RAFAEL FERREIRA COELHO
Projetos de Pesquisa
Unidades Organizacionais
Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Faculdade de Medicina
LIM/55 - Laboratório de Urologia, Hospital das Clínicas, Faculdade de Medicina
LIM/55 - Laboratório de Urologia, Hospital das Clínicas, Faculdade de Medicina
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article ROBOT-ASSISTED EXTENDED PELVIC LYMPH NODE DISSECTION IN PROSTATE CANCER, WHEN AND HOW?(2019) SIERRA, Pablo S.; LESTINGI, Jean F. P.; ALBUQUERQUE, Emanuel V.; PONTES JR., Jose; CARVALHO, Paulo A. de; CAVALCANTE, Alexandre; GUGLIELMETTI, Giuliano B.; NAHAS, William C.; COELHO, Rafael F.OBJECTIVE: To review the literature evaluating the role of the extended pelvic lymph node dissection ePLND during robot assisted radical prostatectomy (RARP) in the management of PCa patients, as well as the preoperative clinic pathologic factors that predict lymph node metastases (LNM). The technique and current outcomes of robotic ePLND will be presented. METHODS: Medline (R)/Pubmed (R) were searched up to august 2018 to find comparative studies of different anatomic limits of pelvic lymph node dissection (PLND) during RARP, open or pure laparoscopic surgery that reported number of nodes retrieved, oncologic outcomes and complications. The search was complemented to identify studies that evaluated diagnostic images and factors that predict LNM. Overall, 44 articles were included for full text review. RESULTS: There is not an imaging technique with an acceptable performance to select patients for PLND, the decision to perform a PLND is based on clinical characteristics described on validated nomograms. Median lymph node yield at RARP range from 5 to 21 depending on the extent of PLND, positivity rate of LN as high as 37% depending on the risk stratification of patients. Robot-assisted can be carried out to any extent with lymph node yields and safety concerns comparable to the open approach. CONCLUSION: Extended pelvic lymph node dissection is recommended to be performed at the time of RARP in intermediate and high-risk patients and cannot be replaced by other modalities. A benefit in terms of oncologic outcomes remains to be established. The robot assisted approach offers shorter length of hospital stay, lower transfusion rates and comparable outcomes compared to other surgical approaches.- Incidence of lymphoceles after robot-assisted pelvic lymph node dissection(2011) ORVIETO, Marcelo A.; COELHO, Rafael F.; CHAUHAN, Sanket; PALMER, Kenneth J.; ROCCO, Bernardo; PATEL, Vipul R.OBJECTIVE To determine the incidence and predictive factors of lymphocele formation in patients undergoing pelvic lymph node dissection (PLND) during robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS Between April and December 2008, 76 patients underwent PLND during RARP for >= cT2c, prostate-specific antigen level >= 10, Gleason score >= 7 prostate cancer. All patients were prospectively followed up with pelvic computed tomography 6-12 weeks after the procedure. All patients received s.c. heparin preoperatively and postoperatively. PLND was limited to zones 1 and 2 as defined by Studer. Plasma-kinetic bipolar forceps were used for haemostasis during PLND. RESULTS At a mean follow-up of 10.8 weeks, 51% (39/76) of patients had developed a lymphocele. Of these 39 lymphoceles 32 (82%) were unilateral and seven (18%) were bilateral. The mean (range) lymphocele size was 4.3 x 3.2 (1.5-12.3) cm; 41% of lymphoceles were < 4 cm, 53.9% were 4-10 cm, and 5.1% were > 10 cm in diameter. Six of the 39 lymphoceles (15.4%) were clinically symptomatic. The symptoms were as follows: pelvic pressure in five patients, abdominal distension with ileus in three patients, leg pain/weakness in one patient and costovertebral tenderness in one patient. Two lymphoceles required intervention. On the logistic regression model the presence of nodal metastases, tumour volume in the prostate specimen and extracapsular extension (ECE) were independent risk factors for the development of a lymphocele. There was no correlation between estimated blood loss, body mass index, pathological Gleason score or number nodes dissected and the presence of lymphocele. CONCLUSIONS The incidence of lymphoceles was higher than anticipated given the believed protective effect of the transperitoneal approach against lymphocele formation. The risk of lymphocele seemed to increase linearly with the presence of more extensive disease, particularly ECE and nodal involvement. The benefit of PLND during RARP should be weighed against the elevated risk of lymphocele formation and its potential complications.
