Valor prognóstico da avaliação urodinâmica e da força do assoalho pélvico na incontinência urinária pós prostatectomia radical

Objetivo: A incontinência urinária é uma complicação importante da prostatectomia radical, causando deterioração na qualidade de vida, inclusive no pós-operatório inicial. O objetivo desse estudo foi identificar fatores preditores do retorno precoce da continência após essa cirurgia. Métodos: Foram avaliados 130 pacientes submetidos a prostatectomia radical por meio de um questionário clínico, o estudo urodinâmico, os instrumentos ICIQ-SF (International Consultation on Incontinence Questionnaire – Short Form) e EISP (Escore Internacional de Sintomas Prostáticos), o teste do absorvente de 1 hora, além da perineometria e da eletromiografia do assoalho pélvico. As avaliações foram realizadas antes e 1 mês após a cirurgia. Resultados: A idade mais avançada (> 60 anos) (OR=1,078 IC: 1,007-1,154, p=0,03) foi um fator de risco para a incontinência urinária precoce após a prostatectomia radical enquanto uma maior força de contração do assoalho pélvico antes da cirurgia foi um fator protetor (OR=0,986 IC: 0,974-0,998, p=0,018). No período pós-operatório, os pacientes incontinentes também apresentavam menor força de contração do assoalho pélvico, além de terem mais queixas miccionais, principalmente relacionadas a urgência, além de estarem menos satisfeitos. As taxas de continência variaram de acordo com o critério de avaliação adotado e apresentaram baixo coeficiente de concordância. A presença de contração involuntária do detrusor antes da cirurgia relacionou-se com uma maior taxa de incontinência urinária e padrão urodinâmico de obstrução infra-vesical pré-operatórios, mas não com a perda de urina após a cirurgia. Conclusão: A idade mais avançada e uma menor força de contração do assoalho pélvico foram fatores de risco para a incontinência urinária precoce após a cirurgia. Pacientes incontinentes no pós-operatório tiveram mais sintomas miccionais e uma pior força de contração do assoalho pélvico.Objective: Urinary incontinence is a major complication of radical prostatectomy, causing quality of life to become worse, even in the initial post operatory period. This article aims to evaluate prognostic factors for early urinary continence following radical prostatectomy. Methods: 130 patients who underwent radical prostatectomy were assessed. The following tests and instruments were used: clinical data questionnaire, urodynamic study, International Consultation on Incontinence Questionnaire – Short Form (ICIQ-SF), International Prostate Symptom Score (IPSS), 1-hour pad test, and pelvic floor muscles perineometry and electromyography. The assessments were performed before, and 1 month after surgery. Results: Older age (OR=1.078 CI: 1.007-1.154, p=0.03) was a risk factor for early urinary incontinence after radical prostatectomy, whereas a stronger contraction force of the pelvic floor before surgery was considered a protective factor (OR=0.986 CI: 0.974-0998, p=0018). In the post operatory period, incontinent patients also presented worse contraction force of the pelvic floor, had more mictional complaints, especially related to urgency, and were less satisfied. Rates of continence varied according to the adopted criteria, and presented low concordance coefficient. Presence of detrusor instability before surgery related to a higher rate of urinary incontinence and urodynamic pattern of bladder outlet obstruction in the preoperative period, but not to urine loss after surgery. Conclusion: Older age and worse contraction force of the pelvic floor were risk factors for urinary incontinence after the surgery. Incontinent patients in the post operatory period had more mictional symptoms and worse contraction force of the pelvic floor.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

Neovagina construction and continent cutaneous urinary reservoir using a previous orthotopic ileal neobladder

ABSTRACT Standard radical cystectomy (RC) in women involves removal of the distal ureters, bladder, proximal urethra, uterus, ovaries, and adjacent vagina. Furthermore, pelvic organ-preserving RC to treat selected women has become an accepted technique and may confer better postoperative sexual and urinary functions than standard RC, avoiding complications such as incontinence, prolapse, neobladder-vaginal fistula (NVF), and sexual dysfunction, without compromising oncological outcome. This article reports a different surgical approach: a patient who underwent a cutaneous continent reservoir and neovagina construction using a previous ileal orthotopic neobladder after RC. Patient presented no complications and she has no evidence of recurrent disease and is sexually active, with a satisfactory continent reservoir. This case is the first report of this procedure that was able to treat concomitant dyspareunia caused by short vagina and neobladder-vaginal fistula. In conclusion, standard radical cystectomy with no vaginal preservation can have a negative impact on quality of life. In the present case, we successfully treated neobladder fistula and short vagina by transforming a previous ileal orthotopic neobladder into two parts: a continent reservoir and a neovagina. However, to establish the best approach in such patients, more cases with long-term follow-up are needed

Synchronous abdominal tumors: is combined laparoscopic surgery in a single approach a safe option?

