Major urological cancer surgery for patients is safe and surgical training should be encouraged during the COVID-19 pandemic : A multi-centre analysis of 30-day outcomes

Funding Information: Funding/Support and role of the sponsor: Wei Shen Tan is funded by the Urology Foundation . Publisher Copyright: © 2021 The Author(s) Copyright: Copyright 2021 Elsevier B.V., All rights reserved.COVID-19 has resulted in the deferral of major surgery for genitourinary (GU) cancers with the exception of cancers with a high risk of progression. We report outcomes for major GU cancer operations, namely radical prostatectomy (RP), radical cystectomy (RC), radical nephrectomy (RN), partial nephrectomy (PN), and nephroureterectomy performed at 13 major GU cancer centres across the UK between March 1 and May 5, 2020. A total of 598 such operations were performed. Four patients (0.7%) developed COVID-19 postoperatively. There was no COVID-19–related mortality at 30 d. A minimally invasive approach was used in 499 cases (83.4%). A total of 228 cases (38.1%) were described as training procedures. Training case status was not associated with a higher American Society of Anesthesiologists (ASA) score (p = 0.194) or hospital length of stay (LOS; p > 0.05 for all operation types). The risk of contracting COVID-19 was not associated with longer hospital LOS (p = 0.146), training case status (p = 0.588), higher ASA score (p = 0.295), or type of hospital site (p = 0.303). Our results suggest that major surgery for urological cancers remains safe and training should be encouraged during the ongoing COVID-19 pandemic provided appropriate countermeasures are taken. These real-life data are important for policy-makers and clinicians when counselling patients during the current pandemic. Patient summary: We collected outcome data for major operations for prostate, bladder, and kidney cancers during the COVID-19 pandemic. These surgeries remain safe and training should be encouraged during the ongoing pandemic provided appropriate countermeasures are taken. Our real-life results are important for policy-makers and clinicians when counselling patients during the COVID-19 pandemic.Peer reviewe

A systematic review and meta-analysis of pelvic drain insertion after robot-assisted radical prostatectomy

Purpose To perform a systematic review and meta-analysis and to assess the clinical benefit of prophylactic pelvic drain placement following Robotic Assisted Laparoscopic Prostatectomy (RALP) with pelvic lymph node dissection (PLND) in patients with localized prostate cancer. Methods An electronic search of databases including Scopus, Medline and EMbase was conducted for articles that considered post-operative outcomes with pelvic drain placement (PD) and without pelvic drain placement (ND) after RALP. The primary outcome was rate of symptomatic lymphocele (requiring intervention) and secondary outcomes were complications as described by the Clavien-Dindo classification system. Quality assessment was performed using the Modified Cochrane Risk of Bias Tool for Quality Assessment. Results Six relevant articles, comprising 1,783 patients (PD = 1,253; ND = 530) were included. Use of PD conferred no difference in symptomatic lymphocoele rate (Risk difference 0.01; 95% CI -0.007 - 0.027), with an overall incidence of 2.2% (95% CI 0.013 - 0.032). No difference in low-grade (I - II; risk difference 0.035, 95% CI -0.065 - 0.148) or high-grade (III - V; risk difference -0.003, 95% CI -0.05 - 0.044) complications was observed between PD and ND groups. Low-grade (I-II) complications were 11.8% (95% CI 0 - 0.42) and 7.3% (95% CI 0 - 0.26), with similar rates of high-grade (III - V) complications, being 4.1% (95% CI 0.008 - 0.084) and 4.3% (95% CI 0.007 - 0.067) for PD and ND groups, respectively. Conclusion Pelvic drain insertion after RALP with ePLND did not confer significant benefits in prevention of symptomatic lymphocoele or post-operative complications. Based on these results, pelvic drain insertion may be safely omitted in uncomplicated cases following consideration of clinical factors

Grafts for mesenterico-portal vein resections can be avoided during pancreatoduodenectomy

BACKGROUND: The aim of this study was to assess whether pancreatoduodenectomy (PD) and en bloc mesenterico-portal resection (PD-VR) could be performed with primary venous reconstruction, avoiding a vascular graft. In addition, the short-term surgical outcomes of this approach were compared with a standard PD (PD-VR). STUDY DESIGN: Two hundred twelve patients underwent PD between January 2004 and June 2011. Clinical data, operative results, pathologic findings, and postoperative outcomes were collected prospectively and analyzed. RESULTS: One hundred fifty patients (71%) had PD-VR and 62 patients underwent PD-VR. The majority (82%) of the venous reconstructions were performed with primary end-to-end anastomosis. Only 1 patient had synthetic interposition graft repair. The volume of intraoperative blood loss and the perioperative blood transfusion requirements were significantly greater, and the duration of the operation was significantly longer in the PD-VR group compared with the PD-VR group. There were no significant differences in the length of hospitalization, postoperative morbidity, or grades of complications between the 2 groups. Multivariate logistic regression identified American Society of Anesthesiologists score as the only predictor of postoperative morbidity. Fifty percent of patients with pancreatic adenocarcinoma (n=101) required VR. A significantly higher rate of positive resection margins (p< 0.001) was noted in the PD-VR subgroup compared with PD-VR subgroup. Furthermore, high intraoperative blood loss and neural invasion were predictive of a positive resection margin. CONCLUSIONS: Pancreatoduodenectomy with VR and primary venous anastomosis avoids the need for a graft and has comparable postoperative morbidity with PD-VR. However, it is associated with an increased operative time, higher intraoperative blood loss, and, for pancreatic ductal adenocarcinoma, a higher rate of positive resection margins compared with PD-VR

Components of a safe cystectomy service during coronavirus disease 2019 in a high-volume centre

Objective: Delivery of a safe cystectomy service is a multidisciplinary exercise. In this article, we detail the measures implemented at our institution to deliver a cystectomy service for bladder cancer patients during coronavirus disease 2019 (COVID-19). / Methods: A ‘one-stop’ enhanced recovery clinic had been established at our hospital, consisting of an anaesthetist, an exercise testing service, urinary diversion nurses, clinical nurse specialists and surgeons. During COVID-19, we modified these processes in order to continue to provide urgent cystectomy safely for bladder cancer. We collected patients’ outcomes prospectively measuring demographic characteristics, oncological and perioperative outcomes, the presence of COVID-19 symptoms and confirmed COVID-19 test results. / Results: From March to May 2020, 25 patients underwent radical cystectomy for bladder cancer. Twenty-four procedures were performed with robotic assistance and one open as part of a research trial. We instituted modifications at various multidisciplinary steps, including patient selection, preoperative optimisation, enhanced recovery protocols, patient counselling and perioperative protocols. Thirty-day mortality was 0%. The 30-day rate of Clavien ⩾3 complications was 8%. Postoperatively, none of the patients developed COVID-19 based on World Health Organization criteria and testing. / Conclusion: We safely delivered a complex cystectomy service during the peak of the COVID-19 pandemic without any COVID-19-related morbidity or mortality. / Level of evidence: Level 2b