rafael coelho - Academia.edu (original) (raw)

Papers by rafael coelho

International Journal of Urology, 2013

The aim of our report was to describe the feasibility of robotic retroperitoneal lymph node disse... more The aim of our report was to describe the feasibility of robotic retroperitoneal lymph node dissection in the contemporary era. We suggest the linear port location and 90° robotic docking as the main key to minimizing instrument clashing and improving the range of surgical accessibility.

Asian Journal of Urology, 2020

To review the most used intracorporeal orthotopic ileal neobladder (ICONB) after radical cystecto... more To review the most used intracorporeal orthotopic ileal neobladder (ICONB) after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives, including new consistent images. Methods: We performed a non-systematic review of the literature with the keywords "bladder cancer", "urinary diversion", "radical cystectomy", and "neobladder". Results: Forty studies were included in the analysis. The most frequent type of ICONB was the modified Studer "U" neobladder (70%) followed by the Hautmann "W" modified neobladder (7.5%), the "Y" neobladder (5%), and the Padua neobladder (5%). The operative time to perform a urinary diversion ranged from 124 to 553 min. The total estimated blood loss ranged from 200 to 900 mL. The rate of positive surgical margins ranged from 0% to 8.1%. Early minor and major complication rates ranged from 0% to 100% and from 0% to 33%, respectively. Late minor and major complication rates ranged from 0% to 70% and from 0% to 25%, respectively. Conclusion: The most frequent types of ICONB are Studer "U" neobladder, Hautmann "W" neobladder, "Y" neobladder, and the Padua neobladder. Randomized studies comparing the performance of the different types of ICONB, the performance in an intra or extracorporeal manner, or the performance of an ICONB versus ICIC are lacking in the literature. To this day, there are not sufficient quality data to determine the supremacy of one technique. This manuscript represents a compendium of the most used ICONB with detailed descriptions of the technical aspects, operative and perioperative outcomes, and new consistent images of each technique.

BJU international, Jan 20, 2018

To show the feasibility, oncological and functional outcomes of neurovascular bundle (NVB) preser... more To show the feasibility, oncological and functional outcomes of neurovascular bundle (NVB) preservation during salvage robot-assisted radical prostatectomy (RARP). In the present institutional review board-approved retrospective analysis, between January 2008 and March 2016, 80 patients underwent salvage RARP, performed by a single surgeon (V.P), because of local recurrence after primary treatment. These patients were categorized into two groups depending on the degree of nerve-sparing (NS) performed: a good-NS group (≥50% of NVB preservation) and a poor-NS group (<50% of NVB preservation). A standard transperitoneal six-port technique, using the DaVinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA), was performed, and either an anterograde or a retrograde approach was used for NVB preservation. Validated questionnaires were used preoperatively (Sexual Health Inventory for Men [SHIM] and American Urological Association scores). Potency after salvage RARP was defined as...

BJU International, 2017

ObjectivesTo create a statistical tool for the estimation of extracapsular extension (ECE) level ... more ObjectivesTo create a statistical tool for the estimation of extracapsular extension (ECE) level of prostate cancer and determine the nerve‐sparing (NS) approach that can be safely performed during radical prostatectomy (RP).Patients and MethodsA total of 11 794 lobes, from 6 360 patients who underwent robot‐assisted RP between 2008 and 2016 were evaluated. Clinicopathological features were included in a statistical algorithm for the prediction of the maximum ECE width. Five multivariable logistic models were estimated for: presence of ECE and ECE width of >1, >2, >3, and >4 mm. A five‐zone decision rule based on a lower and upper threshold is proposed. Using a graphical interface, surgeons can view patient's pre‐treatment characteristics and a curve showing the estimated probabilities for ECE amount together with the areas identified by the decision rule.ResultsOf the 6 360 patients, 1 803 (28.4%) were affected by non‐organ‐confined disease. ECE was present in 1 351...