ABSTRACT Background and Purpose: Recent advances in cancer treatment have resulted in bet- ter prognosis with impact on patient's survival, allowing an increase in incidence of a second primary neoplasm. The development of minimally invasive surgery has provided similar outcomes in comparison to open surgery with potentially less mor- bidity. Consequently, this technique has been used as a safe option to simultaneously treat synchronous abdominal malignancies during a single operating room visit. The objective of this study is to describe the experience of two tertiary cancer hospitals in Brazil, in the minimally invasive treatment of synchronous abdominal neoplasms and to evaluate its feasibility and peri-operative results. Materials and Methods: We retrospectively reviewed the data from patients who were submitted to combined laparoscopic procedures performed in two tertiary hospitals in Brazil from May 2009 to February 2015. Results: A total of 12 patients (9 males and 3 females) with a mean age of 58.83 years (range: 33 to 76 years) underwent combined laparoscopic surgeries for the treatment of at least one urological disease. The total average duration of surgery was 339.8 minutes (range: 210 to 480 min). The average amount of intraoperative bleeding was 276.6mL (range: 70 to 550mL) and length of hospitalization was 5.08 days (range: 3 to 10 days). Two patients suffered minor complications regarding Clavien system during the immediate postoperative period. Conclusions: Combined laparoscopic surgery for the treatment of synchronous tumors is feasible, viable and safe. In our study, there was a low risk of postoperative morbidity

Association between Literacy, Compliance with Prostate Cancer Screening, and Cancer Aggressiveness: Results from a Brazilian Screening Study

Purpose Little is known about the effects of literacy levels on prostate cancer screening. This study evaluates the association between literacy, compliance with screening, and biopsy findings in a large Brazilian screening study. Materials and Methods We analyzed 17,571 men screened for PCa with digital rectal examination (DRE) and total and free prostate-specific antigen (PSA) from January 2004 to December 2007. Of those, 17,558 men had information regarding literate status. Full urological evaluation in a specialized cancer center was recommended in the case of: a) suspicious DRE, b) PSA > 4.0 ng/mL, or c) PSA 2.5-3.9 ng/mL and free/total PSA (f/tPSA) ratio 10 mg/mL (p = 0.03), clinical stage > T2a (p = 0.005), and biopsy Gleason > 7 (p = 0.02) were more common among illiterate men. Conclusions In a screened population, literacy levels were associated with prior PCa evaluations and with compliance with screening protocols. Illiterate men were at higher risk of being diagnosed with more advanced and aggressive PCa

Cutaneous ureterostomy with definitive ureteral stent as urinary diversion option in unfit patients after radical cystectomy Ureterostomia cutânea como opção de derivação urinária em pacientes em condições clínicas após cistectomia radical

PURPOSE: Simple diversions are underutilized, mostly for unfit, bedridden, and very self-limited patients requiring palliative surgical management due to life-threatening conditions. Experience with cutaneous ureterostomy (CU) as palliative urinary diversion option for unfit bladder cancer patients is reported. METHODS: We retrospectively reviewed clinical and operative parameters of 41 patients who underwent CU following RC in three specialized Cancer Centers from July/2005 to July/2010. Muscle-invasive disease (clinical Stage T2/worse), multifocal high-grade tumor, and carcinoma in situ refractory to intravesical immunotherapy were the main indications for RC. Double-J ureteral stents were used in all patients and replaced every 6 months indefinitly. Peri-operative morbidity and mortality were evaluated. RESULTS: Median age was 69 years (interquartile range - IQR 62, 76); 30 (73%) patients were men. Surgery in urgency setting was performed in 25 (61%) of patients, most due to severe bleeding associated with hemodynamic instability; 14 patients (34%) showed an American Society of Anesthesiologists score 4. Median operative time was 180 minutes (IQR 120, 180). Peri-operative complications occurred in 30 (73%) patients, most Clavien grade I and II (66.6 %). There was no per-operative death. Re-intervention was necessary in 7 (17%) patients. Overall survival was 24% after 9.4 months follow-up. CONCLUSIONS: CU with definitive ureteral stenting represents a simplified alternative for urinary diversion after palliative cystectomy in unfit patients. It can be performed quickly, with few early and late postoperative complications allowing RC in a group of patients otherwise limited to suboptimal alternatives. Future studies regarding the quality of life are warranted.<br>OBJETIVO: Relatar a experiência do emprego da ureterostomia cutânea (UC) como forma de derivação urinária definitiva em pacientes portadores de neoplasia vesical avançada, em más condições clínicas e que necessitam de tratamento paliativo. MÉTODOS: Foram analisados retrospectivamente os parâmetros clínicos e operatórios de 41 pacientes submetidos a cistectomia radical e UC em três centros oncológicos especializados. A UC foi a derivação urinária escolhida quando os pacientes não apresentavam condições clínicas de serem submetidos a outro tipo de derivação . Foram avaliados a morbidade peri-operatória e a sobrevida global. RESULTADOS: A idade média dos pacientes foi de 69 anos (intervalo interquartil - IQR 62, 76); 30 (73%) pacientes eram do sexo masculino. Vinte e cinco pacientes (61%) foram submetidos a cirurgia de urgência sendo a maioria devido a hemorragia grave associada a instabilidade hemodinâmica. O tempo cirúrgico médio foi de 180 minutos (IQR 120, 180). As complicações peri-operatórias ocorreram em 30 (73%) pacientes sendo a maioria classificadas como "Clavien" graus I e II (66,6%). Não houve óbito per-operatório. A reabordagem cirúrgica foi necessária em 7 (17%) dos pacientes e a sobrevida global foi de 24% após 9,4 meses de seguimento. CONCLUSÕES: A UC com implante de "stent" ureteral é uma alternativa simples de derivação urinária, após cistectomia paliativa, em pacientes sem condições clínicas de serem submetidos a procedimentos cirúrgicos mais complexos. A UC é um procedimento rápido e apresenta taxas de complicações aceitáveis. Essa alternativa cirúrgica permite melhorar a qualidade de vida dos pacientes portadores de tumores vesicais localmente avançados