as margens cirúrgicas. Também durante o pósoperatório foram avaliadas a potência (IIEF) e a continência (ICIQ). RESULTADOS: Os pacientes apresentaram idade média de 60,6 anos (59,72-61,61), volume prostático ao toque retal de 40 gramas e valor do PSA 6,95 ng/ml (5,79-8,10) semelhantes em todos os grupos (p > 0,05). A biópsia prostática pré-operatória mostrou diferença no escore de Gleason e no tamanho da próstata, sendo que o escore 6 foi menos frequente no grupo 4, representado por 23 pacientes (46%) e no grupo 1, com 39 pacientes (78%) (p < 0,01). Já o tamanho prostático avaliado pelo USTR foi de 39,6 gramas (29,75-48,7) no grupo 4 e 30,5 gramas (23,0-38,15) no grupo 2. A curva de aprendizado estabelecida demonstrou uma diminuição no tempo cirúrgico de 157 minutos (145-170) no grupo 1, para 132 minutos (119-140) no grupo 2 (p < 0,01). A perda sanguínea estimada também se reduziu...

BACKGROUND: Prostate cancer is responsible for 15% of new cases of male cancer and is the fifth leading cause of death. Minimally invasive and mainly, robotic surgery technique became the technique most widely utilized in the United States. Many articles have tried to demonstrate the required learning curve to achieve the plateau. Although, new techniques implementation go through many challenges besides the evaluation of its results, costs also became an issue, which may impact in developing countries health system. OBJECTIVE: We aim to evaluate the learning curve of robot-assisted radical prostatectomy (RARP) for the treatment of prostate cancer, according to continence, potency, surgical time and oncologic control. METHODS: Two hundred patients with localized prostate cancer that underwent RARP by a single surgeon were divided into four groups according to its surgical sequence. Intraoperative data, such as surgical time, estimated blood loss and margins were recorded. Also postoperative functional parameters as continence and potency were gathered using validated questionnaires (ICIQ and IIEF). RESULTS: Patients mean age were 60.6 years (59.72- 61.61), mean prostate volume at digital rectal examination was 40 grams and PSA value 6.95 ng/ml (5.79-8.10) were similar in all groups (p > 0.05). Pre-operative prostate biopsy showed difference in Gleason score and prostate size. Gleason score 6 was less frequent in group 4, 23 patients (46%), than group 1, 39 patients (78%)(p <0.01) and prostate size at TRUS was 39.6 grams (29.75- 48.7) in group 4 and 30.5 grams (23.0- 38.15) in group 2. The established learning curve showed a reduction on surgical time from 157 minutes (145-170) in group 1 to 132 minutes (119-140 min) in group 2 (p < 0.01). The estimated blood loss also decreased almost to half, from 395 ml (250-500) in group 1 to 200 ml (150-250) in group 3 (p < 0.01). Positive margins decreased from 16% to only 8 %, but were statistically similar (p=0.236)....

Score de Gleason 7 en prostatectomía radical: factores predictores de sobrevida libre de recidiva bioquimica / Gleason score 7 radical prostatectomy: predictors of biochemical recurrence-free survival

Evaluar pacientes con puntaje de Gleason de 7 sometidos a Prostatectomía Radical (PR) y determinar factores predictores de sobrevida libre de recidiva bioquímica (SL-RB). MATERIALES Y MÉTODOS: Se analizó una cohorte histórica de 1059 pacientes con Cáncer de Próstata sometidos a PR entre 1999 y 2012, de los cuales 490 cumplieron criterios de inclusión. Se definió como recidiva bioquímica (RB) un APE >0,2 ng/ml. Se consideró significativo un valor p < 0.05. RESULTADOS: La edad promedio y mediana de APE preoperatorio fue de 63 años y 6.6 ng/ml, respectivamente. Se observó RB en el 19,8 por ciento de esta serie con una mediana de seguimiento de 49 meses. El análisis multivariado demostró que los márgenes quirúrgicos (MQ) positivos (HR 1,76, p=0,01), T patológico (pT2 versus pT3, HR 2,0, p=0,007) y el porcentaje de cáncer en la pieza operatoria (HR 1,01, p=0,002) son predictores de SL-RB. El Gleason primario (3+4 versus 4+3) no fue un predictor de SL-RB (p=0,29). CONCLUSIONES: El Gleason primario no es un factor relevante para predecir RB en pacientes con GS 7 patológico. Sin embargo, los MQ positivos, el porcentaje de cáncer en la pieza operatoria, APE preoperatorio y la presencia pT3 son factores predictores de RB en pacientes con GS 7 y por lo tanto a considerar para decidir terapia adyuvante.

