ABSTRACT Introduction To evaluate the possible effects of the coronavirus disease 2019 (COVID-19) pandemic on the oncologic results of patients with prostate cancer regarding clinical staging, presence of adverse pathological outcomes, and perioperative complications. Materials and methods This retrospective study included patients who underwent radical prostatectomy. The time between biopsy and surgery, staging tests, final histopathological evaluation after surgery, lymphadenectomy rate, postoperative complications, and prostatic specific antigen (PSA) levels (initial and 30 days after surgery) were analyzed and compared in a group of patients before and during the pandemic period. Results We included 226 patients: 88 in the pre-pandemic period and 138 during the pandemic period. There was no statistically significant difference in mean age, body mass index, ASA, pathological locally advanced disease, the proportion of patients who underwent lymphadenectomy, and ISUP grade in the biopsy between the groups. Positive surgical margins, prostatic extracapsular extension, and PSA levels at 30 days were also similar between the groups. The mean time between medical consultation and surgery was longer in the pandemic period than in the pre-pandemic (124 vs. 107 days, p<0.001), and the mean time between biopsy and medical consultation (69.5 days vs. 114 days, p<0.001) and between biopsy and surgery (198.5 days vs. 228 days, p=0.013) was shorter during the pandemic. The incidence of severe early and late perioperative complications was similar between the periods. Conclusions There was no delay between diagnosis and treatment at our institution during the COVID-19 pandemic period. No worsening of the prostate cancer features was observed.

ABSTRACT Introduction: We aimed to evaluate the role of remote proctoring during the initial training phases of a robotics curriculum using surgical robot skills simulator exercises. Materials and Methods: Prospective randomized study comprising 36 urology residents and junior staff urologists without previous robotic training. Group 1 (G1) performed exercises without any assistance or support, group 2 (G2) received support from in-person proctor, and group 3 (G3) from a remote proctor through a telementoring system. Qualitative and quantitative analyses were conducted for each exercise and group. Results: The overall score approval rates (OSA) for the different skill exercises were Ring Walk 2 (RW2) 83%, Energy Dissection 2 (ED2) 81%, and Ring Walk 3 (RW3) 14%. RW2 OSA was higher on attempt 3 than on attempt 1 (83.3% vs. 63.9%, p=0.032). ED2 OSA rate was higher in attempt 3 than in attempt 1 (80.6% vs. 52.8%, p=0.002). RW2 OSA was similar among the groups. In ED2, both remote and live assistance were significantly related to upper OSA (G1=47.2%, G2=75.0%, G3=83.3%, p=0.002). RW3 had similar OSA among the groups, which can be explained by the high level of difficulty and low OSA in all the groups. However, in a sensitive quantitative analysis, the mean overall score of the participants in RW3 was higher in both proctored groups (G1=24, G2=57.5, G3=51.5, p=0.042). Conclusion: Robotic performance increased significantly over three attempts for simulation exercises of low, medium, but not high-complexity. Proctoring, either in-person or remotely, has a positive impact on approval performance, particularly in intermediate tasks.

RESUMO Introdução: o tratamento do câncer de adrenal benigno (hormonalmente ativo ou não funcional) e maligno inclui a adrenalectomia. A experiência dos cirurgiões e a cirurgia realizada por cirurgiões de alto volume foram associadas a menos complicações e menor custo. O objetivo do estudo foi descrever e comparar o número de cirurgias, a taxa de mortalidade e o tempo de internação para adrenalectomias realizadas entre 2008 e 2019 na rede pública de saúde de São Paulo. Métodos: trata-se de um estudo ecológico. Os dados foram coletados da Plataforma TabNet do Departamento de Informática do Sistema Único de Saúde. Os hospitais foram divididos em três subgrupos de acordo com o volume cirúrgico e hospitais com e sem programa de residência médica em Urologia. Os resultados foram comparados entre os grupos. Resultados: no período estudado, 943 adrenalectomias foram realizadas em São Paulo. As taxas de mortalidade durante a internação de acordo com o volume cirúrgico hospitalar foram: não foram relatados óbitos em hospitais de baixo volume; 0,015% em hospitais de volume intermediário e 0,004% em alto volume. O tempo médio de permanência na UTI foi de 1,03 dias nos hospitais de baixo volume; 2,8 nos de médio volume e 1,12 nos de alto volume (análise entre centros de médio e alto volume com significância estatística, p=0,016). Conclusão: as taxas de mortalidade foram muito baixas em todos os grupos. A permanência na UTI foi menor em centros de alto volume do que em centros de volume intermediário.

