Cáncer de próstata: biomarcadores prometedores relacionados con la enfermedad agresiva / Prostate Cancer: Promising Biomarkers Related to Aggressive Disease

Antecedentes: A pesar del número rápidamente creciente de marcadores biológicos de pronóstico y/o respuesta a tratamientos específicos posibles en el cáncer de próstata, ninguno ha mostrado hasta la fecha la capacidad de pronosticar por completo el cáncer de próstata en la urología basada en la evidencia. Objetivo: Revisar la literatura pertinente sobre el tema. Adquisición de evidencia: Se llevó a cabo una revisión exhaustiva de la literatura actual centrándose en los prometedores biomarcadores relacionados con el cáncer de próstata agresivo. Resumen de la evidencia: En combinación con la naturaleza heterogénea de la enfermedad, las series de casos mixtas son el diseño de estudio más común, que impiden resultados sólidos y el desarrollo de una estrategia terapéutica eficaz. La mejora de la supervivencia del paciente con cáncer de próstata requiere no solo la identificación de un nuevo objetivo terapéutico, basado en la comprensión detallada de los mecanismos biológicos implicados en la diseminación metastásica y el crecimiento del tumor, sino también consistentes estudios clínicos. Conclusión: Se necesita un mejor diseño de estudio implicando los marcadores potenciales e incluyendo a los pacientes bien clasificados y por estadios, con una metodología sólida y los resultados adecuados (sobre todo la supervivencia) para la evolución en este campo (AU)

Background: Although a rapidly growing number of candidate biological markers of prognosis and/or response to specific treatments in prostate cancer, none have to date showed ability to completely prognosticate prostate cancer on evidence based urology. Objective: To review the pertinent literature on the issue. Acquisition of evidence: A comprehensive review of the current literature was done focusing on promising biomarkers related to aggressive prostate cancer. Summary of evidence: Combined with the heterogeneous nature of the disease, mixt case series are the most common study design, impeding robust results and the development of an effective therapeutic strategy. Improvement in prostate cancer patient survival requires not only the identification of new therapeutic target based on detailed understanding of the biological mechanisms involved in metastatic dissemination and tumor growth but strong clinical studies as well. Conclusion: Better study design involving potential markers and including well-classified and staged patients with robust methodology and adequate outcomes (mainly survival) are necessary to the field evolution (AU)

[Prostate cancer: promising biomarkers related to aggressive disease]. / Cáncer de próstata: biomarcadores prometedores relacionados con la enfermedad agresiva.

BACKGROUND: Although a rapidly growing number of candidate biological markers of prognosis and/or response to specific treatments in prostate cancer, none have to date showed ability to completely prognosticate prostate cancer on evidence based urology. OBJECTIVE: To review the pertinent literature on the issue. ACQUISITION OF EVIDENCE: A comprehensive review of the current literature was done focusing on promising biomarkers related to aggressive prostate cancer. SUMMARY OF EVIDENCE: Combined with the heterogeneous nature of the disease, mixed case series are the most common study design, impeding robust results and the development of an effective therapeutic strategy. Improvement in prostate cancer patient survival requires not only the identification of new therapeutic target based on detailed understanding of the biological mechanisms involved in metastatic dissemination and tumor growth but strong clinical studies as well. CONCLUSION: Better study design involving potential markers and including well-classified and staged patients with robust methodology and adequate outcomes (mainly survival) are necessary to the field evolution.

Bisphosphonate therapy in patients under androgen deprivation therapy for prostate cancer: a systematic review and meta-analysis.

