Management of patients who opt for radical prostatectomy during the COVID‐19 pandemic: An International Accelerated Consensus Statement

BACKGROUND: Coronavirus disease-19 (COVID-19) pandemic caused delays in definitive treatment of patients with prostate cancer. Beyond the immediate delay a backlog for future patients is expected. Such delays can lead to disease progression. OBJECTIVE: We aimed to develop guidance on criteria for prioritization for surgery and reconfiguring management pathways for non-metastatic stage of prostate cancer who opt for surgical treatment. A second aim was to identify the infection prevention and control (IPC) measures to achieve low likelihood of COVID-19 hazard if radical prostatectomy was to be carried out during the outbreak and whilst the disease is endemic. DESIGN, SETTING AND PARTICIPANTS: An accelerated consensus process and systematic review. We conducted a systematic review of the evidence on COVID-19 and reviewed international guidance on prostate cancer. These were presented to an international prostate cancer expert panel (n=34) through an online meeting. The consensus process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. OUTCOME MEASURES: Consensus opinion was defined as ≥80% agreement, which were used to reconfigure the prostate cancer pathways. RESULTS: Evidence on the delayed management of patients with prostate cancer is scarce. There was 100% agreement that prostate cancer pathways should be reconfigured and develop measures to prevent nosocomial COVID-19 for patients treated surgically. Consensus was reached on prioritization criteria of patients for surgery and management pathways for those who have delayed treatment. IPC measures to achieve a low likelihood of nosocomial COVID-19 were coined as "COVID-19 cold sites". CONCLUSION: Re-configuring management pathways for prostate cancer patients is recommended if significant delay (>3-6 months) in surgical management is unavoidable. The mapped pathways provide guidance for such patients. The IPC processes proposed provide a framework for providing radical prostatectomy within an environment with low COVID-19 risk during the outbreak or when the disease remains endemic. The broader concepts could be adapted to other indications beyond prostate cancer surgery

Perioperative and early oncological outcomes after robot-assisted radical prostatectomy (RARP) in morbidly obese patients : a propensity score-matched study

Objective To evaluate the perioperative and pathological outcomes associated with robot-assisted radical prostatectomy (RARP) in morbidly obese men. Patients and Methods Between January 2008 and March 2012, 3041 patients underwent RARP at our institution by a single surgeon (V.P.). In all, 44 patients were considered morbidly obese with a body mass index (BMI) of 6540 kg/m2. A propensity score-matched analysis was conducted using multivariable analysis to identify comparable groups of patients with a BMI of 6540 and <40 kg/m2. Perioperative, pathological outcomes and complications were compared between the two matched groups. Results There was no significant difference in operative time. However, the mean estimated blood loss was higher in morbidly obese patients, at a mean (sd) of 113 (41) vs 130 (27) mL (P = 0.049). Anastomosis was more difficult in morbidly obese patients (P = 0.001). There were no significant differences in laterality, ease of nerve sparing, or transfusion rate between the groups. There were no intraoperative complications in either group. Postoperative pathological outcomes were similar between the groups. Differences in positive surgical margins and ease of nerve sparing approached statistical significance (P = 0.097, P = 0.075 respectively). Postoperative complication rates, pain scores, length of stay and indwelling catheter duration were similar in the groups. Conclusions RARP in morbidly obese patients is technically demanding. However, it can be accomplished with acceptable morbidity and resource use. In the hands of an experienced surgeon, it is a safe procedure and offers beneficial clinical outcomes