ABSTRACT Introduction: treating benign (hormonally active or nonfunctional) and malignant adrenal cancer includes adrenalectomy. The expertise of surgeons and surgery performed by high-volume surgeons were associated with fewer complications and lower cost. We aimed to describe and compare the number of surgeries, mortality rate, and length of hospital stay for adrenalectomies performed between 2008 and 2019 in the public health system of São Paulo. Methods: this was an ecological study. The data were collected using the TabNet Platform of the Unified Health System Department of Informatics. Outcomes analyzed included the number of surgeries performed, mortality rate during hospital stay, and length of hospital stay. Public hospitals in Sao Paulo were divided into three subgroups according to the surgical volume of adrenalectomies performed as well as hospitals with and without a residency program in Urology, and the results were compared among them. Results: a total of 943 adrenalectomies were performed in Sao Paulo between 2008 and 2019. Mortality rates during hospital stay according to hospital surgical volume were no reported deaths in low-volume, 0.015% in intermediate-volume, and 0.004% in high-volume hospitals. The average length of the ICU stay was 1.03 days in low-volume, 2.8 in intermediate-volume, and 1.12 in high-volume hospitals (analysis between intermediate and high volume centers with statistical significance, p=0.016). Conclusions: despite no statistically significant differences among the groups analyzed, mortality rates were very low in all groups. ICU stay was shorter in high-volume centers than in intermediate-volume centers.

ABSTRACT Objective To evaluate the predictive value of positron emission computed tomography or magnetic resonance (PET-CT and PET-MRI) using gallium-68-labeled prostate-specific membrane antigen (68Ga-PSMA) in lymph node involvement in prostate cancer. Methods A retrospective study comprising 91 patients diagnosed with prostate cancer between 2016 to 2020, who underwent 68Ga-PSMA PET-CT or PET-MRI for staging before prostatectomy. The patients were divided into Group 1, with 65 patients with satisfactory pathological lymph node analysis, and Group 2, with 91 patients representing the sum of patients with pathological lymph node analysis and those with postoperative prostate-specific antigen within 60 days after surgery. Receiver Operating Characteristic curves were used to assess accuracy of predictive capacity of imaging exams for lymph node involvement. Results Regarding local clinical staging, the groups showed similar results, and 50% were classified as staging T2a. The accuracy of 68Ga-PSMA PET-CT for prostate cancer lymph node staging was 86.5% (95%CI 0.74-0.94; p=0.06), with a sensitivity of 58.3% and specificity of 95%. The accuracy of 68Ga-PSMA PET-MRI was 84.6% (95%CI 0.69-0.94; p=0.09), with a sensitivity of 40% and specificity of 100%. Considering both 68Ga-PSMA PET-CT and PET-MRI, the accuracy was 85.7% (95%CI 0.76-0.92; p=0.015), with sensitivity of 50% and specificity of 97%. Conclusion The imaging tests 68Ga-PSMA PET-CT and PET-MRI were highly accurate to detect preoperative lymph node involvement, and could be useful tools to indicate the need for extended lymph node dissection during radical prostatectomy.