The objective of this study was to clarify the role of bisphosphonates in the treatment of osteoporosis in patients with prostate adenocarcinoma under androgen deprivation therapy (ADT). The Medline, EMBASE, Cancerlit and the American Society of Clinical Oncology abstract databases were searched for published randomized, placebo-controlled trials evaluating the usage of bisphosphonates in patients with prostate cancer (PC) under ADT. The outcomes assessed were fracture, osteoporosis, incidence of adverse events and changes in bone mineral density (BMD) during treatment. A total of 15 articles (2634 participants) were included in the meta-analysis. Treatment with bisphosphonates showed a substantial effect in preventing fractures (risk ratio (RR), 0.80; P = 0.005) and osteoporosis (RR, 0.39; P <0.00001). Zoledronic acid showed the best number needed to treat (NTT), compared with placebo, in relation to fractures and osteoporosis (NNT = 14.9 and NNT = 2.68, respectively). The between-group difference (bisphosphonates vs placebo) in the lumbar spine and femoral neck BMD were 5.18 ± 3.38% and 2.35 ± 1.16%, respectively. This benefit of bone loss prevention could be reached without major side effects (cardiovascular or gastrointestinal events). Bisphosphonates are effective in preventing bone loss in patients with PC who are under ADT.

[Androgen deprivation therapy and morbid obesity: do they share cardiovascular risk through metabolic syndrome?]. / Terapia de privación de andrógenos y obesidad mórbida: ¿tienenen común el riesgo cardiovascular por síndrome metabólico?

BACKGROUND: Although the use of androgen deprivation therapy (ADT) has resulted in improved survival in men with advanced prostate cancer, the resulting hypogonadism is associated with profound adverse effects comparable to those found in morbid obesity, being cardiovascular risk among the most lethal. OBJECTIVES: Evaluate metabolic syndrome, metabolic abnormalities and cardiovascular risk in patients with prostate cancer under ADT, not under ADT and morbid obese men. METHODS: This is a cross-sectional study that involves 79 men presenting prostate cancer, of whom 54 under ADT and 25 not under ADT and 91 morbidly obese patients paired by sex and age. To define metabolic syndrome, we used the International Diabetes Federation (IDF) criteria. Metabolic abnormalities, metabolic markers and Framingham score to predict the ten year coronary heart disease risk were compared among patients under ADT, not under ADT and morbid obese. RESULTS: Patients under ADT presented significantly greater occurrence of diabetes and central obesity and higher levels of total cholesterol and low density lipoprotein (LDL) compared to eugonadal men. The mean cardiovascular risk was significantly higher in patients under ADT (39.97±12.53% vs. 26.09±14.80%; p=0.021). Morbidly obese subjects had increased ten year coronary heart disease risk; comparable to patients under ADT (p=0.054). CONCLUSION: This study suggests that patients under ADT show higher prevalence of metabolic abnormalities and cardiovascular risk similar to those found in morbidly obese subjects. It is possible that both processes share cardiovascular risk through metabolic syndrome.

Prostatectomía radical endoscópica extraperitoneal: ¿cuál es la pendiente de la curva de aprendizaje? Efectos en la técnica de evolución personal en una experiencia de 5 años / Extraperitoneal endoscopic radical prostatectomy: How steep is the learning curve? Overheads on the personal evolution technique in 5-years experience

Objetivo: Investigar prospectivamente los efectos de la curva de aprendizaje de la prostatectomía radical extraperitoneal endoscópica en sus resultados. Materiales y métodos: En un período de 5 años (2004–2008) se practicó prostatectomía radical laparoscópica con 5–6 puertos a 270 pacientes en un centro de referencia brasileño. En los primeros 70 casos, el protocolo de la curva de aprendizaje incluía a pacientes con índice de masa corporal bajo y cáncer de próstata de poco volumen y bajo grado. Posteriormente no se aplicaron criterios para descartar la cirugía laparoscópica. Se analizó a los pacientes en dos grupos: grupo 1, primeros 70 pacientes (30 transperitoneal y 40 extraperitoneal) —curva de aprendizaje—, y grupo 2, últimos 200 pacientes —sólo prostatectomía radical endoscópica extraperitoneal—. Los parámetros quirúrgicos y los resultados se compararon mediante la prueba de la t de Student y la prueba exacta de Fisher. Resultados: La media de edad fue de 65 años (± 8,2), y los parámetros determinados en los grupos 1 y 2, respectivamente, fueron los siguientes: tiempo quirúrgico medio, 300 (±190) y 180 (±100) min; pérdida de sangre, 330 (±210) y 210 (±180)ml; estancia hospitalaria, 3 (2–5) y 2 (1–3) días; márgenes quirúrgicos positivos, el 15 y el 10%; erección suficiente para la penetración en pacientes previamente potentes, el 73,3 y el 75%, sin diferencia entre los grupos. El 78% de los pacientes de ambos grupos no informó de impotencia previa. Las tasas de incontinencia urinaria grave, transfusión y complicaciones fueron mayores en el grupo 1 (p<0,05): el 10 frente al 2%, el 12 frente al 2,25% y el 30 frente al 12,5%, respectivamente. Se produjo perforación del peritoneo en el 40% de los pacientes y no se precisó conversión a cirugía abierta en ningún caso. En el 85% de los casos se utilizó un procedimiento de preservación de nervios. Tras un seguimiento medio de 3,5 años, el 90% de los pacientes no mostró recidiva del PSA, sin que hubiera diferencia entre los grupos. Conclusión: Las tasas de incontinencia urinaria grave, transfusión y complicaciones están relacionadas con la curva de aprendizaje, que es continua, aunque se hace evidente una mejoría importante después de 70 casos. Debe considerarse la aplicación de un programa de formación intensivo supervisado para limitar los problemas del aprendizaje (AU)

