Measuring cancer burden in prostatic needle core biopsies: simplified assessments outperform complex measurements in assessing outcome: evidence to assist pathologist efficiency and minimize datasets.

AIMS: The optimal method of measuring cancer extent in prostate cancer (PCa) biopsies is unknown. METHODS AND RESULTS: Nine hundred eighty-one men with clinically localised PCa managed conservatively were reviewed with follow up. The number of positive cores (NPC), the Maximum Cancer Length in a core (MCL), Total Cancer Length (TCL), and percentage of positive cores (%+cores) was calculated and univariate and multivariate analysis performed using prostate-specific antigen (PSA), T-stage, and Gleason score. The presence of stromal gaps (SG) was recorded. Univariate models were run where SG made a difference to the MCL. All variables showed significant association with PCa death in univariate models. In multivariate models, incorporating PSA, T-stage, and Gleason score, only %+cores was a significant predictor of outcome, with a 10% increase in %+cores resulting in a hazard ratio (HR) of 1.07 (likelihood-ratio test P > Χ2  = 0.01). There were 120 patients where SG made a difference to the MCL and a total of 20 events in this group. Including SG, on univariate analysis the median MCL was 10 mm and HR was 1.16 (P = 0.007), not including SG, the median MCL was 6 mm and HR was 1.23 (P = 6.3 × 10-4 ). Inclusion or exclusion of SG made no significant difference to TCL as a predictor of outcome. CONCLUSION: Cancer extent is a strong predictor of PCa death but only %+cores added to the multivariate model. Expressed as a fraction of NPC/total number of cores, this is the simplest method of assessment, which we favour over more complicated methods in nontargeted biopsies.

Tracheal tube cuff pressure during anesthesia for robotic-assisted laparoscopic prostatectomy and the efficacy of an automatic cuff pressure controller (SmartCuff): observational studies of 1-sample paired data.

PURPOSE: The cuff pressure of a tracheal tube may increase during robot-assisted laparoscopic surgery for prostatectomy (RALP), which requires pneumoperitoneum in a steep head-down position, but there have been no studies which confirmed this. METHODS: In study 1, we studied how frequently the cuff pressure significantly increased during anesthesia for the RALP. In study 2, we studied if the SmartCuff (Smiths Medical Japan, Tokyo) automatic cuff pressure controller would minimize the changes in the intracuff pressure. With approval of the study by the research ethics committee (approved number: 20115), we measured the cuff pressures in anesthetized patients undergoing RALP and in those undergoing gynecological laparotomy (as a reference cohort), with and without the use of the SmartCuff. RESULTS: In 21 patients undergoing RALP, a clinically meaningful increase (5 cmH2O or greater) was observed in all the 21 patients (P = 0.00; 95% CI for difference: 86-100%), whereas in 23 patients undergoing gynecological laparotomy, a clinically meaningful decrease (5 cmH2O or greater) was observed in 21 of 23 patients (91%, P < 0.0001; 95% CI for difference: 72-99%). With the use of the SmartCuff, there was no significant increase in the incidence of a clinically meaningful change in the intracuff pressure in either cohort. CONCLUSION: The cuff pressure of a tracheal tube would frequently increase markedly in patients undergoing RALP, whereas it would frequently decrease markedly in patients undergoing gynecological laparotomy. The SmartCuff may inhibit the changes in the cuff pressure during anesthesia.

Impact of COVID-19 pandemic on prostate cancer outcomes at an uro-oncology referral center.

INTRODUCTION: To evaluate the possible effects of the coronavirus disease 2019 (COVID-19) pandemic on the oncologic results of patients with prostate cancer regarding clinical staging, presence of adverse pathological outcomes, and perioperative complications. MATERIALS AND METHODS: This retrospective study included patients who underwent radical prostatectomy. The time between biopsy and surgery, staging tests, final histopathological evaluation after surgery, lymphadenectomy rate, postoperative complications, and prostatic specific antigen (PSA) levels (initial and 30 days after surgery) were analyzed and compared in a group of patients before and during the pandemic period. RESULTS: We included 226 patients: 88 in the pre-pandemic period and 138 during the pandemic period. There was no statistically significant difference in mean age, body mass index, ASA, pathological locally advanced disease, the proportion of patients who underwent lymphadenectomy, and ISUP grade in the biopsy between the groups. Positive surgical margins, prostatic extracapsular extension, and PSA levels at 30 days were also similar between the groups. The mean time between medical consultation and surgery was longer in the pandemic period than in the pre-pandemic (124 vs. 107 days, p<0.001), and the mean time between biopsy and medical consultation (69.5 days vs. 114 days, p<0.001) and between biopsy and surgery (198.5 days vs. 228 days, p=0.013) was shorter during the pandemic. The incidence of severe early and late perioperative complications was similar between the periods. CONCLUSIONS: There was no delay between diagnosis and treatment at our institution during the COVID-19 pandemic period. No worsening of the prostate cancer features was observed.