To evaluate patients with Gleason score 7 who underwent radical prostatectomy (RP) and to determine predictors of biochemical recurrence-free survival (SL-RB). MATERIALS AND METHODS: A historical cohort of 1059 patients with prostate cancer who underwent RP between 1999 and 2012, of which 490 met the inclusion criteria were analyzed. Biochemical recurrence (BR) was defined as a PSA > 0.2 ng / ml. A value of p < 0.05 was considered significant. RESULTS: Mean age was 63y-o and median preoperative PSA and 6.6 ng / ml. RB was observed in 19.8 percent of this series, with a median follow up of 49 months. Multivariate analysis showed that positive surgical margins (MQ) (HR 1.76, p = 0.01), pathological T (pT2 versus pT3, HR 2.0, p = 0.007) and the percentage of cancer in the surgical specimen (HR 1.01, p = 0.002) were predictors of SL-RB. Primary Gleason (3 +4 versus 4 +3) was not a predictor of SL-RB (p = 0.29). CONCLUSIONS: Primary Gleason is not relevant for predicting biochemical recurrence (RB) in patients with GS 7 pathological factor. However, positive margins, percentage of cancer in the surgical specimen, preoperative PSA and the presence pT3 are predictors of RB in patients with GS 7 and therefore they must be considered to decide for adjuvant therapy.

Hallazgos patológicos y evolución en prostatectomía radical de pacientes candidatos para vigilancia activa / Pathological findings and follow-up of radical prostatectomy patients candidates for active surveillance

El APE ha derivado en el diagnóstico de CaP en etapas más tempranas de la enfermedad. Por otra parte, existen evidencias de que muchos pacientes son sobretratados. La vigilancia activa tiene como premisa reducir el sobre tratamiento y la morbilidad relacionada con el tratamiento primario. El objetivo de este estudio fue evaluar las características patológicas desfavorables en pacientes sometidos a PR que fueron estratificados pre-operatoriamente de bajo riesgo según 10 modalidades para definir pacientes posibles de seguimiento activo. Realizamos un estudio retrospectivo y analítico de 230 pacientes con diagnóstico de CAP y tratados con PR, realizadas entre 1999 y 2011 en el Centro Urológico Profesor Bengió. Se evaluaron las características clínicas en 10 protocolos de seguimiento activo. Las variables anatomopatológicas evaluadas en la pieza de PR fueron el estadio patológico, SG de la pieza operatoria, la extensión extraprostática (EEP), invasión de vesículas seminales y compromiso de ganglios linfíticos regionales. El informe histopatológico fue realizado por un único uropatólogo (VB).En cada uno de los protocolos se evalúa el índice de recurrencia bioquímica. La población del estudio fue 198 pacientes. La media de edad fue 63 años. La media de APE 12,4/ml. Predominaron los estadíos clínicos T1c (48 por ciento) y T2 (48 por ciento). El índice de concordancia entre el SG de la biopsia y la PR en la serie se observó en 128 pacientes (64,6 por ciento). La extensión extraprostática, invasión de vesículas seminales e invasión ganglionar fue encontrada en 44 (22,2 por ciento), 38 (19,2 por ciento) y 3 (1,5 por ciento) pacientes respectivamente. La presencia de elementos patológicos desfavorables en pacientes candidatos a seguimiento activo oscila entre 12 por ciento y el 32 porciento. En nuestra serie de pacientes tratados con prostatectomía radical, los esquemas de vigilancia activa más estrictos, basados en APE <10ng/ml,...