ABSTRACT Objective To describe and compare the number of surgeries, mortality rate, length of hospital stay, and costs of transurethral resection of the prostate and open prostatectomy for the treatment of benign prostatic hyperplasia, between 2008 and 2018, in the Public Health System in São Paulo, Brazil. Methods Ecological and retrospective study using data from the informatics department of the Brazilian Public Health System database. Procedure codes were “open prostatectomy” and “transurethral resection of the prostate.” The outcomes analyzed were compared between transurethral resection of the prostate and open prostatectomy according to the hospital surgical volume and presence or absence of a residency program. Results A total of 18,874 surgeries were analyzed (77% transurethral resection of the prostate) and overall mortality was not statistically different between procedures. Intermediate and high-volume centers had shorter length of hospital stay than low-volume centers for transurethral resection of the prostate (3.28, 3.02, and 6.58 days, respectively, p=0.01 and p=0.004). Length of hospital stay was also shorter for open prostatectomy in high-volume compared to low-volume centers (4.86 versus 10.76 days, p=0.036). Intrahospital mortality was inversely associated with surgical volume for transurethral resection of the prostate. Centers with residency program had shorter length of hospital stay considering open prostatectomy and less mortality regarding transurethral resection of the prostate. Open prostatectomy was 64% more expensive than transurethral resection of the prostate. Conclusion The findings suggest the importance of investing in specialized centers, which could be potential referral centers for surgical cases.

ABSTRACT Objective To analyze the characteristics of public health services related to radical prostatectomy, according to hospital volume of surgeries and stratified as academic and non-academic centers. Methods An ecological study was conducted using a database available in TabNet platform of the Unified Health System Department of Informatics. Number of surgeries, length of hospital stay, length of stay in intensive care unit, in-hospital mortality rate, and cost of hospitalization were evaluated. The hospitals were divided into three subgroups according to surgery volume (tercile), and results were compared. The same comparisons were made among academic and non-academic centers. We considered academic centers those providing Urology residency program. Results A total of 11,259 radical prostatectomies were performed in the city of São Paulo between 2008 and 2018. We observed a significant trend of increase in radical prostatectomies for treating prostate cancer over the years (p=0.007). The length of stay in intensive care unit, and number of deaths were not statistically different among centers with diverse surgery volume, nor between academic and non-academic centers. However, length of hospital stay was significantly shorter in academic centers (p=0.043), while cost of hospitalization was significantly higher in high-volume center compared to low- (p<0.001) and intermediate-volume centers (p<0.001). Conclusion Length of hospital stay for radical prostatectomies performed in public services in the city of São Paulo was shorter in academic centers, whereas hospitals with a high volume of surgeries showed greater cost of hospitalization.

ABSTRACT Background: Non-metastatic castration resistant prostate cancer (M0 CRPC) has seen important developments in drugs and diagnostic tools in the last two years. New hormonal agents have demonstrated improvement in metastasis free survival in M0 CRPC patients and have been approved by regulatory agencies in Brazil. Additionally, newer and more sensitive imaging tools are able to detect metastasis earlier than before, which will impact the percentage of patients staged as M0 CRPC. Based on the available international guidelines, a group of Brazilian urology and medical oncology experts developed and completed a survey on the diagnosis and treatment of M0 CRPC in Brazil. These results are reviewed and summarized and associated recommendations are provided. Objective: To present survey results on management of M0 CRPC in Brazil. Design, setting, and participants: A panel of six Brazilian prostate cancer experts determined 64 questions concerning the main areas of interest: 1) staging tools, 2) treatments, 3) side effects of systemic treatment/s, and 4) osteoclast-targeted therapy. A larger panel of 28 Brazilian prostate cancer experts answered these questions in order to create country-specific recommendations discussed in this manuscript. Outcome measurements and statistical analysis: The panel voted publicly but anonymously on the predefined questions. These answers are the panelists' opinions, not a literature review or meta-analysis. Therapies not yet approved in Brazil were excluded from answer options. Each question had five to seven relevant answers including two non-answers. Results were tabulated in real time. Conclusions: The results and recommendations presented can be used by Brazilian physicians to support the management of M0 CRPC patients. Individual clinical decision making should be supported by available data, however, for Brazil, guidelines for diagnosis and management of M0 CRPC patients have not been developed. This document will serve as a point of reference when confronting this disease stage.