Same day discharge for robot-assisted radical prostatectomy: a prospective cohort study documenting an Australian approach.

BACKGROUND: The introduction of robotic surgical systems has significantly impacted urological surgery, arguably more so than other surgical disciplines. The focus of our study was length of hospital stay - patients have traditionally been discharged day 1 post-robot-assisted radical prostatectomy (RARP), however, during the ongoing COVID-19 pandemic and consequential resource limitations, our centre has facilitated a cohort of same-day discharges with initial success. METHODS: We conducted a prospective tertiary single-centre cohort study of a series of all patients (n = 28) - undergoing RARP between January and April 2021. All patients were considered for a day zero discharge pathway which consisted of strict inclusion criteria. At follow-up, each patient's perspective on their experience was assessed using a validated post-operative satisfaction questionnaire. Data were reviewed retrospectively for all those undergoing RARP over the study period, with day zero patients compared to overnight patients. RESULTS: Overall, 28 patients 20 (71%) fulfilled the objective criteria for day zero discharge. Eleven patients (55%) agreed pre-operatively to day zero discharge and all were successfully discharged on the same day as their procedure. There was no statistically significant difference in age, BMI, ASA, Charlson score or disease volume. All patients indicated a high level of satisfaction with their procedure. Median time from completion of surgery to discharge was 426 min (7.1 h) in the day zero discharge cohort. CONCLUSION: Day zero discharge for RARP appears to deliver high satisfaction, oncological and safety outcomes. Therefore, our study demonstrates early success with unsupported same-day discharge in carefully selected and pre-counselled patients.

Linear Low-Intensity Extracorporeal Shockwave Therapy as a Method for Penile Rehabilitation in Erectile Dysfunction Patients after Radical Prostatectomy: A Randomized, Single-Blinded, Sham-Controlled Clinical Trial.

INTRODUCTION: The objective of this study was to investigate the effect and feasibility of linear low-intensity extracorporeal shockwave therapy (LI-LiESWT) as a penile rehabilitation method for erectile dysfunction (ED) after bilateral nerve-sparing (NS) radical prostatectomy (RP). METHODS: Patients who had undergone bilateral NS RP (either radical retropubic prostatectomy or robot-assisted laparoscopic RP), 3 or more months prior to the study, and who had no ED preoperatively and were suffering from mild to severe postoperative ED were included in the study. Four treatments were given over a 4-week period, using the PiezoWave2 device with a linear shockwave applicator and the linear shockwave tissue coverage (LSTC-ED®) technique. If the improvement in erectile function was still considered insufficient (less than an IIEF-5 score of 22-25) at 2 months after the start of LI-LiESWT, penile rehabilitation was supplemented by pharmacological penile rehabilitation. The final effect of treatment was evaluated after 12 months. The main outcome measure was changes in the five-item International Index of Erectile Function (IIEF-5) score. RESULTS: Between September 2019 and September 2020, a total of 40 patients were included in the study and randomly divided into 2 groups: treatment group and sham group. Eight patients were excluded from the study and were not evaluated due to other conditions which required additional treatment (COVID-19 disease, postoperative incontinence, urethral stricture, and ischemic stroke). Thirty-two patients were included in the final analysis: 16 in the control group and 16 in the intervention group. At 6 months from the end of treatment, patients in both the treatment and the sham group achieved physiological IIEF-5 values, and the beneficial effect persisted for 12 months after the end of treatment. CONCLUSIONS: LI-LiESWT using the LSTC-ED® technique is a suitable and safe method for penile rehabilitation in patients with ED after bilateral NS RP, not only because of the vasculogenic effect of LI-LiESWT but also because of its neuroprotective and/or regenerative effects.

Same-Day Discharge Protocol for Robot-Assisted Radical Prostatectomy: Experience of a High-Volume Referral Center.

