Effects of perioperative pelvic floor muscle training on early recovery of urinary continence and erectile function in men undergoing radical prostatectomy: a randomized clinical trial

ABSTRACT Aims: Radical prostatectomy (RP) can result in urinary incontinence (UI) and erectile dysfunction (ED), which negatively impact quality of life (QoL). This study aimed to evaluate the effects of a perioperative pelvic floor muscle training (PFMT) program versus usual care on early recovery of urinary continence and erectile function after RP. Materials and Methods: Of 59 eligible men, 31 were randomly allocated into 2 groups: Group 1 (Control, N=15) received usual post-RP care; and Group 2 (Physical therapy, N=16) received two pre-RP physical therapist-guided PFMT sessions, including exercises and electromyographic biofeedback, and verbal and written instructions to continue PFMT until RP, which was then resumed after urethral catheter removal. The International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) and the 5-item version of the International Index of Erectile Function (IIEF-5) questionnaire were used to evaluate UI and ED, respectively. Results: Demographic characteristics were similar in both groups. Three months after RP, the UI rate was 72.7% and 70.0% in Groups 1 and 2, respectively (P >0.05). The severity and frequency of UI and its impact on QoL were evaluated by the ICIQ-Short Form, with scores of 6.9±6.26 in Group 1 and 7.0±5.12 in Group 2 (P >0.05). The IIEF-5 scores were similar in Groups 1 and 2 (5.73±7.43 vs. 6.70±6.68, respectively) (P >0.05). Conclusion: Our pre-RP protocol of two physical therapist-assisted sessions of PFMT plus instructions did not significantly improve urinary continence or erectile function at 3 months after RP.

Costs analysis of surgical treatment of stress urinary incontinence in a brazilian public hospital, comparing Burch and synthetic sling techniques

ABSTRACT Introduction Surgical treatment of urinary incontinence progressed significantly with the introduction of synthetic slings. However, in some public Brazilian hospitals, the costs of these materials prevent their routine use. Objective To compare the costs of ambulatory synthetic sling surgery with an historical series of patients submitted to Burch surgery in a Brazilian public hospital. Materials and Methods Twenty nine incontinent patients were selected to synthetic sling surgery. Demographic data were prospectively collected and also the costs of the procedure, including drugs and materials, use of surgical and recovery wards, medical staff and hospitalization. These data were compared to the costs of 29 Burch surgeries performed before the introduction of synthetic slings. Results Demographic data were similar, although median age was lower in the group submitted to Burch surgery (46.3±8.6 versus 56.2±11.3 (p<0.001)). Cost was significantly lower in patients submitted to sling in all items, except for time spent in recovery ward. Total value of 29 Burch surgeries was R$ 217.766.12, and of R$ 68.049.92 of 29 patients submitted to sling surgery (p<0.001). Conclusion Burch surgery was more expensive than ambulatory synthetic transobturator sling surgery, even when the cost of the synthetic sling was considered.

Overactive bladder - 18 years - Part II

ABSTRACT Traditionally, the treatment of overactive bladder syndrome has been based on the use of oral medications with the purpose of reestablishing the detrusor stability. The recent better understanding of the urothelial physiology fostered conceptual changes, and the oral anticholinergics – pillars of the overactive bladder pharmacotherapy – started to be not only recognized for their properties of inhibiting the detrusor contractile activity, but also their action on the bladder afference, and therefore, on the reduction of the symptoms that constitute the syndrome. Beta-adrenergic agonists, which were recently added to the list of drugs for the treatment of overactive bladder, still wait for a definitive positioning – as either a second-line therapy or an adjuvant to oral anticholinergics. Conservative treatment failure, whether due to unsatisfactory results or the presence of adverse side effects, define it as refractory overactive bladder. In this context, the intravesical injection of botulinum toxin type A emerged as an effective option for the existing gap between the primary measures and more complex procedures such as bladder augmentation. Sacral neuromodulation, described three decades ago, had its indication reinforced in this overactive bladder era. Likewise, the electric stimulation of the tibial nerve is now a minimally invasive alternative to treat those with refractory overactive bladder. The results of the systematic literature review on the oral pharmacological treatment and the treatment of refractory overactive bladder gave rise to this second part of the review article Overactive Bladder – 18 years, prepared during the 1st Latin-American Consultation on Overactive Bladder.

