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Valenzi FM, Fuschi A, Al Salhi Y, Sequi MB, Suraci PP, Pacini M, Scalzo S, Rera OA, Antonioni A, Graziani D, Martino G, Candita G, Gianfrancesco F, Zucchi A, Lombardo R, De Nunzio C, Cicione A, Bozzini G, Rengo M, Capodiferro P, Sciarra A, Petrozza V, Carbone A, Pastore AL. Is early continence recovery related to the length of spared urethra? A prospective multicenter study comparing preoperative MRI and histologic specimen measurements after robotic radical prostatectomy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108319. [PMID: 38603868 DOI: 10.1016/j.ejso.2024.108319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/18/2024] [Accepted: 04/01/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Urinary incontinence (UI) is a common complication after radical prostatectomy, significantly affecting patients' quality of life. This study aimed to correlate the length of preserved urethra in robotic radical prostatectomy (RALP) patients with short-term urinary continence rates within 90 days post-surgery. METHODS A prospective multicentric study enrolled 190 prostate adenocarcinoma patients undergoing RALP. Using preoperative magnetic resonance imaging (mpMRI), urethral length was measured from the external urethral sphincter to the bladder neck. After surgery, histological measurements of the removed urethra were compared to the preoperative mpMRI data. Patients were categorized into two groups at the three-month follow-up based on urinary continence assessed through Urodynamic Study (UDS): Group A (94 patients without UI) and Group B (96 patients with UI). RESULTS Results revealed a significant difference in mean UI recovery time (Group A: 12.35 days, SD: 3.09 vs. Group B: 93.86 days, SD: 34.8, p < 0.0001). A ROC curve identified a 16.5% cut-off value (p < 0.000, sensitivity 87.5%, specificity 91.8%). Both groups showed a significant negative correlation between preserved urethral percentage and UI recovery time (Group A: r -0.655, p < 0.0001; Group B: r -0.340, p: 0.017). Group A had an average of 21.52% preserved urethra, while Group B had 13.86% (p < 0.0001). At one-year follow-up, 93.2% overall patients reported urinary continence without pads. CONCLUSIONS This study emphasizes the positive correlation between preserved urethra percentage in RALP and early urinary continence recovery, highlighting its surgical significance.
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Affiliation(s)
- Fabio Maria Valenzi
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 04100, Latina, Italy
| | - Andrea Fuschi
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 04100, Latina, Italy
| | - Yazan Al Salhi
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 04100, Latina, Italy
| | - Manfredi Bruno Sequi
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 04100, Latina, Italy
| | - Paolo Pietro Suraci
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 04100, Latina, Italy
| | - Matteo Pacini
- Department of Urology, University of Pisa, 56121, Pisa, Italy
| | - Silvio Scalzo
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 04100, Latina, Italy
| | - Onofrio Antonio Rera
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 04100, Latina, Italy
| | - Alice Antonioni
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 04100, Latina, Italy
| | - Damiano Graziani
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 04100, Latina, Italy
| | - Giorgio Martino
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 04100, Latina, Italy
| | - Giuseppe Candita
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 04100, Latina, Italy
| | - Filippo Gianfrancesco
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 04100, Latina, Italy
| | | | - Riccardo Lombardo
- Department of Urology, Faculty of Medicine and Psychiatry, Sant'Andrea Hospital, 00189, Rome, Italy
| | - Cosimo De Nunzio
- Department of Urology, Faculty of Medicine and Psychiatry, Sant'Andrea Hospital, 00189, Rome, Italy
| | - Antonio Cicione
- Department of Urology, Faculty of Medicine and Psychiatry, Sant'Andrea Hospital, 00189, Rome, Italy
| | - Giorgio Bozzini
- Department of Urology, Sant'Anna Hospital, San Fermo della Battaglia, Como, Italy
| | - Marco Rengo
- University of Rome Sapienza, Department of Radiological, Oncological and Pathological Sciences, Academic Diagnostic, Imaging Division - I.C.O.T. Hospital, Via F. Faggiana 1668, 04100, Latina, Italy
| | - Paola Capodiferro
- University of Rome Sapienza, Department of Radiological, Oncological and Pathological Sciences, Academic Diagnostic, Imaging Division - I.C.O.T. Hospital, Via F. Faggiana 1668, 04100, Latina, Italy
| | - Alessandro Sciarra
- Policlinico Umberto I, Department of Urology, Sapienza University of Rome, 00161, Rome, Italy
| | - Vincenzo Petrozza
- Faculty of Pharmacy and Medicine Dept. of Medico-Surgical Sciences and Biotechnologies Histopathology Unit, ICOT, Latina, Italy
| | - Antonio Carbone
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 04100, Latina, Italy
| | - Antonio Luigi Pastore
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 04100, Latina, Italy.