ABSTRACT Background Focal therapy (FT) for localized prostate cancer (PCa) treatment is raising interest. New technological mpMRI-US guided FT devices have never been compared with the previous generation of ultrasound-only guided devices. Materials and Methods We retrospectively analyzed prospectively recorded data of men undergoing FT for localized low- or intermediate-risk PCa with US- (Ablatherm®-2009 to 2014) or mpMRI-US (Focal One®-from 2014) guided HIFU. Follow-up visits and data were collected using internationally validated questionnaires at 1, 2, 3, 6 and 12 months. Results We included n=88 US-guided FT HIFU and n=52 mpMRI-US guided FT HIFU respectively. No major baseline differences were present except higher rates of Gleason 3+4 for the mpMRI-US group. No major differences were present in hospital stay (p=0.1), catheterization time (p=0.5) and complications (p=0.2) although these tended to be lower in the mpMRI-US group (6.8% versus 13.2% US FT group). At 3 months mpMRI-US guided HIFU had significantly lower urine leak (5.1% vs. 15.9%, p=0.04) and a lower drop in IIEF scores (2 vs. 4.2, p=0.07). Of those undergoing 12-months control biopsy in the mpMRI-US-guided HIFU group, 26% had residual cancer in the treated lobe. Conclusion HIFU FT guided by MRI-US fusion may allow improved functional outcomes and fewer complications compared to US- guided HIFU FT alone. Further analysis is needed to confirm benefits of mpMRI implementation at a longer follow-up and on a larger cohort of patients.

ABSTRACT Introduction: Recent data suggest that robotic platform has become the most accessible minimal invasive surgery even for surgeons without previous training in laparoscopy. Laparoscopic partial nephrectomy (LPN) is a well-stablished procedure, however, with high level of complexity and long learning curve that limit its use. Objective: To describe safety, efficiency and learning curve of a single surgeon without previous experience in LPN to reach “TRIFECTA” at robot-assisted partial nephrectomy (RAPN). Patients and Methods: This is a retrospective study, with prospective data collection of 101 patients submitted to RAPN by a single surgeon. In order to analyze the learning curve, sample was chronologically divided in two phases: first phase: P1: 50 first patients, second phase: P2: 51 subsequent patients. TRIFECTA was defined as: ischemia time lower than 25 minutes, negative surgical margin and absence of severe complications (Clavien >2). Results: Mean age of patients was 54 years (SD=11.85), median tumor size was 32mm (SD=17) and surgery was performed with zero ischemia time in 33.6% of patients (29.8% at P1 and 40.9% at P2). Demographic data of patients were similar between both groups, except tumor size (P1=27.5mm vs. P2=35.3mm; p=0.02) and body mass index (BMI) (P1=26.6kg/m2 vs. P2=29kg/m2; p=0.03). Rate of bleeding, surgical time, presence of positive margin and peri-operatory surgical complications were similar in both phases. TRIFECTA was higher in P2 in relation to P1 (P1: 58% vs. P2: 87.8%; p=0.002) and median time of hot ischemia was significantly lower at P2 (P1: 17.3 vs. P2: 11.7; p=0.02). At multivariate analysis independent factors related to TRIFECTA included: chronological phase (OR 10.74; 95% IC: 1.63-70.53; p=0.013) and tumor size (OR 0.95; 95% IC: 0.91-0.99; p=0.024). Conclusion: RAPN seems to be safe and efficient with good functional and oncological results (TRIFECTA) since the beginning. Experience improvement was related to treatment of larger tumors, higher proportion of patients with zero ischemia and higher rate of TRIFECTA.