Objective: Prospectively investigate endoscopic extra peritoneal radical prostatectomy (EERP) learning curve impact on outcomes. Materials and methods: In a 5 year period (2004–2008) 270 patients underwent 5–6 ports laparoscopic radical prostatectomy at a referral center in Brazil. The initial 70 cases learning curve protocol included low body mass index patients with low volume, low grade prostate cancer. After that there were no criteria to exclude laparoscopic surgery. The patients were analyzed in two groups: Group 1, first 70 patients (30 transperitoneal and 40 extra peritoneal)—learning curve and Group 2, last 200 patients - EERP only. Surgical and outcome parameters were compared through Student's t test and Fisher's Exact Test. Results: The mean age was 65 years (±8.2) and comparing Groups 1 and 2, mean operative time was 300 (±190) versus 180 (±100) minutes, blood loss 330 (±210) versus 210 (±180) mL, hospital stay 3 (2 to 5) versus 2 (1 to 3) days, positive surgical margins 15% versus 10%, erection sufficient to penetration in previous potent patients 73.3% versus 75%, respectively with no difference between groups. Overall, 78% of patients referred no previous impotence with groups’ equivalence. Severe urinary incontinence, transfusion and complications rates were higher in group 1 (p<0.05): 10% versus 2%, 12% versus 2.25% and 30% versus 12.5%, respectively. Peritoneum perforation occurred in 40% and conversion to open surgery was not required. Nerve sparing procedure was applied in 85%. In 3.5-years mean follow-up 90% of patients were free of PSA recurrence with no difference between groups. Conclusion: Severe urinary incontinence, transfusion and complications rates are related to learning curve which is continuous, although a significant improvement is pragmatic after 70 cases. An intensive mentored training program should be considered to minimize the learning outlays (AU)

[Extraperitoneal endoscopic radical prostatectomy: How steep is the learning curve? Overheads on the personal evolution technique in 5-years experience]. / Prostatectomía radical endoscópica extraperitoneal: ¿cuál es la pendiente de la curva de aprendizaje? Efectos en la técnica de evolución personal en una experiencia de 5 años.