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Visscher J, Hiwase M, Bonevski B, O'Callaghan M. The association of smoking with urinary and sexual function recovery following radical prostatectomy for localized prostate cancer: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis 2024; 27:222-229. [PMID: 37500786 DOI: 10.1038/s41391-023-00701-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/07/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Urinary and sexual dysfunction after radical prostatectomy remains a major cause of morbidity, despite widespread availability of pharmacological and rehabilitative treatments. Smoking is a modifiable risk factor known to correlate with erectile and urinary dysfunction and we hypothesise that smoking cessation may improve post-prostatectomy urinary and sexual function recovery. Our objective is to systematically evaluate literature describing the association of smoking status with urinary and sexual function in men following radical prostatectomy. METHODS In total, 310 unique records were identified through a systematic search of the MEDLINE, EMBASE, Scopus, Web of Science, CINAHL and CENTRAL databases up to February 2023. Nine studies reported smoking status and post radical prostatectomy urinary and sexual function outcomes in men with localized prostate cancer. Risk of bias was assessed and meta-analysis included six studies. RESULTS Smokers had inferior erectile function after prostatectomy compared to non-smokers (OR 0.73, [95% CI 0.56-0.95]) during follow-up, while urinary incontinence was not statistically different between groups (OR 1.20, [95% CI 0.75-1.91]). Smoking cessation improved the EPIC-26 sexual domain score with 6.6 points on average [p = 0.03] to a clinically significant maximum of 12.5 points at 18-24 months. CONCLUSIONS Smoking is associated with impaired sexual function recovery after radical prostatectomy and quitting may improve sexual function >18 months. Current evidence shows no such association for urinary outcomes. Further studies are needed to corroborate findings.
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Affiliation(s)
- Jordi Visscher
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.
| | - Mrunal Hiwase
- Department of Surgery, Central Adelaide Health Network, Adelaide, SA, Australia
| | - Billie Bonevski
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Michael O'Callaghan
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Flinders Medical Centre, Urology Unit, Adelaide, SA, Australia
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Mac Curtain BM, Sugrue DD, Qian W, O'Callaghan M, Davis NF. Membranous urethral length and urinary incontinence following robot-assisted radical prostatectomy: a systematic review and meta-analysis. BJU Int 2024; 133:646-655. [PMID: 37667431 DOI: 10.1111/bju.16170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
OBJECTIVE To provide an update on the association between preoperative membranous urethral length (MUL) and postoperative urinary incontinence (UI) in men who undergo robot-assisted radical prostatectomy (RARP)/robot-assisted laparoscopic prostatectomy (RALP). MATERIALS AND METHODS Urinary incontinence is common after RARP/RALP, and early recovery of continence is one of the most important functional outcomes following surgery. MUL has been identified as a factor associated with continence recovery after RARP/RALP. A systematic review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using PubMed, Embase, and Scopus databases. Inclusion criteria were English language full journal articles authored within the last 5 years that assessed continence using the Expanded Prostate Cancer Index Composite. The Critical Appraisal Skills Programme tool for retrospective cohort studies was used to evaluate study quality. A random-effects meta-analysis was performed to pool odds ratios (ORs) from available studies relating to continence as a function of MUL. The Grading of Recommendations, Assessment, Development and Evaluations framework was used to synthesise evidence. RESULTS Six studies including 970 patients reported an association between MUL and continence at 12 months. Longer MUL was associated with reduced UI odds at 12 months after surgery (pooled OR 0.74, 95% confidence interval 0.68-0.87, P < 0.001). Significant methodological and statistical heterogeneity was encountered. CONCLUSIONS Preoperative MUL measured on magnetic resonance imaging (MRI) is significantly associated with postoperative continence in men undergoing RARP/RALP. We recommend consideration of MRI measurement of MUL prior to RARP/RALP to guide treatment decisions in this population.