The PSA has resulted in the diagnosis of prostate cancer in earlier stages of the disease. Moreover, there is evidence that many patients are over-treated. Active surveillance tries to prevent overtreatment and reduce the morbidity associated with primary treatment. The aim of this study was to evaluate the adverse pathologic features in patients who underwent RP and were stratified preoperatively as potential candidate for active surveillance through 10 different protocols. A retrospective study of 230 patients diagnosed with CAP treated with PR, conducted between 1999 and 2011 in the Urological Center Professor Bengio. Clinical characteristics were evaluated in 10 active surveillance protocols. Pathologic variables evaluated in RP specimens were pathological stage, surgical specimen SG, extraprostatic extension (EEP), seminal vesicle invasion and regional lymph nodes. The histopathological report was done by a single uropathologist (VB). In each of the protocols biochemical recurrence rate was evaluated. The study population was 198 patients. The average age was 63. The mean PSA 12.4 / ml. Predominant clinical stages T1c (48 percent) and T2 (48 percent). The concordance rate between the SG biopsy and RP in the series was observed in 128 patients (64.6 percent). Extraprostatic extension, seminal vesicle invasion and lymph node involvement was found in 44 (22.2 percent), 38 (19.2 percent) and 3 (1.5 percent) patients, respectively. The presence of unfavorable pathological elements in candidates for active surveillance patients ranges from 12 percent to 32 percent. In our series of patients treated with radical prostatectomy, stricter schemes of active surveillance based on PSA <10ng/ml, clinical stage T1c-T2a, biopsy Gleason score ¡Ü 6 and minimally invasive biopsy (<2 cylinders and <50 percent involvement) show better agreement with favorable histopathology findings in radical prostatectomy and correspond with greater biochemical recurrence-free survival...

Resultados comparativos en el tratamiento del cáncer de próstata localizado con intención curativa / Comparative results in the treatment with curative intent of localized prostate cancer

Introducción: El cáncer de próstata es la segunda causa de muerte por cáncer en los hombres. La determinación del Antígeno Prostático Específico (PSA) que permite detectar muchos tumores órgano-confinados, que hasta hace pocos años pasaban desapercibidos, ha llevado a la migración del diagnóstico hacia estadios más precoces de la enfermedad. La prostatectomía radical ha sido considerada tradicionalmente el tratamiento preferente para el cáncer de próstata localizado en los hombres con una esperanza de vida de 10 años o más. La radioterapia externa (RT) también se ha utilizado extensamente, principalmente en aquellos pacientes no pasibles a ser sometidos a procedimientos invasivos mayores por su elevado riesgo quirúrgico. Tanto la cirugía como la radioterapia externa han obtenido buenos resultados en el control del cáncer de próstata a largo plazo de acuerdo a series publicadas. Sin embargo parecería ser que la prostatectomia radical arrojado mejores resultados en función al periodo libre de enfermedad hasta evidenciarse progresión de la enfermedad. Objetivos: Comparar resultados obtenidos de la evolución de los pacientes con diagnostico de cáncer de próstata en estadio clínico localizado, que fueron tratados por una u otra modalidad. La comparación se realizo en función al periodo libre de enfermedad hasta presentar recidiva de enfermedad, ante pacientes del mismo grupo de riesgo. Materiales y métodos: Se realizó un estudio retrospectivo, analítico y documental de las historias clínicas de 139 pacientes con diagnostico de cáncer de próstata órgano confinado en el período comprendido entre marzo del 2001 y junio del 2010. Los pacientes fueron tratados quirúrgicamente o recibieron radioterapia conformada externa con una radiación promedio de7030 Gy (6500-7560 Gy). Con una edad promedio de 67 años y un seguimiento entre 12 meses y 9 años. Se valoro el periodo transcurrido libre de progresión de enfermedad hasta presentar recaída bioquímica...

Prostate cancer is the second leading cause of cancer death in men. Prostate specific antigen (PSA) determination can be used to detect organ confined tumors in earlier stages of disease. Radical prostatectomy has traditionallybeen considered as the preferred treatment for localized prostate cancer in men with life expectancy over 10 years. External radiation therapy (RT) has also been used extensively,mainly in patients with high surgical risk. Both surgery and radiotherapy have been successful in controlling prostate cancer, according to published series, but radical prostatectomy yielded better results according to disease free period. Objectives: To compare obtained results from the evolution of patients diagnosed with localizes prostate cancer, treated byeither modality. The comparison was carried out according to disease free interval until disease recurrence.Material and methods: A retrospective and documentary analysis was realized between March 2001 and June 2010,including 139 patients diagnosed with localized prostate cancer. The patients were treated surgically or with external radiotherapy, receiving a mean of 7030 Gy radiation (6500-7560 Gy). Patientshave a mean age of 67 years and have been monitored between 12 months and 9 years. Time elapsed free of disease progression without biochemical relapse were analyzed. Each treatment modality was compared with patients who have the same risk.Results: In low risk patients (55), 18 underwent surgical treatment, of which 16,6% observed biochemical recurrence...