Overactive bladder - 18 years - Part I

ABSTRACT Abstract: Overactive bladder syndrome is one of the lower urinary tract dysfunctions with the highest number of scientific publications over the past two decades. This shows the growing interest in better understanding this syndrome, which gathers symptoms of urinary urgency and increased daytime and nighttime voiding frequency, with or without urinary incontinence and results in a negative impact on the quality of life of approximately one out of six individuals – including both genders and almost all age groups. The possibility of establishing the diagnosis just from clinical data made patients' access to specialized care easier. Physiotherapy resources have been incorporated into the urological daily practice. A number of more selective antimuscarinic drugs with consequent lower adverse event rates were released. Recently, a new class of oral drugs, beta-adrenergic agonists has become part of the armamentarium for Overactive Bladder. Botulinum toxin injections in the bladder and sacral neuromodulation are routine modalities of treatment for refractory cases. During the 1st Latin-American Consultation on Overactive Bladder, a comprehensive review of the literature related to the evolution of the concept, epidemiology, diagnosis, and management was conducted. This text corresponds to the first part of the review Overactive Bladder 18-years.

Diagnóstico e tratamento da hiperplasia benigna da próstata / Diagnosis and treatment of benign prostatic hyperplasia

A hiperplasia benigna da próstata (HBP) é uma condição muito prevalente em homens a partir dos 40 anos, atingindo mais da metade da população masculina na sétima década e a quase totalidade na oitava década. Os sintomas a ela relacionados podem causar grande prejuízo à qualidade de vida desses pacientes. O objetivo da presente revisão é resumir a literatura atual sobre a patologia, focando na sua epidemiologia, diagnóstico e manejo. A avaliação inicial do paciente com HBP deve compreender a anamnese com aplicação do escore de sintomas prostáticos (IPSS), exame físico com toque retal, avaliação laboratorial (PSA sérico, exame de urina e função renal), além de métodos de imagem e urodinâmica para casos selecionados. O tratamento inicial para casos leves e moderados é medicamentoso, com o uso de alfa-bloqueadores ou inibidores da 5-alfaredutase, ou ainda a combinação desses. Pacientes que não respondem ao tratamento medicamentoso, com sintomas graves, ou que desenvolvem complicações da HBP devem ser considerados para tratamento cirúrgico. Este consiste em cirurgia aberta para próstatas de grande volume, ressecção transuretral para próstatas menores, além de outros tratamentos invasivos pouco disponíveis ou indisponíveis no nosso meio. O tratamento expectante para casos leves deve ser lembrado. Em conclusão, a HBP é doença com alta prevalência, cujo tratamento deve ser individualizado e instituído antes do surgimento de complicações maiores

Benign prostatic hyperplasia (BPH) is a very prevalent condition in men after 40 years of age, affecting more than half the male population in the seventh decade, and almost all in the eighth decade of life. The related symptoms can cause great damage to the quality of life of these patients. The purpose of this review is to summarize the current literature on the disease, focusing on epidemiology, diagnosis, and management. The initial evaluation of patients with BPH must include anamnesis with scoring of prostatic symptoms (IPSS), physical examination with digital rectal examination, laboratory evaluation (serum PSA, urinalysis and renal function), and imaging and urodynamics for selected cases. The initial treatment for mild to moderate cases is drug-based, using alpha blockers or 5-alpha-reductase inhibitors, or a combination of these. Patients who do respond to drug treatment, with severe symptoms, or who develop complications of BPH should be considered for surgical treatment. This consists in open surgery for large-volume prostates, transurethral resection for smaller prostates, and other invasive treatments little or unavailable in our community. The expectant treatment for mild cases should be considered. In conclusion, BPH is a highly prevalent disease whose treatment should be individualized and started before the onset of major complications

Urethral catheter removal 7 or 14 days after radical retropubic prostatectomy: clinical implications and complications in a randomized study