- Nerve-sparing in salvage robot-assisted prostatectomy: surgical technique, oncological and functional outcomes at a single high-volume institution(2018) BONET, Xavier; OGAYA-PINIES, Gabriel; WOODLIEF, Tracey; HERNANDEZ-CARDONA, Eduardo; GANAPATHI, Hariharan; ROGERS, Travis; COELHO, Rafael F.; ROCCO, Bernardo; VIGUES, Francesc; PATEL, VipulObjectivePatients and MethodsTo 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 the ability to achieve a successful erection with penetration >50% of the time, while full continence after salvage RARPwas defined as 0 pads used. The Kaplan-Meier method was used for survival and predictive estimations, and regression models were used to identify the predictors of potency, continence and biochemical failure (BCF). ResultsConclusionsThe potency rate at 12months was higher in the good-NS group (25.6% vs 4.3%; P = 0.036) regardless of previous SHIM score, and good NS tended to be predictive of potency after salvage RARP (P = 0.065). The full continence rate at 12months and BCF rate were similar in the two groups, and non-radiation primary treatment was the only predictor of continence at 12months after salvage RARP (P = 0.033). Our data support the feasibility and safety of NVB preservation for salvage RARP conducted in select patients in a high-volume institution and the subsequent better recovery of adequate erections for intercourse.
- Opioids and premature biochemical recurrence of prostate cancer: a randomised prospective clinical trial(2021) RANGEL, Felipe P.; JR, Jose O. C. Auler; CARMONA, Maria J. C.; CORDEIRO, Mauricio D.; NAHAS, William C.; COELHO, Rafael F.; SIMOES, Claudia M.Background: Prostate cancer is one of the most prevalent neoplasms in male patients, and surgery is the main treatment. Opioids can have immune modulating effects, but their relation to cancer recurrence is unclear. We evaluated whether opioids used during prostatectomy can affect biochemical recurrence-free survival. Methods: We randomised 146 patients with prostate cancer scheduled for prostatectomy into opioid-free anaesthesia or opioid-based anaesthesia groups. Baseline characteristics, perioperative data, and level of prostate-specific antigen every 6 months for 2 yr after surgery were recorded. Prostate-specific antigen >0.2 ng ml(-1) was considered biochemical recurrence. A survival analysis compared time with biochemical recurrence between the groups, and a Cox regression was modelled to evaluate which variables affect biochemical recurrence-free survival. Results: We observed 31 biochemical recurrence events: 17 in the opioid-free anaesthesia group and 14 in the opioidbased anaesthesia group. Biochemical recurrence-free survival was not statistically different between groups (P=0.54). Cox regression revealed that biochemical recurrence-free survival was shorter in cases of obesity (hazard ratio [HR] 1.63, confidence interval [CI] 0.16-3.10; p=0.03), high D'Amico risk (HR 1.58, CI 0.35-2.81; P=0.012), laparoscopic surgery (HR 1.6, CI 0.38-2.84; P=0.01), stage 3 tumour pathology (HR 1.60, CI 0.20-299) and N1 status (HR 1.34, CI 0.28-2.41), and positive surgical margins (HR 1.37, CI 0.50-2.24; P=0.002). The anaesthesia technique did not affect time to biochemical recurrence (HR -1.03, CI -2.65-0.49; P=0.18). Conclusions: Intraoperative opioid use did not modify biochemical recurrence rates and biochemical recurrence-free survival in patients with intermediate and high D?Amico risk prostate cancer undergoing radical prostatectomy. Clinical trial registration: NCT03212456.