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Affiliation(s)
- Benjamin M Mac Curtain
- School of Medicine, University of Galway, Galway, Ireland
- St John of God Subiaco Hospital, Subiaco, Western Australia, Australia
| | - Diarmuid D Sugrue
- Department of Urology, SA Health, Flinders Medical Centre, Bedford, South Australia, Australia
| | - Wanyang Qian
- St John of God Subiaco Hospital, Subiaco, Western Australia, Australia
| | | | - Niall F Davis
- Department of Urology, Beaumont Hospital, Dublin, Ireland
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Boellaard TN, van Dijk-de Haan MC, Heijmink SWTPJ, Tillier CN, Veerman H, Mertens LS, van der Poel HG, van Leeuwen PJ, Schoots IG. Membranous urethral length measurement on preoperative MRI to predict incontinence after radical prostatectomy: a literature review towards a proposal for measurement standardization. Eur Radiol 2024; 34:2621-2640. [PMID: 37737870 PMCID: PMC10957670 DOI: 10.1007/s00330-023-10180-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/29/2023] [Accepted: 07/07/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVES To investigate the membranous urethral length (MUL) measurement and its interobserver agreement, and propose literature-based recommendations to standardize MUL measurement for increasing interobserver agreement. MUL measurements based on prostate MRI scans, for urinary incontinence risk assessment before radical prostatectomy (RP), may influence treatment decision-making in men with localised prostate cancer. Before implementation in clinical practise, MRI-based MUL measurements need standardization to improve observer agreement. METHODS Online libraries were searched up to August 5, 2022, on MUL measurements. Two reviewers performed article selection and critical appraisal. Papers reporting on preoperative MUL measurements and urinary continence correlation were selected. Extracted information included measuring procedures, MRI sequences, population mean/median values, and observer agreement. RESULTS Fifty papers were included. Studies that specified the MRI sequence used T2-weighted images and used either coronal images (n = 13), sagittal images (n = 18), or both (n = 12) for MUL measurements. 'Prostatic apex' was the most common description of the proximal membranous urethra landmark and 'level/entry of the urethra into the penile bulb' was the most common description of the distal landmark. Population mean (median) MUL value range was 10.4-17.1 mm (7.3-17.3 mm), suggesting either population or measurement differences. Detailed measurement technique descriptions for reproducibility were lacking. Recommendations on MRI-based MUL measurement were formulated by using anatomical landmarks and detailed descriptions and illustrations. CONCLUSIONS In order to improve on measurement variability, a literature-based measuring method of the MUL was proposed, supported by several illustrative case studies, in an attempt to standardize MRI-based MUL measurements for appropriate urinary incontinence risk preoperatively. CLINICAL RELEVANCE STATEMENT Implementation of MUL measurements into clinical practise for personalized post-prostatectomy continence prediction is hampered by lack of standardization and suboptimal interobserver agreement. Our proposed standardized MUL measurement aims to facilitate standardization and to improve the interobserver agreement. KEY POINTS • Variable approaches for membranous urethral length measurement are being used, without detailed description and with substantial differences in length of the membranous urethra, hampering standardization. • Limited interobserver agreement for membranous urethral length measurement was observed in several studies, while preoperative incontinence risk assessment necessitates high interobserver agreement. • Literature-based recommendations are proposed to standardize MRI-based membranous urethral length measurement for increasing interobserver agreement and improving preoperative incontinence risk assessment, using anatomical landmarks on sagittal T2-weighted images.
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Affiliation(s)
- Thierry N Boellaard
- Department of Radiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | | | - Stijn W T P J Heijmink
- Department of Radiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Corinne N Tillier
- Department of Urology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Hans Veerman
- Department of Urology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Urology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Laura S Mertens
- Department of Urology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Urology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Pim J van Leeuwen
- Department of Urology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Ivo G Schoots
- Department of Radiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands.
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Nitta M, Tazawa M, Takahashi K, Naruse J, Oda K, Kano T, Uchida T, Umemoto T, Ogawa T, Kawamura Y, Hasegawa M, Shoji S, Miyajima A. Variations in predictors for urinary continence recovery at different time periods following robot-assisted radical prostatectomy. Asian J Endosc Surg 2024; 17:e13243. [PMID: 37740401 DOI: 10.1111/ases.13243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/18/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION Urinary dysfunctions are common sequelae following prostatectomy. This study aimed to discover factors that can predict urinary continence recovery at various time periods after robot-assisted laparoscopic radical prostatectomy (RARP). METHODS This was a retrospective analysis of data of 419 consecutive patients. Only patients followed up for ≥1 year were enrolled. An answer of "zero pad per day" in the Expanded Prostate Cancer Index Composite urinary assessment (question 5) denoted continence. Possible predictors of urinary continence recovery were evaluated at 3, 3-6, and 6-12 months after the operation. RESULTS Continence rates at 3, 6, and 12 months after RARP were 12.9%, 21.2%, and 40.2%, respectively. The proportions of patients using 0-1 pad were 54.2%, 75.7%, and 83.1% at 3, 6, and 12 months after RARP, respectively. Multivariable regression analysis revealed that a membranous urethral length (MUL) ≥11 mm was significantly associated with urinary continence recovery both within 3 months (odds ratio: 0.367, P = .003) and 3-6 months (odds ratio: 0.354, P = .001) after RARP. The analysis also revealed that, in patients with urinary continence at 6 months, a large prostate volume (odds ratio: 1.973, P = .044) and a high body mass index (odds ratio: 2.874, P = .027) were negative predictors of urinary continence recovery within 6-12 months. CONCLUSION A longer MUL was linked to urinary continence recovery within 6 months following RARP, whereas a large prostate volume and a high body mass index were adverse predictors of urinary continence recovery beyond 6 months.
