Robot-assisted radical prostatectomy: Advancements in surgical technique and perioperative care

We reviewed the evolving strategies, practice patterns, and recent advancements aimed at improving the perioperative and surgical outcomes in patients undergoing robot-assisted radical prostatectomy for the management of localized prostate cancer

Managing Urology Consultations During COVID-19 Pandemic: Application of a Structured Care Pathway

OBJECTIVE: To describe and evaluate a risk-stratified triage pathway for inpatient urology consultations during the SARS-CoV-2 (COVID-19) pandemic. This pathway seeks to outline a urology patient care strategy that reduces the transmission risk to both healthcare providers and patients, reduces the healthcare burden, and maintains appropriate patient care. MATERIALS AND METHODS: Consultations to the urology service during a 3-week period (March 16 to April 2, 2020) were triaged and managed via one of 3 pathways: Standard, Telemedicine, or High-Risk. Standard consults were in-person consults with non COVID-19 patients, High-Risk consults were in-person consults with COVID-19 positive/suspected patients, and Telemedicine consults were telephonic consults for low-acuity urologic issues in either group of patients. Patient demographics, consultation parameters and consultation outcomes were compared to consultations from the month of March 2019. Categorical variables were compared using Chi-square test and continuous variables using Mann-Whitney U test. A P value \u3c.05 was considered significant. RESULTS: Between March 16 and April 2, 2020, 53 inpatient consultations were performed. By following our triage pathway, a total of 19/53 consultations (35.8%) were performed via Telemedicine with no in-person exposure, 10/53 consultations (18.9%) were High-Risk, in which we strictly controlled the urology team member in-person contact, and the remainder, 24/53 consultations (45.2%), were performed as Standard in-person encounters. COVID-19 associated consultations represented 18/53 (34.0%) of all consultations during this period, and of these, 8/18 (44.4%) were managed successfully via Telemedicine alone. No team member developed COVID-19 infection. CONCLUSION: During the COVID-19 pandemic, most urology consultations can be managed in a patient and physician safety-conscious manner, by implementing a novel triage pathway

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Urologic Care of a Multiple Sclerosis Patient Population-Single Provider Experience

Introduction: Multiple sclerosis (MS) is a demylinating neurologic condition affecting approximately 2 million people worldwide. Lower urinary tract dysfunction is common with 50-90% having voiding symptoms. If lower urinary tract symptoms are recognized and a urological referral is made, little is known regarding the outcomes of these patients within a urology practice. The objective of this study was to evaluate the MS population of a single provider to gain a better understanding of patient characteristics, urodynamic findings, treatment outcomes and follow-up patterns. Methods: A retrospective chart review was performed on all patients with a diagnosis of multiple sclerosis in the practice of a single provider at Vattikuti Urology Institute from January 2013 to December 2017. Patient demographics, urodynamic study (UDS) data, management outcomes and patient reported questionnaire responses were recorded and analyzed with descriptive statistics. Results: A total of 147 patients were initially included with a diagnosis of MS. Please see Table 1 for patient characteristics. After removing patients lost to follow-up, 47.6% of the original population was considered active. Among those that did undergo UDS (120), 24% had a diagnosis of detrusor sphincter dyssynergia, 60% had neurogenic detrusor overactivity (NDO) and 33% had poor detrusor function. Some element of the overactive bladder symptom complex was the presenting chief complaint of 107/147 patients. Among the active patients with NDO, 48.7% received botox. For the active NDO patients that did receive botox, statistical significance was found in the change of all urinary quality of life (QOL) questionnaires (AUA-SS, AUA QOL, Michigan Incontinence Symptom Index) that were used between pre and post treatment. There was no statistically significant change in QOL scores for the active NDO population that had not received botox. Conclusion: Significant barriers exist for patients with MS. Given the improvement in quality of life that can be achieved with appropriate treatment and the significant number of patients that are lost to follow-up, it is important to provide patients with education regarding the effects of MS on their urinary system at their initial visit. A treatment pathway, patient navigator and multidisciplinary approach could be helpful to improve patient outcomes

Menon-precision prostatectomy (MPP): An idea, development, exploration, assessment, long-term follow-up (IDEAL)stage 1 study