Journal of robotic surgery, Jan 31, 2016

Our aim was to evaluate factors associated with persistently elevated prostate-specific antigen (... more Our aim was to evaluate factors associated with persistently elevated prostate-specific antigen (PSA) and biochemical recurrence following robotic-assisted radical prostatectomy (RARP). The study population (N = 5300) consisted of consecutive patients who underwent RARP for localized prostate cancer by a single surgeon (VP) from January 2008 through July 2013. A query of our Institutional Review Board-approved registry identified 162 men with persistently elevated PSA (group A), defined as PSA level ≥0.1 ng/ml at 6 weeks after surgery, who were compared with rest of the cohort group having undetectable PSA, group B (<0.1 ng/ml). A univariate and multivariate logistic regression analysis was used to evaluate the significant association between various variables and the following: (1) persistently elevated PSA, (2) BCR (PSA value ≥0.2 ng/ml) on follow-up in the persistent PSA group. On multivariate analysis, only the following parameters were significantly associated with persisten...

BJU international, Jan 26, 2015

To analyze the continence outcomes of robot assisted radical prostatectomy (RARP) in suboptimal p... more To analyze the continence outcomes of robot assisted radical prostatectomy (RARP) in suboptimal patients that have challenging continence recovery factors: enlarged prostates, elderly patients, higher Body Mass Index (BMI), salvage prostatectomy and bladder neck procedures prior to RARP MATERIAL & METHODS: From January 2008 through November 2012, 4023 patients underwent RARP by a single surgeon at our institution. Retrospective analysis of prospectively collected data identified 3362 men who had minimum of one year of follow-up. This cohort of patients was stratified into six groups: Group I, age 70 and over (n=451); Group II, BMI 35 and over (n=197); Group III, prior bladder neck procedures (n=103); Group IV, prostate weight 80 g and over (n=280); and Group V, salvage prostatectomy patients (n=41). Group VI consisted of patients (n=2447) with none of these risk factors. Continence outcomes at follow-up were analyzed for all groups. The continence rate at 1 year and mean time to con...

International braz j urol, 2010

Purpose: Nerve sparing radical prostatectomy is the gold standard for the treatment of prostate c... more Purpose: Nerve sparing radical prostatectomy is the gold standard for the treatment of prostate cancer. Over the past decade, more and more surgeons and patients are opting for a robot-assisted procedure. The purpose of this paper is to briefly review different techniques and outcomes of nerve sparing robot assisted laparoscopic prostatectomy (RALP). Materials and Methods: We performed a MEDLINE search from 2001 to 2009 using the keywords "robotic prostatectomy", "cavernosal nerve", "pelvic neuroanatomy", "potency", "outcomes" and "comparison". Extended search was also performed using the references from these articles. Results: Several techniques of nerve sparing are available in literature for RALP, which have been described in this manuscript. These include, "the veil of Aphrodite", "athermal retrograde neurovascular release", "clipless antegrade nerve sparing" and "clipless cautery free technique". The comparative and the non comparative series showing outcomes of RALP have been described in the manuscript. Conclusions: The basic principles for nerve sparing revolve around minimal traction, athermal dissection, and approaching the correct planes. It has not been documented if any one technique is better than the other. Regardless of technique, patient selection, wise clinical judgment and a careful dissection are the keys to achieve optimal oncological outcomes following RALP.

Robotic Urologic Surgery, 2011

The aim of this study is to assesses the predictive value of CHADS2 scores, CHA2DS2-VASc scores a... more The aim of this study is to assesses the predictive value of CHADS2 scores, CHA2DS2-VASc scores and Charlson Comorbidity Index Score (CCIS) for stroke among patients with prostate cancer. Materials and Methods: We used Taiwan registry data base, National Health Insurance Research Database (NHIRD) in this study. We identified participants with non-atrial fibrillation (AF) prostate cancer diagnoses who underwent radical prostatectomy between January 1,1997 and December 31,2011. CHADS2 scores, CHA2DS2-VASc scores and CCIS were used to stratify the ischemic stroke risk. The scores were calculated based on the comorbilities recorded before radical prostatectomy. The receiver operating characteristics curve (ROC) was used to assess the prediction accuracy for ischemic stroke. All participants were followed from the date of enrollment until ischemic stroke, death, or the end of the 5-year follow up period. Results: There were5414 patients diagnosed with prostate cancer undergoing radical prostatectomy in this study. The mean age at diagnosis was 65 ± 6 years. The prediction accuracy for ischemic stroke in better in CHADS2 scores (AUC ¼ 0.971) and CHA2DS2-VASc scores (AUC ¼ 0.953) than CCIS (AUC ¼ 0.504). Conclusions: Our results show that the CHADS2 score could be applied for ischemic stroke prediction in prostate cancer patients underwent radical prostatectomy. Cardiovascular risks evaluation and management are suggested for these patient with higher CHADS2 score.