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Affiliation(s)
- Masahiro Nitta
- Department of Urology, Tokai University School of Medicine, Kanagawa, Japan
| | - Moeko Tazawa
- Department of Urology, Tokai University School of Medicine, Kanagawa, Japan
| | - Kumpei Takahashi
- Department of Urology, Tokai University School of Medicine, Kanagawa, Japan
| | - Jun Naruse
- Department of Urology, Tokai University School of Medicine, Kanagawa, Japan
| | - Kazuya Oda
- Department of Urology, Tokai University School of Medicine, Kanagawa, Japan
| | - Tatsuo Kano
- Department of Urology, Tokai University School of Medicine, Kanagawa, Japan
| | - Takato Uchida
- Department of Urology, Tokai University School of Medicine, Kanagawa, Japan
| | - Tatsuya Umemoto
- Department of Urology, Tokai University School of Medicine, Kanagawa, Japan
| | - Takahiro Ogawa
- Department of Urology, Tokai University School of Medicine, Kanagawa, Japan
| | - Yoshiaki Kawamura
- Department of Urology, Tokai University School of Medicine, Kanagawa, Japan
| | - Masanori Hasegawa
- Department of Urology, Tokai University School of Medicine, Kanagawa, Japan
| | - Sunao Shoji
- Department of Urology, Tokai University School of Medicine, Kanagawa, Japan
| | - Akira Miyajima
- Department of Urology, Tokai University School of Medicine, Kanagawa, Japan
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Muñoz-Calahorro C, Parada-Blázquez MJ, García-Sánchez C, López-Arellano L, Vizcaíno-Velázquez P, Medina-López RA. Inter-observer variability in male pelvic-floor MRI measurements that might predict post-prostatectomy incontinence. World J Urol 2023; 41:1147-1155. [PMID: 36795146 DOI: 10.1007/s00345-023-04320-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 01/27/2023] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION Current studies are focusing on the relationship between anatomical variables in preoperative prostate MRI and the development of post-prostatectomy incontinence (PPI). Nevertheless, there is little evidence regarding the reliability of these measurements. The objective of this study was to analyze the concordance between urologists and radiologists for anatomical measurements that might be PPI predictors. MATERIAL AND METHODS Pelvic floor measurements with 3T-MRI were performed by two radiologists and two urologists independently and blindly. Interobserver agreement was determined using the intraclass correlation coefficient (ICC) and the Bland-Altman plot. RESULTS The concordance was good-acceptable for most measurements, except for the levator ani and puborectalis muscle thickness (some ICC values < 0.20/p value > 0.05). The anatomical parameters with the highest degree of agreement were intravesical prostatic protrusion (IPP) and prostate volume (most of the ICC values > 0.60). The membranous urethral length (MUL) and the angle of the membranous urethra-prostate axis (aLUMP) presented ICC > 0.40. The obturator internus muscle thickness (OIT), urethral width and intraprostatic urethral length presented a fair-moderate degree of agreement (ICC > 0.20). Regarding the agreement between different specialists, the highest degree was obtained for the two radiologists and for urologist 1-radiologist 2 (moderate median agreement), while urologist 2 with each of the radiologists had a regular median agreement. CONCLUSIONS MUL, IPP, prostate volume, aLUMP, OIT, urethral width and prostatic length show acceptable inter-observer concordance and they would be reliable as possible predictors of PPI. Levator ani and puborectalis muscle thickness show bad agreement. Interobserver agreement might not be greatly influenced by previous professional experience.
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Wang Y, Zhang S, Huang H, Qiu X, Fu Y, Lyu X, Xu L, Zhuang J, Guo H. A retrospective study to evaluate the effect of preoperative hormonal therapy on continence recovery. Front Oncol 2023; 12:1059410. [PMID: 36713499 PMCID: PMC9880985 DOI: 10.3389/fonc.2022.1059410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/28/2022] [Indexed: 01/15/2023] Open
Abstract
Objective To evaluate whether different preoperative hormonal therapy options affect postoperative continence and to identify risk/protective factors for continence recovery. Methods This is a retrospective analysis of several clinical trials (NCT04356430, NCT04869371, NCT04992026 and NCT05406999). Data from patients treated with hormonal therapy followed by RARP were collected and analyzed. Continence was defined as 0 pad/day or one safety pad. Results The study included 230 patients with adequate information. The median time to continence recovery is 8 weeks. A total of 216 (93.9%) participants recovered to urinary continence within 12 months after surgery. 21 (9.1%) participants achieved immediate continence. 69, 85, 27 and 14 participants restored continence at 1 month, 1-3 month, 3-6 month, 6-12 month, accounting for 30.0%, 40.0%, 11.7% and 6.1% accordingly. No difference in continence recovery was found among different preoperative hormonal treatment options (p=0.821). Cox regression showed that membranous urethral length (MUL) was the only independent factor influencing urinary continence recovery either in the univariate analysis (OR=1.13, 95%CI: 1.04-1.22, p=0.002) or in the multivariate analysis (OR=1.12, 95%CI: 1.04-1.20, p=0.002). Different preoperative treatment options were not associated with urinary recovery. More advanced preoperative T stage (OR=0.46, 95%CI: 0.24-0.85, p=0.014) delayed the recovery of immediate continence. MUL was associated with continence restoring at 1 month (OR=1.20, 95%CI: 1.03-1.39, p=0.017), 3 month (OR=1.27, 95%CI: 1.07-1.51, p=0.006), 6 month (OR=1.34, 95%CI: 1.07-1.67, p=0.011) and 12 month (OR=1.36, 95%CI: 1.01-1.84, p=0.044). Conclusion There is no difference in postoperative continence recovery among ADT, ADT+Docetaxel and ADT+Abiraterone preoperative treatment options. More advanced T stage indicated poor immediate continence recovery. Longer membranous urethral length was a promotional factor for both short-time and long-time continence recovery.