Objective: As the coronavirus disease 2019 (COVID-19) global pandemic continues, there is increased value in performing same-day discharge (SDD) protocols to minimize viral exposure and maintain the appropriate surgical treatment for oncologic patients. In this scenario, we performed a prospective analysis of outcomes of our patients undergoing SDD protocol after robot-assisted radical prostatectomy (RARP). Materials and Methods: The SDD criteria included patients with no intraoperative complications, stable postoperative hemoglobin levels (compared with preoperative values), stable vital signs, normal urine output, ambulation with assistance and independently without dizziness, tolerance of clear liquids without nausea or vomiting, pain control with oral medication, and patient/family confidence with SDD. Patients older than 70 years, concomitant general surgery operations, multiple comorbidities, and complex procedures such as salvage surgery were excluded from our protocol. Results: Of the 101 patients who met the criteria for SDD, 73 (72%) had an effective SDD. All SDF (same day discharge failure) patients were discharged one day after surgery. Intraoperative characteristics were not statistically different with a median operative time of 92 (81-107) vs 103 (91-111) minutes for SDD and SDF, respectively. Of the 28 SDF patients, the most common reasons for staying were anesthesia-related factors of nausea (35%), drowsiness (7%), patient/caregiver preference (25%), pain (14%), labile blood pressure (7%), arrhythmia (7%), and dizziness (7%). There was no significant difference in readmission rates, complication rates, or postoperative pain scores between SDD and SDF patients. Conclusions: In our experience, SDD for patients undergoing RARP can be safely and feasibly incorporated into a clinical care pathway without increasing readmission rates. We were effective in 72% of cases because of coordinated care between anesthetics, nursing staff, and appropriate patient selection. We also believe that incorporating pre- and postoperative patient education and assurance is crucial to minimize their exposure to COVID-19 during the surgical treatment for prostate cancer.

The role of COVID-19 in prostate tissue inflammation: first pathological evidence.

According to current studies, COVID-19 might have an impact on semen quality. Therefore, SARS-CoV-2 may affect other traits of male reproductive system, including the prostate. Thus, we recruited patients who experienced COVID-19 infection in-between prostate biopsy and radical prostatectomy and compared prostate samples inflammation, measured with IRANI score, to those who did not. Indeed, we recruited 20 patients, aged 69 (62-73) years, finding no difference between the 10 patients with COVID-19 infection and the others in IRANI score and all its sub-scores. Hence, according to our exploratory and limited results, COVID-19 infection might have no gross effect on prostate inflammation.

The Impact of the Ongoing COVID-19 Epidemic on the Increasing Risk of Adverse Pathology in Prostate Cancer Patients Undergoing Radical Prostatectomy.

We aimed to assess whether the ongoing course of the COVID-19 epidemic has been associated with an increased risk of adverse pathology (AP) findings in prostate cancer (PC) patients treated with radical prostatectomy (RP). We performed a retrospective data analysis which included 408 consecutive, non-metastatic, previously untreated PC patients who underwent RP in our institution between March 2020 and September 2021. Patients were divided into two equally numbered groups in regard to the median surgery date (Early Epidemic [EE] and Late Epidemic [LE]) and compared. Adverse pathology was defined as either grade group (GG) ≥ 4, pT ≥ 3a or pN+ at RP. Patients in the LE group demonstrated significantly higher rates of AP than in the EE group (61 vs. 43% overall and 50 vs. 27% in preoperative non-high-risk subgroup, both p < 0.001), mainly due to higher rates of upgrading. On multivariable analysis, consecutive epidemic week (odds ratio: 1.02, 95% confidence interval: 1.00-1.03, p = 0.009) as well as biopsy GG ≥ 2 and a larger prostate volume (mL) were associated with AP in non-high-risk patients. The study serves as a warning call for increased awareness of risk underassessment in contemporarily treated PC patients.

Impact of the COVID-19 outbreak on prostate cancer care in the Netherlands.

INTRODUCTION: The COVID-19 outbreak has affected care for non-COVID diseases like cancer. We evaluated the impact of the COVID-19 outbreak on prostate cancer care in the Netherlands. METHODS: Prostate cancer diagnoses per month in 2020-2021 versus 2018-2019 were compared based on preliminary data of the Netherlands Cancer Registry (NCR) and nationwide pathology network. Detailed data was retrieved from the NCR for the cohorts diagnosed from March-May 2020 (first COVID-19 wave) and March-May 2018-2019 (reference). Changes in number of diagnoses, age, disease stage and first-line treatment were compared. RESULTS: An initial decline of 17% in prostate cancer diagnoses during the first COVID-19 wave was observed. From May onwards the number of diagnoses started to restore to approximately 95% of the expected number by the end of 2020. Stage at diagnosis remainedstable over time. In low-risk localised prostate cancer radical prostatectomy was conducted more often in week 9-12 (21% versus 12% in the reference period; OR=1.9, 95% CI; 1.2-3.1) and less active surveillance was applied (67% versus 78%; OR=0.6, 95% CI; 0.4-0.9). In the intermediate-risk group, a similar change was observed in week 13-16. Radical prostatectomy volumes in 2020 were comparable to 2018-2019. CONCLUSION: During the first COVID-19 wave the number of prostate cancer diagnoses declined. In the second half of 2020 this largely restored although the number remained lower than expected. Changes in treatment were temporary and compliant with adapted guidelines. Although delayed diagnoses could result in a less favourable stage distribution, possibly affecting survival, this seems not very likely.