Prostatectomía radical asistida por robot da Vinci: experiencia inicial en 50 casos consecutivos / Da Vinci robot-assisted radical prostatectomy: initial experience in 50 consecutive cases

Objective: To report our initial experience in 50 cases submitted to a Robotic Radical Prostatectomy (RRP), evaluating results and the learning curve. Material and Methods: From January to October 2010 we performed 50 consecutives cases of RRP with the da Vinci S-HD Surgical System®. The database was performed prospectively, and was analyzed retrospectively. We evaluate demographic data (age, body mass index) and perioperative data such as clinical stage, preoperative PSA (Prostate Specific Antigen), Gleason Score, ASA, operative times, estimated blood loss, morbidity, hospital stay, time of bladder catheterization and positive margins. A statistical analysis of exponential regression was performed to estimate the learning curve. Results: The mean age was 62 years and the most frequent clinical stage was T1c (84 percent). The mean PSA was 6.36 ng/mL and in 50 percent of the patients the Gleason Score was 7. The median surgical time was 199 minutes. The mean blood loss was 666 mL (50-4.000 mL). The hospital stay and the average bladder catheterization time were 2 and 6 days, respectively. There were 2 conversions to a laparoscopic approach, none to open surgery, and 8 percent of postoperative complication (all Clavien 1). Inmediat urinary continence and potency rates were 88.3 percent and 33.3 percent, respectively. When comparing the 25 initial cases versus the last 25, there was a decrease in surgical time and estimated blood loss (254 minutes vs 189 minutes and 876 mL vs 467 mL, respectively). We also found a lower rate of positive margins (20 percent vs 12 percent). The learning curve statistically estimated is 40 procedures. Conclusion: The surgeon's experience determine a decrease in surgical time, intraoperative bleeding and especially in the rate of positive margins.

Objetivo: Comunicar nuestra experiencia inicial en 50 casos de Prostatectomía Radical Robótica (PRR), evaluando resultados y curva de aprendizaje. Material y Métodos: Desde enero a octubre de 2010 se realizaron 50 PRR con el sistema da Vinci S-HD®. La base de datos fue confeccionada en forma prospectiva y se evaluaron en forma retrospectiva los datos demográficos (edad, índice de masa corporal), estadio clínico, valor de Antígeno Prostático Específico (APE), Score de Gleason, ASA, tiempos quirúrgicos, sangrado estimado, complicaciones, estadía hospitalaria, tiempo de sonda vesical y tasa de márgenes positivos. Se realizó un análisis estadístico de regresión exponencial para estimar la curva de aprendizaje del método. Resultados: La edad media fue de 62 años y el estadio clínico más frecuente fue el T1c (84 por ciento). El valor medio de APE fue de 6,36 ng/mL. El score de Gleason en un 50 por ciento correspondió al 7 y la media del ASA a 2. La mediana del tiempo quirúrgico fue de 199 minutos. El sangrado medio estimado fue de 666 mL (50-4.000 mL). La media de la estadía hospitalaria y el tiempo de sonda fueron de 2 y 6 días, respectivamente. Hubo 2 conversiones a cirugía laparoscópica, ninguna a cirugía abierta y un 8 por ciento de complicaciones postoperatorias (todas Clavien 1). La tasa de continencia y de potencia inmediata fue de 88,3 por ciento y 33,3 por ciento, respectivamente. Cuando comparamos los 25 casos iniciales versus los 25 finales hubo un descenso significativo en el tiempo quirúrgico y sangrado estimado (254 minutos vs 189 minutos y 876 mL vs 467 mL, respectivamente). También encontramos una menor tasa de márgenes positivos en el grupo 2 (12 por ciento vs 20 por ciento). El análisis estadístico determinó la curva de aprendizaje en 40 procedimientos. Conclusión: Una mayor experiencia del cirujano, determina una disminución en los tiempos quirúrgicos, sangrado intraoperatorio y sobre todo en la tasa de márgenes positivos.