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Affiliation(s)
- Yuwen Wang
- Department of Urology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China,Medical School of Southeast University Nanjing Drum Tower Hospital, Nanjing, China
| | - Shun Zhang
- Department of Urology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China,Institute of Urology, Nanjing University, Nanjing, China
| | - Haifeng Huang
- Department of Urology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China,Institute of Urology, Nanjing University, Nanjing, China
| | - Xuefeng Qiu
- Department of Urology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China,Institute of Urology, Nanjing University, Nanjing, China
| | - Yao Fu
- Department of Pathology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiaoyu Lyu
- Department of Urology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China,Institute of Urology, Nanjing University, Nanjing, China
| | - Linfeng Xu
- Department of Urology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China,Institute of Urology, Nanjing University, Nanjing, China,*Correspondence: Hongqian Guo, ; Junlong Zhuang, ; Linfeng Xu,
| | - Junlong Zhuang
- Department of Urology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China,Institute of Urology, Nanjing University, Nanjing, China,*Correspondence: Hongqian Guo, ; Junlong Zhuang, ; Linfeng Xu,
| | - Hongqian Guo
- Department of Urology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China,Medical School of Southeast University Nanjing Drum Tower Hospital, Nanjing, China,Institute of Urology, Nanjing University, Nanjing, China,*Correspondence: Hongqian Guo, ; Junlong Zhuang, ; Linfeng Xu,
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8
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van Dijk-de Haan MC, Boellaard TN, Tissier R, Heijmink SWTPJ, van Leeuwen PJ, van der Poel HG, Schoots IG. Value of Different Magnetic Resonance Imaging-based Measurements of Anatomical Structures on Preoperative Prostate Imaging in Predicting Urinary Continence After Radical Prostatectomy in Men with Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Focus 2022; 8:1211-1225. [PMID: 35181284 DOI: 10.1016/j.euf.2022.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 12/18/2021] [Accepted: 01/28/2022] [Indexed: 12/16/2022]
Abstract
CONTEXT Measurements of anatomical structures on preoperative prostate magnetic resonance imaging (MRI) are used in risk models for treatment decisions to predict urinary continence (UC) following radical prostatectomy (RP). However, the association between these parameters and UC is unclear. OBJECTIVE To systematically summarize the literature on prognostic preoperative prostate MRI measurements of (peri)prostatic structures in relation to time to recovery of postoperative UC in men with prostate cancer. EVIDENCE ACQUISITION Online libraries were searched up to August 27, 2021. Article selection and critical appraisal were performed by two reviewers. All papers reporting on preoperative MRI measurements with UC correlation in univariable or multivariable analyses were included. EVIDENCE SYNTHESIS In the 50 studies included (mostly retrospective), 57 MRI parameters were evaluated. The pooled analyses showed that greater membranous urethra length (MUL) was prognostic for regaining UC at 1 mo (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.10-1.21), 3 mo (OR 1.23, 95% CI 1.16-1.31), 6 mo (OR 1.16, 95% CI 1.08-1.25), and 12 mo (OR 1.19, 95% CI 1.10-1.29). Several other anatomical structures showed at least in one study a significant correlation with later return to UC: four prostate-related parameters (greater depth, apical protrusion, larger intravesical protrusion, small dorsal vascular complex), five urethra-related parameters (thicker wall, severe fibrosis, smaller volume, larger preoperative angle between the prostate axis and membranous urethra, shorter minimal residual MUL), and six musculoskeletal-related parameters (lower perfusion ratio, thinner levator ani muscle, larger inner or outer levator distance, shorter pelvic diaphragm length, and larger midpelvic area). CONCLUSIONS Greater MUL as measured on preoperative MRI was an independent prognostic factor for return to UC within 1 mo after RP and remained prognostic at 12 mo. Other anatomical structures may potentially be predictive, but these would need to be substantiated in prospective trials before being adopted in postoperative UC risk models for treatment decisions in men with prostate cancer. PATIENT SUMMARY We summarized study data on the relation between measurements of anatomical structures on preoperative magnetic resonance imaging scans and urinary continence after removal of the prostate. Greater length of one part of the urethra (membranous urethra) is associated with faster return to continence. Other anatomical structures have potential for predicting postoperative continence, but need further investigation.
