Peri-operative, functional and early oncologic outcomes of salvage robotic-assisted radical prostatectomy after high-intensity focused ultrasound partial ablation

BACKGROUND: Partial ablation of the prostate using high-intensity focussed ultrasound (HIFU-PA) is a treatment option for localised prostate cancer. When local recurrence occurs, salvage robot-assisted radical prostatectomy is a treatment option for selected patients, but there is a paucity of data on the peri-operative safety, functional and oncologic outcomes of sRARP.. The objective of this study was therefore to describe peri-operative safety, functional and early oncologic outcomes following salvage robot-assisted radical prostatectomy (sRARP) for local recurrence after HIFU-PA. METHODS: Retrospective analysis of a prospective database of 53 consecutive men who underwent sRARP after HIFU-PA from 2012 to 2018. Continence and erectile-function were reported pre-HIFU, pre-sRARP, 3-months post-sRARP and 12-months post-sRARP. Complications, PSMs and need for subsequent ADT/radiotherapy were assessed. RESULTS: 45 men were suitable for inclusion and had sufficient data for analyses. Median duration from HIFU to sRARP was 30.0 months and median follow-up post-sRARP was 17.7 months. Median age, PSA and ISUP group were 63.0 yrs., 7.2 ng/mL and 2; 88.9% were cT2. Median operative-console time, blood loss and hospital stay were 140 min, 200 ml and 1 day respectively. Clavien-Dindo grade 1, 2 and 3 complications 90d) complications occurred in 13.2%. At sRARP pathology, ISUP 3-5 occurred in 51.1%, pT3a/b in 64.5%, and PSMs in 44.4% (37.5% for pT2, 48.3% for pT3). Of men with > 3-months follow-up after sRARP, 26.3% underwent adjuvant radiotherapy/ADT for residual disease or adverse pathologic features; 5.3% experienced BCR requiring salvage ADT/radiotherapy. Freedom from ADT/radiotherapy was 66.7% at 12-months. Pad-free rates were 100% pre-HIFU, 95.3% post-HIFU, 29.4% 3-months post-sRARP, and 65.5% 12-months post-sRARP. Median IIEF-5 scores pre-HIFU, post-HIFU, 3- and 12-months post-sRARP were 23.5, 16, 5 and 5, respectively. Potency rates were 81.8, 65.5, 0 and 0%, respectively. Bilateral/unilateral nerve sparing were feasible in 7%/22%. CONCLUSION: Salvage RARP was safe with acceptable but sub-optimal continence and poor sexual-function and poor oncologic outcomes. One in three men required additional treatment within 12-months. This information may aid men and urologists with treatment selection and counselling regarding primary HIFU-PA vs primary RARP and when considering salvage RARP

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

Can dehydrated human amnion/chorion membrane accelerate the return to potency after a nerve-sparing robotic-assisted radical prostatectomy? Propensity score-matched analysis

The objective of this study is to determine if the use of dehydrated human amnion/chorion membrane (dHACM) allograft wrapped around the NVB during a robotic-assisted radical prostatectomy (RARP) accelerates the return to potency. 940 patients with preoperative SHIM >20 underwent RARP with some degree of bilateral NS. Of these, 235 patients underwent RARP, with bilateral placement of dHACM graft around the NVBs. They were matched in a 1:3 proportion with a similar group of patients (n = 705) who did not receive the allograft (control group or group 2). Minimum follow-up was 12 months. Postoperative outcomes were analyzed between propensity-matched dHACM graft (group 1) and non-graft groups (group 2). Kaplan\u2013Meier survival curves were compared across techniques using the log-rank test. There were no significant demographic differences between the two groups. Potency was defined as the ability to achieve and maintain satisfactory erections firm enough for sexual intercourse, with or without the use of PDE-5 inhibitors. The mean time to potency was significantly lower in group 1 (2.37 months) versus group 2 (3.94 months) (p < 0.0001). The potency recovery rates were superior for group 1 at all early time points measured except at 12 months. The time to potency was significantly shorter in the dHACM group with full NS, 2.19 \ub1 1.84 versus 2.78 \ub1 2.70 mo. in the non-dHACM with full NS (p = 0.029). In the dHACM group with partial NS, the mean time to potency was 3.05 \ub1 2.32 versus 3.92 \ub1 3.42 mo. in the non-dHACM with partial NS (p = 0.021). Patients who received the dHACM wrap around the NVB after RARP accelerates the return to potency when compared to a similar control group without the use of the allograft. We also demonstrated that this faster return to potency occurs regardless of the degree of the NS preservation. Younger patients (<55 years of age) had the highest overall advantage if they received the graft. Our results indicate that dHACM placement at the site of the prostatic NVB does not increase the risk of BCR after RARP, neither in the presence of PSM, extra-prostatic disease ( 65pT3) nor high Gleason score (Gleason 658)

SALVAGE ROBOTIC-ASSISTED LAPAROSCOPIC PROSTATECTOMY (SRARP)

INTRODUCTION & OBJECTIVES: There is a significant cohort of patients who experience recurrent prostate cancer after primary ablative therapy. Salvage robot assisted radical prostatectomy (sRARP) represents a feasible treatment option in these cases. The purpose of the study is to examine the functional and biochemical outcomes in a large series of sRARP performed by a single surgeon (VRP). MATERIAL & METHODS: We retrospectively reviewed our database of more than 6,500 patients who have undergone RARP. Over a period of 8 years (2008-2015) we identified 65 patients who have had sRARP following different types of primary ablative treatment failure. The Kaplan-Meier method was used to estimate survival. Both univariate and multivariate regression analysis were used to determine predictors of biochemical recurrence. RESULTS: The median interval from primary therapy to sRARP was 48 (range 26-85) months. The median age of patients undergoing sRARP was 69 (65-73) years. The 11 (16.9%) patients had positive surgical margins, 14 (21.6%) \u2013 extraprostatic extension and 16 (24.6%) seminal vesicle invasion (pT3b). There were no cases of rectal injury or any intraoperative complications. 16 (25%) patients had a biochemical failure after a median follow-up of 16.5 (6-56) months and 10 (15%) required adjuvant hormone therapy. 85% of patients that had sRALP were free of additional therapy at a median of 16.5 months. All 65 patients were continent prior to salvage RARP and 34 (52.3%) of them reported full continence after surgery (no pad used). The 29 (44.6%) of them partial continence1-2 pads and 5 (3.1%) 65 3 pads, respectively. 19 (29.2%) patients were considered potent before sRARP and 9 (47.4%) of them retained potency after the sRARP. Tumour stage pT3b (seminal vesicle invasion), pre-op Gleason >7, and positive surgical margins were predictive of biochemical recurrence. CONCLUSIONS: Our series supports the feasibility of sRARP as a suitable treatment option for patients who have experienced local recurrence of prostate cancer. Our outcomes for biochemical recurrence, potency, and continence are reasonable, maintaining a reasonable balance between cancer control data, quality of life issues and risk of complications. Longer follow-up will be necessary in determining the full extent of sRARP in providing adequate cancer control and quality of life issue

THE USE OF SCAFFOLDING TISSUE BIOGRAFTS TO BOLSTER THE VESICOURETHRAL ANASTOMOSIS DURING SALVAGE ROBOT-ASSISTED RADICAL PROSTATECTOMY REDUCES LEAK RATES AND CATHETER TIMES

THE USE OF SCAFFOLDING TISSUE BIOGRAFTS TO BOLSTER THE VESICOURETHRAL ANASTOMOSIS DURING SALVAGE ROBOT-ASSISTED RADICAL PROSTATECTOMY REDUCES LEAK RATES AND CATHETER TIME