Investigative Radiology, 2014

Objectives: The objective of this study was to evaluate the role of 3-T multiparametric magnetic ... more Objectives: The objective of this study was to evaluate the role of 3-T multiparametric magnetic resonance imaging (MP-MRI) and magnetic resonanceYguided biopsy (MRGB) in early risk restratification of patients on active surveillance at 3 and 12 months of follow-up. Materials and Methods: Within 4 hospitals participating in a large active surveillance trial, a side study was initiated. Pelvic magnetic resonance imaging, prostate MP-MRI, and MRGB were performed at 3 and 12 months (latter prostate MP-MRI and MRGB only) after prostate cancer diagnosis in 1 of the 4 participating hospitals. Cancer-suspicious regions (CSRs) were defined on prostate MP-MRI using Prostate Imaging Reporting And Data System (PI-RADS) scores. Risk restratification criteria for active surveillance discontinuance were (1) histopathologically proven magnetic resonance imaging suspicion of node/bone metastases and/or (2) a Gleason growth pattern (GGP) 4 and/or 5 and/or cancer multifocality (Q3 foci) in MRGB specimens of a CSR on MP-MRI. Results: From 2009 to 2012, a total of 64 of 82 patients were consecutively and prospectively included and underwent MP-MRI and a subsequent MRGB. At 3 and 12 months of follow-up, 14% (9/64) and 10% (3/30) of the patients were risk-restratified on the basis of MP-MRI and MRGB. An overall CSR PI-RADS score of 1 or 2 had a negative predictive value of 84% (38/45) for detection of any prostate cancer and 100% (45/45) for detection of a GGP 4 or 5 containing cancer upon MRGB, respectively. A CSR PI-RADS score of 4 or higher had a sensitivity of 92% (11/12) for detection of a GGP 4 or 5 containing cancer upon MRGB. Conclusions: Application of MP-MRI and MRGB in active surveillance may contribute in early identification of patients with GGP 4 or 5 containing cancers at 3 months of follow-up. If, during further follow-up, a PI-RADS score of 1 or 2 continues to have a negative predictive value for GGP 4 or 5 containing cancers, a PI-RADS standardized reported MP-MRI may be a promising tool for the selection of prostate cancer patients suitable for active surveillance.

The Journal of urology, 2011

Positive surgical margins are an independent predictive factor for biochemical recurrence after r... more Positive surgical margins are an independent predictive factor for biochemical recurrence after radical prostatectomy. We analyzed the incidence of and associative factors for positive surgical margins in a multi-institutional series of 8,418 robotic assisted radical prostatectomies.

Therapeutic advances in urology, 2011

TURP for many years has been considered the gold standard for surgical treatment of BPH. Symptoms... more TURP for many years has been considered the gold standard for surgical treatment of BPH. Symptoms relief, improvement in Maximum flow rate and reduction of post void residual urine have been reported in several experiences. Notwithstanding a satisfactory efficacy, concerns have been reported in terms of safety outcomes:intracapsular perforation, TUR syndrome, bleeding with a higher risk of transfusion particularly in larger prostates have been extensivelyreported in the literature.IN THE RECENT YEARS THE USE OF NEW FORMS OF ENERGY AND DEVICES SUCHAS BIPOLAR RESECTOR, HO: YAG and potassium-titanyl-phosphate laserare challenging the role of traditional TURP for BPH surgical treatment.In 1999 TURP represented the 81% of surgical treatment for BPHversus 39% of 2005. Is this a marketing driven change or is there areal advantage in new technologies?We analyzed guidelines and higher evidence studies to evaluate therole of the most relevant new surgical approaches compared to TURPfor the tr...