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Affiliation(s)
| | - Thierry N Boellaard
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Renaud Tissier
- Biostatistics Unit, Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Pim J van Leeuwen
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ivo G Schoots
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Radiology & Nuclear Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
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9
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Oza P, Walker NF, Rottenberg G, MacAskill F, Malde S, Taylor C, Sahai A. Pre-prostatectomy membranous urethral length as a predictive factor of post prostatectomy incontinence requiring surgical intervention with an artificial urinary sphincter or a male sling. Neurourol Urodyn 2022; 41:973-979. [PMID: 35266177 PMCID: PMC9313820 DOI: 10.1002/nau.24904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/30/2021] [Accepted: 01/15/2022] [Indexed: 11/10/2022]
Abstract
AIMS To ascertain whether the membranous urethral length (MUL) is predictive of postprostatectomy incontinence (PPI) that requires surgery such as artificial urinary sphincter (AUS) or male sling (MS). METHODS Men who had undergone AUS or MS for PPI were identified from a prospectively maintained database and compared to a control group of men who were continent at 12 months after radical prostatectomy. MUL in sagittal and coronal planes, sphincter height and width were measured on prebiopsy T2-weighted MRI scans. Sphincter volume was estimated as an ellipsoid cylinder. RESULTS A total of 95 patients (64 AUS and 31 MS) were compared to 60 continent controls. There was no statistical difference in presenting PSA, prostate volume, and T-stage. The mean MUL in sagittal and coronal planes was 11.31 mm (SD: 2.6, range: 6-17 mm) and 11.43 mm (SD: 2.94, range: 5-17 mm) in patients who had AUS and MS, respectively; 15.23 mm (SD: 4.2, range: 8.25-25 mm) and 15.75 mm (SD: 4.1, range: 8-24 mm) in controls (p < 0.01). No men in the PPI surgery group had an MUL >17 mm compared to 35% (20/57 sagittal, 20/58 coronal) of controls. The odds ratio for requiring surgery for PPI was 13.4 for sagittal MUL <9 mm and 3.2 if the MUL <12 mm. CONCLUSIONS Patients who had surgery for PPI had a significantly shorter MUL and sphincter volume than continent controls. Men with an MUL >17 mm are unlikely to require surgery for PPI whereas an MUL <12 mm significantly increases the risk of requiring surgery for PPI. MUL should be considered when discussing treatment options for prostate cancer.
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Affiliation(s)
- Priyanka Oza
- Department of Urology, Guy's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUK,Faculty of Life Sciences & MedicineKing's College LondonLondonUK
| | | | - Giles Rottenberg
- Department of RadiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Findlay MacAskill
- Department of Urology, Guy's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Sachin Malde
- Department of Urology, Guy's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Claire Taylor
- Department of Urology, Guy's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Arun Sahai
- Department of Urology, Guy's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUK,Faculty of Life Sciences & MedicineKing's College LondonLondonUK
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10
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Greenberg SA, Cowan JE, Lonergan PE, Washington SL, Nguyen HG, Zagoria RJ, Carroll PR. The effect of preoperative membranous urethral length on likelihood of postoperative urinary incontinence after robot-assisted radical prostatectomy. Prostate Cancer Prostatic Dis 2022; 25:344-350. [DOI: 10.1038/s41391-022-00527-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/01/2022] [Accepted: 03/03/2022] [Indexed: 11/09/2022]
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11
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Colarieti A, Thiruchelvam N, Barrett T. Evaluation of image-based prognostic parameters of post-prostatectomy urinary incontinence: A literature review. Int J Urol 2021; 28:890-897. [PMID: 34101272 DOI: 10.1111/iju.14609] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/04/2021] [Indexed: 12/18/2022]
Abstract
Prostate cancer is the second most common male cancer, and radical prostatectomy is a highly effective treatment for intermediate and high-risk disease. However, post-prostatectomy urinary incontinence remains a major functional side-effect in patients undergoing radical prostatectomy. Despite recent improvements in preoperative imaging quality and surgical techniques, it remains challenging to predict or prevent occurrence of this complication. The aim of this research was to review the current published literature on pre- and postoperative imaging evaluation of the prostate and pelvic structures, to identify added value in the prediction of post-prostatectomy urinary incontinence. A computerized bibliographic search of the PubMed library was carried out to identify imaging-based articles evaluating the pelvic floor and surrounding structures pre- and/or postradical prostatectomy to predict post-prostatectomy urinary incontinence. A total of 32 articles were included. Of these, 29 papers assessed the importance of magnetic resonance imaging evaluation, with a total of 16 parameters evaluated. The most common parameters were intravesical protrusion, the membranous urethral length, prostatic volume and periurethral fibrosis. Preoperative membranous urethral length and its preservation after surgery showed the strongest correlation with urinary incontinence. Three studies evaluated ultrasound, with all carried out postoperatively. This technique benefits from a dynamic evaluation, and the results are promising for proximal urethral hypermobility and the degree of bladder neck funneling on the Valsalva maneuver. Several imaging studies evaluated the predictors of post-prostatectomy urinary incontinence, with preoperative membranous urethral length offering the most promise. However, the current literature is limited by the single-center nature of studies, and the heterogeneity in patient populations and methodologies used.