- Reply from Authors re: Khurshid R. Ghani, Mani Menon. Posterior Reconstruction: Weighing the Evidence. Eur Urol 2012;62:791-3 The Posterior Reconstruction Debate(2012) ROCCO, Bernardo; COZZI, Gabriele; SPINELLI, Matteo G.; COELHO, Rafael F.; SANTORO, Luigi; PATEL, Vipul R.; ROCCO, Francesco
- Reply to: Axel Heidenreich. Still Unanswered: The Role of Extended Pelvic Lymphadenectomy in Improving Oncological Outcomes in Prostate Cancer. Eur Urol 2021;79:605-6(2021) LESTINGI, Jean F. P.; GUGLIELMETTI, Giuliano B.; TRINH, Quoc-Dien; COELHO, Rafael F.; JR, Jose Pontes; BASTOS, Diogo A.; CORDEIRO, Mauricio D.; SARKIS, Alvaro S.; FARAJ, Sheila F.; MITRE, Anuar I.; SROUGI, Miguel; NAHAS, William C.
- Robotic-assisted laparoscopic prostatectomy (RALP): a new way to training(2016) ROCHA, Raphael; FIORELLI, Rossano Kepler Alvim; BUOGO, Gilberto; RUBISTEIN, Mauricio; MATTOS, Rogerio Moraes; FROTA, Rodrigo; COELHO, Rafael Ferreira; PALMER, Kenneth; PATEL, VipulThe implementation of RALP program is usually associated with a steep learning curve (LC). Fellows are proctored for few cases, with long operating times, inferior outcomes and an increased number of complications. We report the initial results of 100 RALP procedures performed in Rio de Janeiro, Brazil, with the implementation of a structured program. Our goal was to evaluate if our approach to training would yield a safer outcomes for patients undergoing the procedure during the LC. From October 2012 to January 2014, five surgeons began a training program in RALP. Each surgeon attended a certification course, wet lab, dry lab, didactic course and observed live cases. Each trainee performed 20 cases of RALP under supervision of an experienced preceptor. The median surgical time was 175 min [interquartile range (IQR) 141-180 min]. There were four complications Clavien II (4 %) and three Clavien IIIa (3 %), no conversions nor transfusions. The median estimated blood loss was 200 ml (IQR 150-300 ml). The median hospital stay was 2 days (IQR 1-2 days). The median catheterization time was 7 days (IQR 6-7 days). Overall positive surgical margin rate (PM) was 19 %; stage-specific PSM rates were 12 % in pT2 and 53 % in pT3. The biochemical recidive-free survival rate (PSA<0.01 ng/ml) was 91 % over an average follow-up of 6 months. The continence rates were (no pad) 74 % within 3 months and 94 % within 6 months. The implementation of a training program with advanced precepting allowed us to overcome the initial LC with reasonable results and with minimal complications.
- Is Extraprostatic Extension of Cancer Predictable? A Review of Predictive Tools and an External Validation Based on a Large and a Single Center Cohort of Prostate Cancer Patients(2019) ROCCO, Bernardo; SIGHINOLFI, Maria Chiara; SANDRI, Marco; EISSA, Ahmed; ELSHERBINY, Ahmed; ZOEIR, Ahmed; TADZIA, Harvey; PALAYAPALAYAM, Hariharan; KAMEH, Darien; COELHO, Rafael; PULIATTI, Stefano; ZUCCOLOTTO, Paola; MONTIRONI, Rodolfo; WIKLUND, Peter; MICELI, Salvatore; BIANCHI, Giampaolo; PATEL, VipulOur aim was to review and externally validate all the available predictive tools (PTs) predicting extraprostatic extension (EPE) using the area under the curve, calibration plots, and scaled Brier score. A literature search was performed showing 19 models predicting EPE. External validation was carried out on 6360 prostate cancer patients submitted to RP. Most of the PTs showed poor discrimination and unsatisfactory calibration. The majority of the available PTs are not reliable for the prediction of EPE in populations other than the development one; thus, they may not be completely appropriate for patients' counselling or for surgical strategy preplanning. (C) 2019 Elsevier Inc.