COVID-19 Vaccination Manifesting as Unilateral Lymphadenopathies Detected by 18F-Choline PET/CT.

ABSTRACT: A 79-year-old man with a history of prostate adenocarcinoma treated with prostatectomy underwent 18F-FCH PET/CT for restaging purpose, which was negative for relapse but showed the presence of choline-positive lymph nodes in the left axilla. The patient underwent a COVID-19 vaccination in the left arm 6 days prior. Thus, PET/CT findings were considered as inflammatory lymph nodes. With the current drive of global COVID-19 immunization, this case underlines the importance of knowing vaccination history to interpret correctly the findings and to avoid false-positive reports.

The impact of COVID-19 on surgical volume and surgical training at a high-volume pelvic oncology centre.

INTRODUCTION: The coronavirus (COVID-19) pandemic has overwhelmed most health services. As a result, many surgeries have been deferred and diagnoses delayed. The aim of this study was to assess the effect of the COVID-19 pandemic at a high-volume pelvic oncology centre. METHODS: A retrospective review was performed of clinical activity from 2017 to 2020. We compared caseload for index procedures 2017-2019 (period 1) versus 2020 (period 2) to see the effect of the COVID pandemic. We then compared the activity during the first lockdown (March 23rd) to the rest of the year when we increased our theatre access by utilising a 'clean' site. RESULTS: The average annual number of robotic assisted radical cystectomy (RARC) and robotic assisted radical prostatectomy (RARP) performed during period 1 was 82 and 352 respectively. This reduced to 68 (17.1% reduction) and 262 (25.6% reduction) during period 2. The number of patients who underwent prostate brachytherapy decreased from 308 to 243 (21% reduction). The number of prostate biopsies decreased from 420 to 234 (44.3% reduction). The number of radical orchidectomies decreased from 18 to 11 (39% reduction). The mean number of RARC and RARP per month during period 2 was 5.5 and 22. This decreased to 4 and 9 per month during the first national lockdown but was maintained thereafter despite two further lockdowns. CONCLUSION: There has been a substantial decrease in urological oncology caseload during the COVID pandemic. The use of alternate pathways such as 'clean' sites can ensure continuity of care for cancer surgery and training needs.

HoloMentor: A Novel Mixed Reality Surgical Anatomy Curriculum for Robot-Assisted Radical Prostatectomy.

OBJECTIVES: The disruption to surgical training and medical education caused by the global COVID-19 pandemic highlighted the need for realistic, reliable, and engaging educational opportunities available outside of the operating theatre and accessible for trainees of all levels. This article presents the design and development of a virtual reality curriculum which simulates the surgical mentorship experience outside of the operating theatre, with a focus on surgical anatomy and surgical decision-making. METHOD: This was a multi-institutional study between London's King's College and Imperial College. The index procedure selected for the module was robotic radical prostatectomy. For each stage of the surgical procedure, subject-matter experts (N = 3) at King's College London, identified (1) the critical surgical-decision making points, (2) critical anatomical landmarks, and (3) tips and techniques for overcoming intraoperative challenges. Content validity was determined by an independent panel of subject-matter experts (N = 8) at Imperial College, London, using Fleiss' kappa statistic. The experts' teaching points were combined with operative footage and illustrative animations, and projected onto a virtual reality headset. The module was piloted to surgical science students (N = 15). Quantitative analysis compared participants' confidence regarding their anatomical knowledge before and after taking the module. Qualitative data were gathered from students regarding their views on using the virtual reality model. RESULTS: Multi-rater agreement between experts was above the 70.0% threshold for all steps of the procedure. Seventy-three percentage of pilot study participants "agreed" or "strongly agreed" that they achieved a better understanding of surgical anatomy and the rationale behind each procedural step. This was reflected in an increase in the median knowledge score after trialing the curriculum (p < 0.001). 100% of subject-matter experts and 93.3% of participants "agreed" or "strongly agreed" that virtual mentorship would be useful for future surgical training. CONCLUSIONS: This study demonstrated that virtual surgical mentorship could be a feasible and cost-effective alternative to traditional training methods with the potential to improve technical skills, such as operative proficiency and nontechnical skills such as decision-making and situational judgement.