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Affiliation(s)
- Anna Colarieti
- Department of Radiology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Nikesh Thiruchelvam
- Department of, Urology, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Tristan Barrett
- Department of, Radiology, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,CamPARI Clinic, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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12
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Contemporary Review of MRI in Benign Genitourinary Pelvic Medicine: What Every Urologist Should Know. CURRENT BLADDER DYSFUNCTION REPORTS 2021. [DOI: 10.1007/s11884-021-00631-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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13
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Lardas M, Grivas N, Debray TPA, Zattoni F, Berridge C, Cumberbatch M, Van den Broeck T, Briers E, De Santis M, Farolfi A, Fossati N, Gandaglia G, Gillessen S, O'Hanlon S, Henry A, Liew M, Mason M, Moris L, Oprea-Lager D, Ploussard G, Rouviere O, Schoots IG, van der Kwast T, van der Poel H, Wiegel T, Willemse PP, Yuan CY, Grummet JP, Tilki D, van den Bergh RCN, Lam TB, Cornford P, Mottet N. Patient- and Tumour-related Prognostic Factors for Urinary Incontinence After Radical Prostatectomy for Nonmetastatic Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Focus 2021; 8:674-689. [PMID: 33967010 DOI: 10.1016/j.euf.2021.04.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/23/2021] [Indexed: 12/22/2022]
Abstract
CONTEXT While urinary incontinence (UI) commonly occurs after radical prostatectomy (RP), it is unclear what factors increase the risk of UI development. OBJECTIVE To perform a systematic review of patient- and tumour-related prognostic factors for post-RP UI. The primary outcome was UI within 3 mo after RP. Secondary outcomes included UI at 3-12 mo and ≥12 mo after RP. EVIDENCE ACQUISITION Databases including Medline, EMBASE, and CENTRAL were searched between January 1990 and May 2020. All studies reporting patient- and tumour-related prognostic factors in univariable or multivariable analyses were included. Surgical factors were excluded. Risk of bias (RoB) and confounding assessments were performed using the Quality In Prognosis Studies (QUIPS) tool. Random-effects meta-analyses were performed for all prognostic factor, where possible. EVIDENCE SYNTHESIS A total of 119 studies (5 randomised controlled trials, 24 prospective, 88 retrospective, and 2 case-control studies) with 131 379 patients were included. RoB was high for study participation and confounding; moderate to high for statistical analysis, study attrition, and prognostic factor measurement; and low for outcome measurements. Significant prognostic factors for postoperative UI within 3 mo after RP were age (odds ratio [OR] per yearly increase 1.04, 95% confidence interval [CI] 1.03-1.05), membranous urethral length (MUL; OR per 1-mm increase 0.81, 95% CI 0.74-0.88), prostate volume (PV; OR per 1-ml increase 1.005, 95% CI 1.000-1.011), and Charlson comorbidity index (CCI; OR 1.28, 95% CI 1.09-1.50). CONCLUSIONS Increasing age, shorter MUL, greater PV, and higher CCI are independent prognostic factors for UI within 3 mo after RP, with all except CCI remaining prognostic at 3-12 mo. PATIENT SUMMARY We reviewed the literature to identify patient and disease factors associated with urinary incontinence after surgery for prostate cancer. We found increasing age, larger prostate volume, shorter length of a section of the urethra (membranous urethra), and lower fitness were associated with worse urinary incontinence for the first 3 mo after surgery, with all except lower fitness remaining predictive at 3-12 mo.
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Affiliation(s)
- Michael Lardas
- Department of Urology, Metropolitan General Hospital, Athens, Greece.