- Changing clinical trends in 10 000 robot-assisted laparoscopic prostatectomy patients and impact of the 2012 US Preventive Services Task Force's statement against PSA screening(2019) ONOL, Fikret F.; GANAPATHI, Hariharan P.; ROGERS, Travis; PALMER, Kenneth; COUGHLIN, Geoff; SAMAVEDI, Srinivas; COELHO, Rafael; JENSON, Cathy; SANDRI, Marco; ROCCO, Bernardo; PATEL, VipulObjectives To evaluate the clinical trend changes in our robot-assisted laparoscopic prostatectomy (RALP) practice and to investigate the effect of 2012 US Preventive Services Task Force (USPSTF) statement against PSA screening on these trends. Patients and Methods Data of 10 000 RALPs performed by a single surgeon between 2002 and 2017 were retrospectively analysed. Time trends in successive 1000 cases for clinical, surgical and pathological characteristics were analysed with linear and logistic regression. Time-trend changes before and after the USPSTF's statement were compared using a logistic regression model and likelihood-ratio test. Results Unfavourable cancer characteristics rate, including D'Amico high risk, pathological non-organ-confined disease and Gleason score >= 4+4 increased from 11.5% to 23.3%, 14% to 42.5%, and 7.7% to 20.9%, respectively, over time (all P < 0.001). Significant time-trend changes were detected after the USPSTF's statement with an increase in the positive trend of Gleason >= 4+4 and increase in the negative trends of Gleason <= 3+4 tumours. There was a significant negative trend in the rate of full nerve-sparing (NS) with a decrease from 59.3% to 35.7%, and a significant positive trend in partial NS with an increase from 15.8% to 62.5% over time (both P < 0.001). The time-trend slope in 'high-grade' partial NS significantly decreased and 'low-grade' partial NS significantly increased after the USPSTF's statement. The overall positive surgical margin rate increased from 14.6% to 20.3% in the first vs last 1000 cases (P < 0.001), with a significant positive slope after the USPSTF's statement. Conclusions The proportion of high-risk patients increased in our series over time with a significant impact of the USPSTF's statement on pathological time trends. This stage migration resulted in decreased utilisation of high-quality NS and increased performance of poor-quality NS.
- Correlation between chromosome 9p21 locus deletion and prognosis in clinically localized prostate cancer(2017) BARROS, Erika Aparecida Felix de; PONTES-JUNIOR, Jose; REIS, Sabrina Thalita; LIMA, Amanda Eunice Ramos; SOUZA, Isida C.; SALGUEIRO, Jose Lucas; FONTES, Douglas; DELLE, Humberto; COELHO, Rafael Ferreira; VIANA, Nayara Izabel; LEITE, Katia Ramos Moreira; NAHAS, William C.; SROUGI, MiguelBackground: Some studies have reported that deletions at chromosome arm 9p occur frequently and represent a critical step in carcinogenesis of some neoplasms. Our aim was to evaluate the deletion of locus 9p21 and chromosomes 3, 7 and 17 in localized prostate cancer (PC) and correlate these alterations with prognostic factors and biochemical recurrence after surgery. Methods: We retrospectively evaluated surgical specimens from 111 patients with localized PC who underwent radical prostatectomy. Biochemical recurrence was defined as a prostate-specific antigen (PSA) >0.2 ng/mL and the mean postoperative follow-up was 123 months. The deletions were evaluated using fluorescence in situ hybridization with centromeric and locus-specific probes in a tissue microarray containing 2 samples from each patient. We correlated the occurrence of any deletion with pathological stage, Gleason score, ISUP grade group, PSA and biochemical recurrence. Results: We observed a loss of any probe in only 8 patients (7.2%). The most common deletion was the loss of locus 9p21, which occurred in 6.4% of cases. Deletions of chromosomes 3, 7 and 17 were observed in 2.3%, 1.2% and 1.8% patients, respectively. There was no correlation between chromosome loss and Gleason score, ISUP, PSA or stage. Biochemical recurrence occurred in 83% cases involving 9p21 deletions. Loss of 9p21 locus was significantly associated with time to recurrence (p = 0.038). Conclusions: We found low rates of deletion in chromosomes 3, 7 and 17 and 9p21 locus. We observed that 9p21 locus deletion was associated with worse prognosis in localized PC treated by radical prostatectomy.