European Urology, 2010

Background: Perioperative complications following robotic-assisted radical prostatectomy (RARP) h... more Background: Perioperative complications following robotic-assisted radical prostatectomy (RARP) have been previously reported in recent series. Few studies, however, have used standardized systems to classify surgical complications, and that inconsistency has hampered accurate comparisons between different series or surgical approaches. Objective: To assess trends in the incidence and to classify perioperative surgical complications following RARP in 2500 consecutive patients. Design, setting, and participants: We analyzed 2500 patients who underwent RARP for treatment of clinically localized prostate cancer (PCa) from August 2002 to February 2009. Data were prospectively collected in a customized database and retrospectively analyzed. Intervention: All patients underwent RARP performed by a single surgeon. Measurements: The data were collected prospectively in a customized database. Complications were classified using the Clavien grading system. To evaluate trends regarding complications and radiologic anastomotic leaks, we compared eight groups of 300 patients each, categorized according the surgeon's experience (number of cases). Results and limitations: Our median operative time was 90 min (interquartile range [IQR]: 75-100 min). The median estimated blood loss was 100 ml (IQR:100-150 ml). Our conversion rate was 0.08%, comprising two procedures converted to standard laparoscopy due to robot malfunction. One hundred and forty complications were observed in 127 patients (5.08%). The following percentages of patients presented graded complications: grade 1, 2.24%; grade 2, 1.8%; grade 3a, 0.08%; grade 3b, 0.48%; grade 4a, 0.40%. There were no cases of multiple organ dysfunction or death (grades 4b and 5). There were significant decreases in the overall complication rates (p = 0.0034) and in the number of anastomotic leaks (p < 0.001) as the surgeon's experience increased. Conclusions: RARP is a safe option for treatment of clinically localized PCa, presenting low complication rates in experienced hands. Although the robotic system provides the surgeon with enhanced vision and dexterity, proficiency is only accomplished with consistent surgical volume; complication rates demonstrated a tendency to decrease as the surgeon's experience increased.

European Urology, 2009

L'analisi cumulativa degli studi comparativi RRP-LRP non ha mostrato differenze L'analisi cumulat... more L'analisi cumulativa degli studi comparativi RRP-LRP non ha mostrato differenze L'analisi cumulativa degli studi comparativi RRP-RALP ha mostrato un vantaggio statisticamente significativo della RALP (RR 1,58) e u r o p e a n u r o l o g y 5 5

European Urology, 2007

Objective: To evaluate the initial functional and oncologic results of 184 robot-assisted radical... more Objective: To evaluate the initial functional and oncologic results of 184 robot-assisted radical prostatectomies performed at our hospital. Methods: A retrospective study was made of the first 184 consecutive robot-assisted radical prostatectomies performed at our hospital between February 2003 and December 2005. The procedures were performed by two surgeons who used the da Vinci robot with three robot arms. A transperitoneal approach was used in all patients. All patients had clinically organ-confined prostate cancer (cT2c). The median follow-up was 6 mo. Results: A positive surgical margin was found in 29 of the 184 patients (mean: 15.7%). The percentage positive surgical margins for the organconfined (pT2) and non-organ-confined prostate cancers (pT3) were 2.5% and 38%, respectively. Ninety-five percent of patients were completely continent or wore one safety liner. Forty-three percent of the continent patients achieved complete continence within 28 d. Eighty-one percent of the patients who were younger than 60 yr and received a nervesparing procedure were potent and able to perform sexual intercourse. This percentage dropped to 51% in patients older than 60 yr. No major complications were encountered. Conclusions: The functional and oncologic results of this minimally invasive procedure seem very promising. Longer follow-up of the data and larger prospective studies are necessary to confirm these promising results.

European Urology, 2009

Background: Several studies have shown that robot-assisted laparoscopic radical prostatectomy (RA... more Background: Several studies have shown that robot-assisted laparoscopic radical prostatectomy (RALP) is feasible, with favorable complication rates and short hospital times. However, the early recovery of urinary continence remains a challenge to be overcome. Objective: We describe our technique of periurethral retropubic suspension stitch during RALP and report its impact on early recovery of urinary continence. Design, setting, and participants: We analyze prospectively 331 consecutive patients who underwent RALP, 94 without the placement of suspension stitch (group 1) and 237 with the application of the suspension stitch (group 2). Surgical procedure: The only difference between the groups was the placement of the puboperiurethral stitch after the ligation of the dorsal venous complex (DVC). The periurethral retropubic stitch was placed using a 12-in monofilament polyglytone suture on a CT-1 needle. The stitch was passed from right to left between the urethra and DVC, and then through the periostium on the pubic bone. The stitch was passed again through the DVC, and then through the pubic bone in a figure eight, and then tied. Measurements: Continence rates were assessed with a self-administered validated questionnaire (Expanded Prostate Cancer Index Composite [EPIC]) at 1, 3, 6, and 12 mo after the procedure. Continence was defined as the use of no absorbent pads or no leakage of urine. Results and limitations: In group 1, the continence rate at 1, 3, 6, and 12 mo postoperatively was 33%, 83%, 94.7%, and 95.7%, respectively; in group 2, the continence rate was 40%, 92.8%, 97.9%, and 97.9%, respectively. The suspension technique resulted in significantly greater continence rates at 3 mo after RALP (p = 0.013). The median/mean interval to recovery of continence was also statistically significantly shorter in the suspension group (median: 6 wk; mean: 7.338 wk; 95% confidence interval [CI]: 6.387-8.288) compared to the nonsuspension group (median: 7 wk; mean: 9.585 wk; 95% CI: 7.558-11.612; log rank test, p = 0.02). Conclusions: The suspension stitch during RALP resulted in a statistically significantly shorter interval to recovery of continence and higher continence rates at 3 mo after the procedure.