OBJETIVO: Avaliar a hipótese de que um período de sete dias de sonda vesical de demora após prostatectomia radical retropúbica é efetivo e seguro, sem a necessidade da realização de cistografia. MÉTODOS: Entre janeiro de 2000 e julho de 2002, setenta e três pacientes submetidos à prostatectomia radical retropúbica foram prospectivamente randomizados em dois grupos: grupo 1 ù 37 pacientes em que a sonda vesical foi removida 7 dias após o procedimento e, grupo 2 ù 36 nos quais a sonda foi removida 14 dias após a cirurgia. Os dois grupos apresentavam características clínicas similares, os cirurgiões e técnicas foram as mesmas, e nenhuma cistografia foi realizada para avaliar a presença de vazamentos. RESULTADOS: Dois pacientes no grupo 1 apresentaram sangramento e retenção por coágulos após a retirada da sonda no sétimo dia pós-operatório, e foram manejados através da recolocação da sonda vesical por mais 7 dias. Dois pacientes do grupo 2 desenvolveram esclerose do colo vesical e foram tratados através de incisão do colo vesical com sucesso. A taxa de continência foi a mesma, com dois casos de incontinência em cada grupo. Em torno de duas fraldas por dia eram utilizadas pelos pacientes com incontinência. O seguimento médio foi de 17.5 meses (2 ù 30 meses). Não houve formação de fístula urinária, urinoma ou abcesso pélvico após a retirada da sonda vesical. Dois pacientes foram excluidos da análise desta série: um faleceu devido a embolia pulmonar no terceiro dia pós-operatório, e o outro desenvolveu fístula urinária suprapúbica antes da retirada do cateter, que foi mantido por 16 dias. CONCLUSÃO: A retirada da sonda vesical 7 dias após a prostatectomia radical retropúbica, sem realização de cistografia, tem uma baixa taxa de complicações de curto prazo, equivalentes às da retirada da sonda aos 14 dias de pós-operatório.

Neoplasia Endócrina cística näo-funcionante de pâncreas / Non-functioning endocrine cystic neoplasia of the pancreas

é descrito o caso de uma paciente de 45 anos portadora de neoplasia endócrina cística näo-funcionante de pâncreas. Apresentava dor abdominal, exames laboratoriais normais e métodos de imagem que demonstraram lesäo cística na cauda pancreática. O tratamento cpnsistiu em pancreateectomia caudal esplenectomia, sendo o pós-operatório sem complicaçöes. A paciente permanece assintomática após 2 anos de acompanhamento. Apesar da onfrequência dessa forma de apresentaçäo das neoplasias endócrinas pancreáticas, ela deve ser incluida no diagnóstico diferencial das neoplasias císticas do pâncreas

Colangite obstrutiva supurativa aguda (COSA) / Acute obstructive suppurative cholangite

Os autores apresentam uma série de 12 casos, consecutivos, de colangite obstrutiva supurativa aguda (COSA), tratados cirurgicamente. A etiologia mais frequënte foi a coledocolitíase observada em 75 por cento dos casos. Fatores de risco como idade avançada, icterícia e comprometimento da função renal foram os principais indicadores prognósticos. Cinco (41,67 por cento) pacientes evoluíram ao óbito. O diagnóstico precoce com descompressão imediata da via biliar associado a medidas de suporte e antibioticoterapia são as únicas alternativas de sucesso no tratamento de tal afecção.

Estudo gasometrico arterial comparativo entre colecistectomia aberta e videolaparoscopica / Arterial gasometric comparative study between standard and videolaparoscopic cholecystectomy

Estudo que comparou os resultados de gasometrias arteriais coletadas no trans-operatorio de dois grupos de 18 pacientes submetidos a colecistectomias atraves da abordagem videolaparoscopica (grupo A) e classica (grupo B). O pH arterial variou entre 7,43 e 7,46 ao longo da cirurgia no grupo A, e no grupo B entre 7,47 e 7,48 nao havendo diferenca estatistica na analise entre grupos. E importante a realizacao destes exames no transcorrer da cirurgia pois, a exemplo da presente serie, adequacoes anestesicas podem ser necessarias para corrigir eventuais alteracoes metabolicas

Fatores de risco e complicaçöes pós-operatórias em pacientes com hiperbilirrubinemia / Risk factors and postoperative complications in patients with hyperbilirubinemia

Foi realizada uma análise retrospectiva de 213 pacientes submetidos a cirurgias radicais ou paliativas sobre a via biliar principal, motivadas por icterícia colestática, tanto de origem benigna quanto maligna. Deste grupo, foram levantados dados pré-operatórios como idade, sexo, níveis de bilirrubina e natureza da lesäo, e estes foram cotejados com a mortalidade e morbidade pós-operatória. A análise dos resultados mostrou um maior índice de morbi-mortalidade pós-operatória nos pacientes com níveis progressivamente mais altos de bilirrubina pré-operatória, idade elevada e natureza maligna da lesäo, sendo a insuficiência renal aguda pós-operatória a principal complicaçäo.