NUANCES IN NERVE SPARING DURING RARP

INTRODUCTION & OBJECTIVES: We have previously published our work identifying anatomical landmarks for grading of nerve sparing. We now demonstrate further nuances in nerve preservation during RARP. MATERIAL & METHODS: The present study is a combination of a single surgeon experience after 5000 patients and a compilation of videos detailing some possible scenarios that surgeons might face when performing nerve sparing. RESULTS: Case 1: 55 year old man with PSA of 5, SHIM score 25, DRE reveals T1c with and low volume disease. Complete bilateral nerve sparing is performed. Case 2: 60 year old man with SHIM score of 25, PSA of 7.2, and normal DRE. During the dissection of NVB, the surgeon initially misses the correct plane then correcting it to proceed more medially and preserve the capsular artery, thereby achieving a full nerve spare. Case 3: is a 47 year old man with a SHIM score of 25, and an intermediate risk grade cancer having a partial nerve sparing. In Case four, we show you the technique to protect the base during robot-assisted radical prostatectomy. All patients had negative surgical margins. CONCLUSIONS: Case 1: 55 year old man with PSA of 5, SHIM score 25, DRE reveals T1c with and low volume disease. Complete bilateral nerve sparing is performed. Case 2: 60 year old man with SHIM score of 25, PSA of 7.2, and normal DRE. During the dissection of NVB, the surgeon initially misses the correct plane then correcting it to proceed more medially and preserve the capsular artery, thereby achieving a full nerve spare. Case 3: is a 47 year old man with a SHIM score of 25, and an intermediate risk grade cancer having a partial nerve sparing. In Case four, we show you the technique to protect the base during robot-assisted radical prostatectomy. All patients had negative surgical margins

PREDICTORS OF COMPLETE NERVE SPARING DURING ROBOT-ASSISTED RADICAL PROSTATECTOMY

PREDICTORS OF COMPLETE NERVE SPARING DURING ROBOT-ASSISTED RADICAL PROSTATECTOM

IMPORTANT TECHNICAL MODIFICATIONS TO IMPROVE OUTCOMES IN RARP - LESSONS LEARNED AFTER 5.000 CASES

IMPORTANT TECHNICAL MODIFICATIONS TO IMPROVE OUTCOMES IN RARP - LESSONS LEARNED AFTER 5.000 CASE

RATE, LOCATION AND PREDICTIVE FACTORS OF POSITIVE SURGICAL MARGINS IN HIGH-RISK PATIENTS UNDERGOING ROBOT-ASSISTED RADICAL PROSTATECTOMY

RATE, LOCATION AND PREDICTIVE FACTORS OF POSITIVE SURGICAL MARGINS IN HIGH-RISK PATIENTS UNDERGOING ROBOT-ASSISTED RADICAL PROSTATECTOM

Nuances in nerve sparing during robotic assisted radical prostatectomy

INTRODUCTION AND OBJECTIVES: We have previously published our work identifying anatomical landmarks for grading of nerve sparing. We now demonstrate further nuances in nerve preservation during Robotic assisted Radical Prostatectomy. METHODS: The present study is a combination of a single surgeon experience after 5000 patients and a compilation of videos detailing some possible scenarios that surgeons might face when performing nerve sparing. RESULTS: Case 1: 55 year old man with PSA of 5, SHIM score 25, DRE reveals T1c with and low volume disease. Complete bilateral nerve sparing is performed. Case 2: 60 year old man with SHIM score of 25, PSA of 7.2, and normal DRE. During the dissection of NVB, the surgeon initially misses the correct plane then correcting it to proceed Vol. 189, No. 4S, Supplement, Monday, May 6, 2013 THE JOURNAL OF UROLOGY e521 more medially and preserve the capsular artery, thereby achieving a full nerve spare. Case 3: is a 47 year old man with a SHIM score of 25, and an intermediate risk grade cancer having a partial nerve sparing. In Case four, we show you the technique to protect the base during robot-assisted radical prostatectomy. All patients had negative surgical margins. CONCLUSIONS: Nerve sparing should be tailored according to the patient’s preoperative pathology as well as intraoperative tissue characteristics. Surgeon’s experience plays a key part. Preoperative pathology and intraoperative visual cues as well as attention to tissue planes are paramount to achieve good outcomes

Important technical modifications to improve outcomes in robotic assisted radical prostatectomy - lessons learned after 5.000 cases

Important technical modifications to improve outcomes in robotic assisted radical prostatectomy - lessons learned after 5.000 case