ABSTRACT This letter to the Editor aims to provide suggestions and recommendations for the management of urological conditions in times of COVID-19 crisis in Brazil and other low- and middle-income countries. It is important to highlight that one of the main characteristics of this pandemic is the oversaturation of the health system capacity, mostly due to a high demand for personal protective equipment (PPE), Hospital/ICU beds, as well as ventilators. In places with limited resources and where the health care systems are already saturated, such consideration is even more worrisome. Therefore, most worldwide authorities are recommending to avoid, as much as possible, patient’s elective visits to hospitals, as well as a judicious use of the operating room in order to mitigate the strain put on the health system. While efforts should be directed to the care of COVID-19 patients, other conditions (especially urgencies and oncological cases) must continue to be assisted. Thus, through a panel of experts, we have prepared a practical guide for urologists based on the recommendations from the main Urologic Associations, as well as data from the literature to support the suggested management. We will try to follow the standard guideline recommendations from the American Urological Association (AUA) and European Association of Urology (EAU), with the aim of pursuing the best outcomes possible. However, some recommendations were based on the consensus of the panel, taking into consideration the reality of developing countries and the unprecedented situation caused by the COVID-19 crisis.

ABSTRACT Purpose: Ultrasound-magnetic resonance imaging (US-MRI) fusion biopsy (FB) improves the detection of clinically significant prostate cancer (PCa). We aimed to compare the Gleason upgrading (GU) rates and the concordance of the Gleason scores in the biopsy versus final pathology after surgery in patients who underwent transrectal ultrasound (TRUS) systematic random biopsies (SRB) versus US-MRI FB for PCa. Materials and Methods: A retrospective analysis of data that were collected prospectively from January 2011 to June 2016 from patients who underwent prostate biopsy and subsequent radical prostatectomy. The study cohort was divided into two groups: US-MRI FB (Group A) and TRUS SRB (Group B). US-MRI FB was performed in patients with a previous MRI with a focal lesion with a Likert score ≥3; otherwise, a TRUS SRB was performed. Results: In total, 73 men underwent US-MRI FB, and 89 underwent TRUS SRB. The GU rate was higher in Group B (31.5% vs. 16.4%; p=0.027). According to the Gleason grade pattern, GU was higher in Group B than in Group A (40.4% vs. 23.3%; p=0.020). Analyses of the Gleason grading patterns showed that Gleason scores 3+4 presented less GU in Group A (24.1% vs. 52.6%; p=0.043). The Bland-Altman plot analysis showed a higher bias in Group B than in Group A (-0.27 [-1.40 to 0.86] vs. −0.01 [-1.42 to 1.39]). In the multivariable logistic regression analysis, the only independent predictor of GU was the use of TRUS SRB (2.64 [1.11 – 6.28]; p=0.024). Conclusions: US-MRI FB appears to be related to a decrease in GU rate and an increase in concordance between biopsy and final pathology compared to TRUS SRB, suggesting that performing US-MRI FB leads to greater accuracy of diagnosis and better treatment decisions.

ABSTRACT Introduction: Renal ptosis is defined as the renal descent when there is a change from supine to orthostatic position, usually with a change of two vertebral bodies or more than five cm apart. Although rare, it is one of the causes of chronic flank pain or of upper abdomen. The typical patient of renal ptosis is young, female, thin, with complaint of pain when in an upright position (1, 2). Objective: Demonstrate a robot-assisted nephropexy technique in a young woman diagnosed with symptomatic renal ptosis on the right kidney, confirmed by imaging tests. Materials and Methods: A 29-year-old female patient with a history of chronic right-sided pain and palpable renal mobility on physical examination. The diagnosis of renal ptosis was confirmed by ultrasound imaging, excretory urography (Figure-1), and renal scintigraphy with 99mTc-DTPA (Figure-2). She was submitted to a robotic-assisted right nephropexy with a polypropylene mesh fixing the right kidney to the ipsilateral psoas muscle fascia. Result: We reported a 96-minute surgical time. The patient was discharged in the first postoperative day. At the one-month follow-up, there was an important improvement of the symptoms, with normality renal function and imaging tests describing adequate renal positioning. Conclusions: Robotic-assisted nephropexy is feasible and can be an excellent minimally invasive alternative technique for the proposed surgery. We reported a shorter hospital stay and a faster postoperative recovery compared with the opened procedure.