Urology
Resident in Urology, Hospital Prof. Doutor Fernando Fonseca, EPE
Penile cancer is an uncommon tumor, with an incident of 1/100,000 in developed countries. There are many associated risk factors, such as phimosis, chronic penile inflammation, HPV, smoking, among others. The only protective factor is neonatal circumcision. HPV is associated with 1/3 of invasive penile cancer. Squamous cell carcinoma is the most common histological subtype. 80% of penile cancer is curable if diagnosed early. However, there is significant delay in seeking health care, with some patients coming with more than 1 year’s delay. Physical examination of the penile lesion and groin for inguinal lymph node disease is vital for diagnostic evaluation and future patient management. Penile ultrasound and MRI are valid options to stage corporal invasion and CT or PET/CT to stage lymph node involvement when indicated. Local treatment is the treatment to the primary lesion and its recurrence does not significantly influence long-term survival. Therefore, if possible, penile preservation treatments should be offered. There are many options to achieve better cosmetic and functional outcomes, depending on the degree of invasiveness. The number and the extent of lymph node involvement is the main prognostic factor, and thus correct staging and treatment is mandatory. When nodes are not palpable, staging surgery might be needed. When nodes are palpable, radical inguinal lymphadenectomy is indicated. It is associated with relevant morbidity; however, the fear of complications should not delay a potentially life-saving surgery. Penile cancer treatment has a significant negative impact on quality of life and sexual function. Penile sparing treatment seems to have better results than more invasive options.
Published
Nov 2021
Non-muscle invasive bladder cancer (NMIBC) represents 75% of bladder cancer. It commonly recurs and may progress to muscle invasive (MIBC). BCG immunotherapy is an adjuvant treatment recommended in intermediate and high-risk NMIBC. Treatment failure with intravesical BCG immunotherapy is defined as any high-grade recurrence during or after BCG treatment. BCG-unresponsive is defined as all BCG-refractory (recurrence during BCG treatment) and some BCG-relapsing (recurrence after completion of treatment) papillary recurrence after 6 months and for Cis recurrence after 12 months. BCG-unresponsive bladder cancer is unlikely to respond to further BCG treatment: therefore BCG is not useful. Radical cystectomy is the standard and preferred treatment option; however, it is associated with significant morbidity and mortality. Therefore, many patients are unwilling or unable to undergo the procedure. Until 2020, valrubicin was the only drug approved by the FDA, with disappointing results on its trial. Pembrolizumab was approved by the FDA in 2020 based on KEYNOTE 057 results, making it the second drug approved in this setting. Many other treatments, such as sequential intravesical gemcitabine and docetaxel instillations, hyperthermic intravesical chemotherapy, radiofrequency-induced thermo-chemotherapy effect (RITE), intravesical nadofaragene firadenovec gene therapy, oportuzumab monatox have been studied on this setting. These last two treatments are the most promising and are awaiting FDA review for approval.
Published
May 2021
In recent years, the principles of open Simple Prostatectomy, performed to treat Benign Prostatic Hyperplasia in prostates larger than 80 mL, have been successfully transferred to laparoscopic and robot-assisted approaches, with the advantage of allowing faster recovery and reduced blood loss. Despite these advantages, most patients require continuous bladder irrigation in the postoperative period and will have ejaculatory dysfunction as result of the removal of the prostatic urethra, affecting patients’ quality of life. The laparoscopic simple prostatectomy with prostatic urethra preservation is the solution to overcome and solve these complications related to traditional surgical techniques and even transurethral endoscopic enucleations.
Published
Apr 2021
Radical Prostatectomy remains one of the surgeries most often performed by urologists and a main treatment option for prostate cancer. There are several approaches: the open radical prostatectomy (ORP), the laparoscopic radical prostatectomy (LRP) and the robot laparoscopic-assisted radical prostatectomy (RARP). Many studies have compared these different approaches. However, they have failed to show clear superiority in functional and in oncological outcomes. Therefore, there is a growing interest in developing new surgical techniques in order to improve these outcomes. The Retzius-sparing RARP was developed by the Bocciardi group in 2010. In this approach, the anterior compartment and its structures are spared. The rationale behind it is the contribution of these structures to the continence and potency, therefore by preserving them, better functional outcomes would be obtained. Recent meta-analyses comparing it to anterior RARP have been published and the quality of the evidence has been growing. On the functional outcomes, in terms of continence, it was associated with better early and late continence. When concerning potency, data is lacking, with results suggesting possible advantage. On safety outcomes, complication rates have been similar. When concerning oncological outcomes, no differences appear to exist between groups. However, there has been discussion about anterior positive surgical margins. The Retzius-sparing approach on LRP has no published studies. The surgical steps used have been the same of the RARP. Technically, it can be more challenging since the surgical instruments are straight. Its utilization might be an advantage in centers where the RARP is not available. The transposition of this technique to LRP is feasible in the hands of an experienced laparoscopic surgeon. The Retzius-sparing LRP might provide the same functional advantages already demonstrated by the RARP.
Published
Feb 2021
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