Introduction & Objectives: Despite the encouraging increased utilization of active surveillance, a significant proportion of prostate cancer (PCa)patients don\u27t qualify for this approach. In an attempt to mitigate the negative sequelae of radically treating PCa surgically, and diminish the harm of potential overtreatment, our senior investigator (MM)devised the novel MPP technique. In this IDEAL Phase 1 study, our objective was to describe the peri-operative morbidity and functional outcomes and in the first 8 patients who underwent this procedure between Jan 2017 and June 2017. Materials & Methods: Patients were offered MPP if they satisfied the following criteria on biopsy: 1)PSA £15 ng/ml, 2)stage £cT2, 3)dominant unilateral lesion with Gleason score £4+3 with any number of cores or % cores involved ipsilaterally on biopsy, and 4)no primary Gleason score 34 contralaterally with £3 cores involved contralaterally with no \u3e50% involvement on biopsy; and 5)preoperatively potent without PDE5 inhibitors. This procedure entails complete surgical removal of one half of the prostate (i.e. the side with dominant nodule on biopsy)and removal of most of the other half; however, a thin rim of the prostate capsule on the non/less-affected side is maintained. Kaplan-Meier curves were used to estimate: 1)urinary continence recovery (use of 0 pad/day); 2)Sexual function recovery (erection sufficient for intercourse). Results: Median (interquartile range [IQR])age and PSA were 54 yrs (52-57)and 4 ng/ml (3.6-5.8)respectively. Pre-operatively, 50% of patients had Gleason 3+4 disease and were classified as NCCN intermediate-risk. Only 1 patient (12.5%)met Epstein\u27s criteria for active surveillance. During surgery, intraoperative frozen sections from the remnant prostatic tissue were taken, and all resulted negative for malignancy. All patients had pT2 disease. Median (IQR)console time was 134 min (107.7-148.0). No complication was recorded after surgery. At 4-, 8-, and 12-months from surgery, 100%, 100%, and 100% recovered urinary continence (all patients recovered within 4 months), 87.5%, 87.5%, and 100% recovered sexual function, and median (IQR)PSA was 0.25 (\u3c0.1-1.22), 0.14 (\u3c0.1-0.92)and 0.20 (\u3c0.1-0.4)ng/mL, respectively. Conclusions: Similar to the case of conservative surgical treatment in breast cancer, we propose a conservative surgical treatment for localized PCa, which showed excellent post-op functional outcomes recovery, and a very limited morbidity. While the initial PSA response seems satisfactory, a longer follow up is necessary to examine the oncological outcomes of the procedure

Extended pelvic lymph-node dissection is independently associated with improved overall survival in patients with prostate cancer at high-risk of lymph-node invasion.

It is generally agreed upon that extended pelvic lymph-node dissection (ePLND) provides valuable staging information and helps guide adjuvant therapy, and should be undertaken in prostate cancer (CaP) patients with aggressive preoperative disease features at the time of radical prostatectomy [1, 2]. However, whether it has a \u27direct\u27 therapeutic benefit in the aforesaid patients has remained difficult to demonstrate [3]. The only patients that seem to derive a survival advantage from ePLND are patients with pN1 disease [4] - this cited study suggested a direct therapeutic effect of ePLND, with a 7% incremental benefit in 10-year cancer-specific survival per every additional lymph-node removed (p=0.02). However, it did not identify these patients preoperatively

Anti-Androgen Therapy Overcomes the Time Delay in Initiation of Salvage Radiation Therapy and Rescues the Oncological Outcomes in Men with Recurrent Prostate Cancer After Radical Prostatectomy: A Post Hoc Analysis of the RTOG-9601 Trial Data

BACKGROUND: It is unknown whether the addition of anti-androgen therapy (AAT) to late salvage radiation therapy (sRT) can lead to oncological outcomes equivalent to that of early sRT in men with recurrent prostate cancer (CaP) after surgery. METHODS: Data on 670 men who participated in the Radiation Therapy Oncology Group (RTOG)-9601 trial and who experienced biochemical recurrence were extracted using the National Clinical Trials Network (NCTN) data archive platform. Patients were stratified into four treatment groups: early sRT (pre-sRT prostate-specific antigen [PSA] \u3c 0.7 ng/mL) and late sRT (pre-sRT PSA ≥ 0.7 ng/mL) with/without concomitant AAT, based on cut-offs reported in the original trial. Time-varying Cox proportional hazards and Fine-Gray competing-risk regression analyses assessed the adjusted hazards of overall mortality, CaP-specific mortality, and metastasis among the four treatment groups. RESULTS: At 15-years (median follow-up of 14.7 years), for patients treated with early sRT, early sRT with AAT, late sRT, and late sRT with AAT, the overall mortality, CaP-specific mortality, and metastasis rates were 22.9, 22.8, 40.1, and 22.9% (log-rank p = 0.0039), 12.1, 3.9, 22.7, and 8.0% (Gray\u27s p = 0.0004), and 18.8, 14.6, 35.9, and 19.5% (Gray\u27s p = 0.0004), respectively. Time-varying multivariable adjusted analysis demonstrated increased hazards of overall mortality in patients receiving delayed sRT versus early sRT (hazards ratio [HR] 1.49, 95% confidence interval [CI] 1.02-2.17); however, no difference remained after the addition of concomitant AAT to late sRT (HR 0.85, 95% CI 0.55-1.32, referent early sRT). Likewise, the hazards of cancer-specific mortality and metastatic progression were worse for late sRT when compared with early sRT, but were no different after the addition of AAT to late sRT. CONCLUSIONS: Poorer outcomes associated with late sRT in men with recurrent CaP may be rescued by delivery of concomitant AAT