OBJECTIVE: Prospectively investigate endoscopic extra peritoneal radical prostatectomy (EERP) learning curve impact on outcomes. MATERIALS AND METHODS: In a 5 year period (2004-2008) 270 patients underwent 5-6 ports laparoscopic radical prostatectomy at a referral center in Brazil. The initial 70 cases learning curve protocol included low body mass index patients with low volume, low grade prostate cancer. After that there were no criteria to exclude laparoscopic surgery. The patients were analyzed in two groups: Group 1, first 70 patients (30 transperitoneal and 40 extra peritoneal)-learning curve and Group 2, last 200 patients - EERP only. Surgical and outcome parameters were compared through Student's t test and Fisher's Exact Test. RESULTS: The mean age was 65 years (+/-8.2) and comparing Groups 1 and 2, mean operative time was 300 (+/-190) versus 180 (+/-100) minutes, blood loss 330 (+/-210) versus 210 (+/-180) mL, hospital stay 3 (2 to 5) versus 2 (1 to 3) days, positive surgical margins 15% versus 10%, erection sufficient to penetration in previous potent patients 73.3% versus 75%, respectively with no difference between groups. Overall, 78% of patients referred no previous impotence with groups' equivalence. Severe urinary incontinence, transfusion and complications rates were higher in group 1 (p<0.05): 10% versus 2%, 12% versus 2.25% and 30% versus 12.5%, respectively. Peritoneum perforation occurred in 40% and conversion to open surgery was not required. Nerve sparing procedure was applied in 85%. In 3.5-years mean follow-up 90% of patients were free of PSA recurrence with no difference between groups. CONCLUSION: Severe urinary incontinence, transfusion and complications rates are related to learning curve which is continuous, although a significant improvement is pragmatic after 70 cases. An intensive mentored training program should be considered to minimize the learning outlays.

A randomised, double-blind study comparing the efficacy and tolerability of controlled-release doxazosin and tamsulosin in the treatment of benign prostatic hyperplasia in Brazil.

Brazilian patients with benign prostatic hyperplasia were randomised in a 12-week, double-blind, double-dummy study to receive doxazosin gastrointestinal therapeutic system (GITS) 4 mg q.i.d. (n = 82) or tamsulosin 0.4 q.i.d. (n = 83). Primary endpoints were the absolute and percentage change from baseline in symptoms measured by International Prostate Symptom Score (IPSS). Secondary endpoints included IPSS, quality-of-life (QOL) question from the IPSS, and questions 6 and 7 of the Sexual Function Abbreviated Questionnaire (SFAQ) at weeks 4 and 12. Doxazosin GITS and tamsulosin improved IPSS with no significant differences between groups at week 12. During weeks 4-8, tamsulosin-treated patients demonstrated a slower improvement (p < 0.001) in IPSS than doxazosin GITS-treated patients. The proportion of satisfied patients was observed earlier with doxazosin GITS (p = 0.006) vs. tamsulosin. At week 12, the proportion of patients with little or no difficulty at ejaculation (Q6 of SFAQ) was higher in the doxazosin GITS group (p = 0.019). Both treatments were well tolerated.

Synchronous bilateral carcinoma of the adrenal gland: 2 case reports.

The existence of synchronous bilateral adrenal masses is an uncommon condition except in the relatively more frequent cases of pheochromocytoma or metastatic tumors. Two cases of synchronous nonfunctioning bilateral adrenal cortex carcinoma, removed during the same operation, are described. The patients currently are receiving hormonal supplementation, and were well 16 and 12 months postoperatively.

[Percutaneous treatment of varicocele: technical considerations and limitations of the method]. / Tratamento percutâneo da varicocele: considerações técnicas e limitações do método.

Three cases of varicocele were treated with good results by selective embolization of the spermatic vein. The technique of the procedure is discussed.

Transplante renal em criancas. / Renal transplantation in children

Os autores analisam experiencia com 73 transplantes renais realizados em 60 criancas com idade inferior a 15 anos, em um periodo de 16 anos. Trinta e sete estao vivos e com o aloenxerto funcionante.A sobrevida do enxerto foi de 79% no primeiro ano e 59% no decimo ano de seguimento, quando o rim era de doador vivo e 56% e 18%, quando de doador cadaver. A sobrevida do paciente foi de 94% no 1o. ano, 81% no 20, 64% no 5o. e 61% no 10o. ano, quando com rim de doador vivo, e 71% no primeiro, 33% no quinto e 25% no decimo, quando de doador cadaver. Complicacoes infecciosas foram vistas em 61% dos casos e as cirurgicas sem 23% dos pacientes. Crescimento ocorreu nas criancas transplantadas antes da idade de 10 anos. Concluem que a melhor terapeutica para a crianca uremica e o transplante renal