Prostatectomia radical laparoscópica / Radical laparoscopic prostatectomy

Radical laparosocpic prostatectomy (RLP) is an attractive therapeutic modality for localized prostate cancer. The results obtained with this technique are similar to those obtained with open radical prostatectomy, which continues to be the gold standard for the treatment of prostate cancer. The surgical access for RLP can be extra-peritoneal or trans-peritoneal. The advantages of laparoscopy are lower bleeding rates, less need for transfusion and shorter recuperation time and hospital stay. The oncological results of RLP are similar, but in any case better, that those obtained with open retropubic radical prostatectomy. Recent reports raised the concern that laparoscopic prostatectomy could have higher rates of relapse of cancer. However this opinion is questionable. RLP is a difficult technique and should be performed by experienced teams. Robot assistance facilitates the procedure and could improve functional and oncological results. Therefore RLP is nowadays an alternative to traditional retropubic prostatectomy.

La Prostatectomia radical laparoscópica (PRL) se ha convertido en una técnica atractiva para el tratamiento quirúrgico del cáncer de próstata localizado. Si bien, los resultados actuales son inicialmente comparables a la prostatectomia radical abierta, es importante mencionar que la tendencia quirúrgica en cáncer de próstata, se ha modificado a pesar de que no hay estudios que confirmen la superioridad del método endoscópico y hoy, el estándar dorado sigue siendo la prostatectomia radical abierta. Dos rutas de acceso quirúrgico pueden ser utilizadas para la realización de PRL, la vía extraperitoneal y la transperitoneal. Un menor sangrado y menor tasa de transfusión, así como, tiempo de hospitalización y recuperación más cortos, son ventajas incuestionables para los procedimientos laparoscópicos. Los resultados oncológicos y funcionales de la prostatectomia laparoscópica son hoy en día comparables, pero en ningún caso mejores que la técnica retropúbica abierta estándar. Recientemente, Hu y colaboradores, en base a una revisión de cerca de 3.000 pacientes tratados en los Estados Unidos, plantean la posibilidad de que los pacientes tratados con prostatectomia laparoscópica (pura o asistida por robot), pudiesen tener mayor riesgo de recurrencia de la enfermedad. Esta es una posición discutible, ya que el análisis, a pesar de ser extenso es limitado para establecer conclusiones finales en el tema. Es importante recordar que la PRL sigue siendo una intervención técnicamente difícil y debiera ser realizada en centros seleccionados con equipos experimentados. La prostatectomía laparoscópica asistida por Robot, facilita el procedimiento y en suma, pareciera mejorar los resultados oncológicos y funcionales. La PRL es hoy en día una alternativa válida a la prostatectomía retropúbica tradicional, con ciertas ventajas adicionales.

Prostatectomía radical laparoscópica: primeros dos casos realizados por urólogos costarricenses / Laparoscopic radical prostatectomy: first two cases performed by Costa Rican Urologists

Se reportan los primeros dos casos de prostatectomía radical laparoscópica (PRL) realizada por urólogos costarricenses. La PRL se realizó con colocación de 4 trocares luego de poner la cámara en cicatriz umbilical. El tiempo operatorio total fue de 240 y 205 minutos, la pérdida de sangre estimada fue de 150 y 100 ml respectivamente. Se extrajeron las próstatas con vesículas seminales por una incisión umbilical de 3 cm. Un dreno cerrado con succión se esternalizó por una de las incisiones de los trócares de 5mm. No hubo complicaciones trans ni post operatorias. La estadía hospitalaria post operatoria fue de 3 y 2 días, el dreno se retiró al tercer y segundo día post operado y las sondas Foley se retiraron a los 14 días. Las próstatas pesaron 27 y 23 gramos, los puntajes Gleason fueron de (3+4) y (3+3) ambos tuvieron márgenes negativos, sin infiltración vascular ni nerviosa. La PRL es un procedimiento mínimamente invasivo para hombres con cáncer de próstata órgano confiado realizable, seguro y reproducible. Con mejor resultado cosmético y menor dolor posoperatorio...

Adenocarcinoma de próstata de volumen mínimo: estudio de 12 casos en piezas de prostatectomía / Minimal volume prostatic adenocarcinoma: study of 12 cases in specimens of radical prostatectomy