Extraperitoneal single-port robot-assisted radical prostatectomy: initial experience and description of technique.

OBJECTIVE: To describe our technique of extraperitoneal single-port (SP) robot-assisted radical prostatectomy (RARP) and present our clinical experience with the first 10 cases. PATIENTS AND METHODS: In all, 10 consecutive patients diagnosed with localised prostate cancer underwent extraperitoneal SP-RARP using the da Vinci SP® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). Exclusion criteria included previous surgery through an infra-umbilical midline incision, prostate size >100 g, or preoperative evidence of extraprostatic disease. All surgeries were performed by a single surgeon with previous experience of >3000 cases in robotic surgery. Demographics and perioperative information were collected including: operative time, estimated blood loss (EBL), complications, length of stay, and days with Foley catheter. The extraperitoneal SP-RARP is performed as follows. Firstly, a 3-cm incision ~2 cm below the umbilicus is made. Dissection of the extraperitoneal space is achieved using a kidney shaped Spacemaker™ balloon (Covidien, Dublin, Ireland), placed through the infra-umbilical incision caudally reaching the retropubic space. Thereafter, the balloon is deployed; the space is created and verified under direct vision with a laparoscopic endoscope. A GelPOINT® mini advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) is inserted and a dedicated 25-mm multichannel port is placed with a 12-mm accessory laparoscopic port through the gel-seal cap into the same incision. The da Vinci SP surgical platform robot is docked with the patient in a supine position. RARP is performed replicating the technique previously described for multi-arm platforms or transperitoneal SP-RARP. No drain and no additional assistant ports were utilised. RESULTS: The patient's ages ranged between 48 and 70 years, and the mean preoperative prostate-specific antigen (PSA) level was 9 ng/mL. No conversions or intraoperative complications were recorded. The median (interquartile range) operative time was 197.5 (185.5-229.7) min. EBL ranged between 50 and 400 mL, six patients were discharged on the same day as the surgery and the median time with a Foley catheter after surgery was 8 days. CONCLUSIONS: Extraperitoneal SP-RARP is a feasible and safe surgical option to treat localised prostate cancer. In our early experience, promising results and possible advantages were found such as: a small single incision, no additional ports, no Trendelenburg positioning, minimal postoperative pain and use of opioids, and same day discharge. Further investigations need to be done to validate these advantages.

COVID-19 pandemic impact on uro-oncological disease outcomes at an Italian tertiary referral center.

PURPOSE: To assess differences in referral and pathologic outcomes for uro-oncology cases prior to and during the COVID pandemic, comparing clinical and pathological data of cancer surgeries performed at an academic referral center between 2019 and 2020. METHODS: We collected data of 880 prostate biopsies, 393 robot-assisted radical prostatectomies (RARP) for prostate cancer (PCa), 767 trans-urethral resections of bladder tumor (TURB) and 134 radical cystectomies (RC) for bladder cancer (BCa), 29 radical nephro-ureterectomies (RNU) for upper tract urothelial carcinoma, 130 partial nephrectomies (PN) and 12 radical nephrectomies (RN) for renal cancer, and 41 orchifunicolectomies for testicular cancer. Data of patients treated in 2019 (before COVID-19 pandemic) were compared to patients treated in 2020 (during pandemic). RESULTS: No significant decline in uro-oncological surgical activity was seen between 2019 and 2020. No significant increase in time between diagnosis and surgery was observed for all considered cancers. No differences in terms of main pathologic features were observed in patients undergoing RARP, TURB, RNU, RN/PN, or orchifunicolectomy. A higher proportion of ISUP grade 3 and 4 PCa were diagnosed in 2020 at biopsy (p = 0.001), but this did not translate into worse pathological grade/stage at RARP. In 2020, more advanced disease features were seen after RC, including lymph node involvement (p = 0.01) and non-organ confined disease (p = 0.02). CONCLUSION: Neither decline in uro-oncologic activity nor delay between diagnosis and treatment was observed at our institution during the first year of COVID-19 pandemic. No significant worsening of cancer disease features was found in 2020 except for muscle-invasive BCa.