| | - Nikos Grivas
- Department of Urology, University General Hospital of Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Thomas P A Debray
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Fabio Zattoni
- Urology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
| | | | | | | | | | - Maria De Santis
- Department of Urology, Charité Universitätsmedizin Berlin, Germany; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Andrea Farolfi
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
| | - Nicola Fossati
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giorgio Gandaglia
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Silke Gillessen
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland
| | - Shane O'Hanlon
- Medicine for Older People, Saint Vincent's University Hospital, Dublin, Ireland
| | - Ann Henry
- Leeds Cancer Centre, St. James's University Hospital and University of Leeds, Leeds, UK
| | - Matthew Liew
- Department of Urology, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
| | - Malcolm Mason
- Division of Cancer & Genetics, Cardiff University School of Medicine, Velindre Cancer Centre, Cardiff, UK
| | - Lisa Moris
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Daniela Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, VU University, Amsterdam, The Netherlands
| | | | - Olivier Rouviere
- Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Henk van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Peter-Paul Willemse
- Department of Oncological Urology, University Medical Center, Utrecht Cancer Center, Utrecht, The Netherlands
| | - Cathy Y Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, ON, Canada
| | - Jeremy P Grummet
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, and Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Thomas B Lam
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Philip Cornford
- Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
| | - Nicolas Mottet
- Department of Urology, University Hospital, St. Etienne, France
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14
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Muñoz-Calahorro C, García-Sánchez C, Barrero-Candau R, García-Ramos JB, Rodríguez-Pérez AJ, Medina-López RA. Anatomical predictors of long-term urinary incontinence after robot-assisted laparoscopic prostatectomy: A systematic review. Neurourol Urodyn 2021; 40:1089-1097. [PMID: 33851426 DOI: 10.1002/nau.24652] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/22/2021] [Accepted: 02/22/2021] [Indexed: 02/06/2023]
Abstract
AIMS There is scarce evidence of anatomical risk factors that might affect long-term post-prostatectomy incontinence (PPI) in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). This systematic review aims to identify anatomical measurements in preoperative magnetic resonance imaging (MRI) that might be associated with increased risk of urinary incontinence (UI) 1 year after RALP. METHODS A comprehensive search on Pubmed and Scopus databases up to November 2020 was performed. Eight articles met the inclusion criteria and were finally selected. RESULTS The selected studies included 1146 patients. Seven articles focused on membranous urethral length (MUL); all of them related MUL to long-term PPI in univariate analysis and five of them in multivariate analysis. Four studies presented MUL difference to measure the magnitude of the effect. Average MUL (mm) was 15.9 (SD, 2.6), 16.1 (95% confidence interval [CI]: 13.9-18.9), 12.1 (95% CI 9.7-14.9) and 14.5 in continent patients and 13.9 (SD, 2.9), 10 (95% CI: 8.7-12.1), 10.3 (95% CI: 8.7-12.4) and 9.3 in incontinent patients, with statistically significant differences in all cases. Five studies presented the odds ratio as a result; although there was substantial heterogeneity in the methods used to obtain it, there was consistency in finding an inverse association between MUL and PPI. Other measurements including prostatic-urethral angle, membranous urethral thickness, intraprostatic urethral length and intravesical prostatic protrusion have been reported in few studies, and no association with long-term PPI was found. Levator ani muscle thickness was related to long-term PPI in one article. CONCLUSION Greater MUL on preoperative MRI is associated with lower risk of UI 1 year after RALP.
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15
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Faria EF, Maciel CVM, Berger A, Mitre A, Dauster B, Freitas CH, Fraga C, Chade D, Dall'Oglio M, Carvalho F, Campos F, Carvalhal GF, Lemos GC, Guimarães G, Zampolli H, Alves JR, Manzano JP, Fortes MA, Rocha MFH, Rubinstein M, Luz M, Romanelli P, Coelho R, Rocha R, Machado RD, Dos Reis RB, Zequi S, Guida R, Muglia V, Tobias-Machado M. Recommendations on robotic-assisted radical prostatectomy: a Brazilian experts' consensus. J Robot Surg 2021; 15:829-839. [PMID: 33426578 DOI: 10.1007/s11701-020-01186-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
Radical prostatectomy is a commonly adopted treatment for localized/locally advanced prostate cancer in men with a life expectancy of ten years or more. Robotic-assisted radical prostatectomy (RARP) is comparable to open radical prostatectomy on cancer control and complication rates; however, new evidence suggests that RARP may have better functional outcomes, especially with respect to urinary incontinence and erectile dysfunction. Some of the surgical steps of RARP are not adequately described in published literature and, as such, may have an impact on the final outcomes of the procedure. We organized a Brazilian experts' panel to evaluate best practices in RARP. The confection of the recommendations broadly involved: selection of the experts; establishment of working groups; systematic review of the literature and elaboration of a questionnaire; and construction of the final text with the approval of all participants. The participants reviewed the publications in English from December 2019 to February 2020. A one-round Delphi technique was employed in 188 questions. Five reviewers worked on the final recommendations using consensual and non-consensual questions. We found 59.9% of questions with greater than 70% agreement that were considered consensual. Non-consensual questions were reported according to the responses. The recommendations were based on evidence-based literature and individual perceptions adapted to the Brazilian reality, although some issues remain controversial. We believe that these recommendations may help urologists involved in RARP and hope that future discussions on this surgical procedure may evolve over the ensuing years.
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Affiliation(s)
| | | | - André Berger
- Hospital Moinhos de Vento, Porto Alegre , RS, Brazil
| | - Anuar Mitre
- University of São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Daher Chade
- Instituto Cancer de São Paulo, São Paulo, SP, Brazil
| | | | | | - Franz Campos
- Instituto Nacional do Cancer, Rio de Janeiro, RJ, Brazil
| | | | | | | | | | | | | | | | | | | | - Murilo Luz
- Hospital Albert Einstein, São Paulo, SP, Brazil
| | | | - Rafael Coelho
- Instituto Cancer de São Paulo, São Paulo, SP, Brazil
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