Adenocarcinoma de volumen mínimo es aquella neoplasia menor de 0,5 cm³ en prostatectomía radicales. Son tumores de pronóstico excelente, generalemente ógano-confinados y totalmente resecados. Seleccionamos 12 casos de adenocarcinoma con un volumen de 0,5 cm³ en piezas de prostatectomias radicales. El promedio de edades fue 60,55 años. Los tumores eran órgano-confinados y el Gleason osciló entre 5 y 9. El promedio del diámetro tumoral fue 4,9 mm y del volumen fue 0,129 cm³. Las biopsias por punción fueron revisadas en 9 de los 12 pacientes. En ellas el porcentaje tumoral ocupaba entre 3% y 30% de la totalidad de la biopsia. Consideramos que para el diagnóstico del adenocarcinoma de volumen mínimo en la pieza de prostatectomía radical se debe estudiar la totalidad del espécimen en forma sistemática, ya que el diagnóstico de carcinoma de volumen mínimo en la biopsia por punción puede no corresponder con un tumor menor de 0,5 cm³ en la prostatectomía radical

Minimal volume prostactic adenocarcinoma is defined as a neoplasia less than 0.5 cm³ in radical prostatectomy. These are tumors of excellent prognosis, generally organ confined, and totally resected. We selected 12 cases of adenocarcinoma with less than 0.5 cm³ in volumen in specimens of radical prostatectomy. The average age was 60.55 years. Tumors were organ-confined and the Gleason score rangel from 5 to 9. The average tumor diameter was 4.9 mm and volume was 0.129 cm³. Needle biopsies were studied in 9 out of 12 patients. In these, the tumor percentage in biopsy was from 3% to 30%. We consider that for the diagnosis of a minimal volume adenocarcinoma in the specimen of radical prostatectomy, the specimen must be totally and systematically submitted and studied, since the diagnosis of minimal volume carcinoma in the core biopsy might not correspond with a tumor of less than 0.5 cm³ in the radical prostatectomy

Relación entre el diagnóstico clínico preoperatorio y el histopatológico posoperatorio, en pacientes con cáncer prostático localizado / Relationship between clinical preoperative diagnosis and postoperative histology in patients with localized prostate cancer

Introducción: Las variables relevantes preoperatorias con que cuenta el urólogo para una toma de decisión frente a un cáncer prostático localizado son: la edad, el tacto rectal, el antígeno prostático específico (APE) e informe histológico de la biopsia por punción con el Gleason. Además se pueden incluir otras variables como el volumen prostático, número de muestras de biopsias positivas, porcentaje de la muestra comprometida, etc. Nosotros quisimos evaluar el grado de concordancia entre el diagnóstico clínico-patológico preoperatorio con el hallazgo histológico, posoperatorio en pacientes prostatectomizados, debido a la implicancia pronóstica y en la toma de decisión que pudiese tener. Material y Método: Se estudiaron retrospectivamente 119 prostatectomías radicales entre marzo de 2004 y junio de 2009. Se consideraron: edad, tacto, antígeno prostático específico (APE) y score de Gleason. Se excluyeron pacientes con tratamiento antiandrogénico u hormonal neoadjuvante. Resultados: En el preoperatorio la mediana de edad fue de 66 años (61-68), de APE 7,35 ng/ml (5,38-11,8) y de Gleason fue de 6 (5-7). El 87,4 por ciento de los pacientes tenía un APE >4,0 ng/ml. El 54 por ciento (n= 64) tenía un estadio clínico T1c y el 46 por ciento (n= 55) un estadio T2. En el posoperatorio 23,5 por ciento (n= 28) tuvo un estadio pT2 y el 74 por ciento (n= 88) un estadio pT3. En pacientes con estadio pT2 el APE preoperatorio fue de 5,9 ng/ml (4,4-9,4), en el estadio pT3 fue de 7,9 ng/ml (5,7-12,8). El score de Gleason en pT2 fue de 5 (5-6), en el pT3 fue de 6 (5-7). No encontramos diferencia de edad en los estadios pT2 (67 años) y pT3 (68 años). Conclusiones: En el estudio histopatológico posoperatorio de pacientes con estadio clínico T1c y T2, se confirmó un estadio pT2 sólo en 23,5 por ciento, el 74 por ciento tenían un estadio pT3 (a, b). En el cáncer prostático localizado, el tacto rectal no fue útil en su correlación con el estadio histológico...