European Urology, 2011

Background: Widespread use of prostate-specific antigen screening has resulted in younger and hea... more Background: Widespread use of prostate-specific antigen screening has resulted in younger and healthier men being diagnosed with prostate cancer. Their demands and expectations of surgical intervention are much higher and cannot be adequately addressed with the classic trifecta outcome measures. Objective: A new and more comprehensive method for reporting outcomes after radical prostatectomy, the pentafecta, is proposed. Design, setting, and participants: From January 2008 through September 2009, details of 1111 consecutive patients who underwent robot-assisted radical prostatectomy performed by a single surgeon were retrospectively analyzed. Of 626 potent men, 332 who underwent bilateral nerve sparing and who had 1 yr of follow-up were included in the study group. Measurements: In addition to the traditional trifecta outcomes, two perioperative variables were included in the pentafecta: no postoperative complications and negative surgical margins. Patients who attained the trifecta and concurrently the two additional outcomes were considered as having achieved the pentafecta. A logistic regression model was created to evaluate independent factors for achieving the pentafecta. Results and limitations: Continence, potency, biochemical recurrence-free survival, and trifecta rates at 12 mo were 96.4%, 89.8%, 96.4%, and 83.1%, respectively. With regard to the perioperative outcomes, 93.4% had no postoperative complication and 90.7% had negative surgical margins. The pentafecta rate at 12 mo was 70.8%. On multivariable analysis, patient age (p = 0.001) was confirmed as the only factor independently associated with the pentafecta. Conclusions: A more comprehensive approach for reporting prostate surgery outcomes, the pentafecta, is being proposed. We believe that pentafecta outcomes more accurately represent patients' expectations after minimally invasive surgery for prostate cancer. This approach may be beneficial and may be used when counseling patients with clinically localized disease.

European Archives of Oto-Rhino-Laryngology, 2012

Objective: To determine factors that may potentially predict a prolonged hospital stay after sche... more Objective: To determine factors that may potentially predict a prolonged hospital stay after scheduled tonsillectomy in the pediatric population. Study Design: Retrospective chart review. Subjects and Methods: A review of pediatric patients who had undergone a tonsillectomy at a tertiary medical center from July 2007 to November 2010 was made. Preoperative variables were analyzed to determine predictors of prolonged hospital stay (defined as [24 h) that may have influenced their length of stay. Setting: Tertiary care medical center. Results: 827 patient charts were reviewed. One hundred and one patients (12.2 %) had hospital stays [24 h. Indications for tonsillectomy included obstructive sleep apnea (69.2 %), tonsillitis (13.8 %), and tonsillar asymmetry (0.9 %). Seventyseven (76.2 %) patients of the extended stay group had a delayed discharge because of poor oral intake. Fever and respiratory complications accounted for 0.5 and 1.8 % respectively of those patients who had extended stays. Patients with extended stays were younger (p \ 0.001) and weighed less (p \ 0.001). Patients with a history of sickle cell crises, reactive airway disease, bronchodilator use, and anti-reflux medication use (p \ 0.05) were more likely to have a prolonged hospital stay. Conclusion: Factors from the history and physical of pediatric patients may predict which children are at higher risk for extended hospital stays after routine tonsillectomy. Predictors of extended stays include those under the age of four and children weighing \20 kg, those with a history of sickle cell crises or reactive airway disease, and those using bronchodilators or antireflux medication.