Introduction: Relevant preoperative variables in patients with localized prostate cancer are: age, digital rectal examination (DRE), prostatic specific antigen (PSA) level and Gleason score in the transrectal biopsy. Other variables include prostate volume, number of positive biopsy samples, percentage of involvement in the biopsy, etc. We evaluated the agreement between the preoperative clinico pathologic diagnosis and the postoperative histology report in patients submitted to prostatectomy. Material and method: This is a retrospective review of 119 radical prostatectomies performed between March 2004 and June 2009. We recorded age, DRE, PSA level, and Gleason score. Patients receiving anti-androgenic treatment or neoadjuvant hormonal treatment were excluded. Results: Preoperative findings: median age was 66 years (61-68), median PSA level was 7.35 ng/ml(5.38-11.8) and median Gleason score was 6 (5-7). PSA level >4 ng/ml was found in 87.4 percent of the patients. Clinical stage T1c was found in 54 percent (n=64) of the cases whereas 46 percent (n=55) were stage T2. Postoperative findings: stage pT2 was found in 23.5 percent (n=28) of the patients whereas 74 percent (n =88)were pT3 stage. In pT2 patients, preoperative PSA was 5,9 ng/ml (4.4-9.4). In pT3 patients, PSA was7.9 ng/ml (5.7-12.8). Gleason score in pT2 was 5 (5-6); in pT3 patients, Gleason score was 6 (5-7). No age difference was found between pT2 stage (67 years) and pT3 stage (68 years).Conclusions: Postoperative histology in patients with T1c and T2 stages confirmed a pT2 stage only in 23.5 percent of the cases; 74 percent of the cases were pT3 (a,b) stage. In localized prostate cancer, DRE was not useful for the correlation with pathologic staging, especially for stage pT3 cases. Preoperative Gleason score was relatively useful; we found understaging 36.2 percent of the cases and overstaging 21.8 percent of the patients. These variables should be considered in the initial evaluation of...

Câncer de próstata e testosterona: riscos e controvérsias: [revisão] / Prostate carcinoma and testosterone: risks and controversies: [review]

O hipogonadismo é uma síndrome clínica e bioquímica que pode estar associada a um prejuízo significativo na qualidade de vida (QoL) do homem. Com o aumento na expectativa de vida e sobrevida do câncer prostático (CaP), espera-se um número maior de diagnósticos de hipogonadismo em homens submetidos ao tratamento potencialmente curativo do CaP. Apesar da contraindicação clássica do emprego de terapia de reposição com testosterona (TRT) em homens com diagnóstico ou suspeita de CaP, não há evidência convincente de que a normalização dos níveis de testosterona séricos em homens com baixos níveis seja deletéria. Em poucas séries de casos que descreveram a TRT após o tratamento do CaP, não houve casos de progressão clínica ou bioquímica do tumor. Não obstante a literatura seja limitada, os dados disponíveis sugerem que a TRT pode ser considerada em homens hipogonádicos selecionados, previamente tratados curativamente para o CaP de baixo risco e sem evidência de doença ativa.

Hypogonadism is a clinical and biochemical syndrome which may cause significant detriment in the quality of life. With the increase in life expectancy and prostate cancer survival a significant increase in the number of men with hypogonadism who have undergone presumably curative treatment for PCa is anticipated. Despite the widespread contraindication of testosterone in men with known or suspected prostate cancer, there is no convincing evidence that the normalization of testosterone serum levels in men with low, but not castrate levels, is deleterious. Although further studies are necessary before definitive conclusions can be drawn, the available evidence suggests that testosterone replacement therapy can be cautiously considered in selected hypogonadal men treated with curative intent for low risk prostate cancer and without evidence of active disease.

Análise da ploidia celular em adenocarcinoma de próstata localizado tratado pela prostatectomia radical / Cellular ploidy analysis in organ confined prostate adenocarcinoma treated by radical prostatectomy

Metodologia: Tiveram a ploidia celular mensurada por citometria estática digital 61 pacientes com adenocarcinoma de próstata clinicamente localizado e tratados com prostatectomia radical entre janeiro de 1999 e dezembro de 2003. Resultados: Foram identificados 31 pacientes com histogramas diploides e 30 pacientes aneuploides. Não houve associação entre ploidia celular e fatores prognósticos como idade, margem tumoral, volume tumoral, diferenciação celular, escore de Gleason e níveis de PSA. No entanto, quando a regressão logística de Cox foi aplicada para sobrevida livre de doença, a presença de margem comprometida e a ploidia celular foram os únicos fatores prognósticos significantes (p=0,0136 e p=0,0148, respectivamente). Conclusão: Neste estudo com um pequeno número de pacientes, a ploidia celular mensurada através da citometria estática representou um fator prognóstico independente e mais forte que a diferenciação celular para sobrevida livre de doença em pacientes com adenocarcinoma de próstata localizado.