Management of patients with high-risk and advanced prostate cancer in the Middle East: resource-stratified consensus recommendations.

PURPOSE: Prostate cancer care in the Middle East is highly variable and access to specialist multidisciplinary management is limited. Academic tertiary referral centers offer cutting-edge diagnosis and treatment; however, in many parts of the region, patients are managed by non-specialists with limited resources. Due to many factors including lack of awareness and lack of prostate-specific antigen (PSA) screening, a high percentage of men present with locally advanced and metastatic prostate cancer at diagnosis. The aim of these recommendations is to assist clinicians in managing patients with different levels of access to diagnostic and treatment modalities. METHODS: The first Advanced Prostate Cancer Consensus Conference (APCCC) satellite meeting for the Middle East was held in Beirut, Lebanon, November 2017. During this meeting a consortium of urologists, medical oncologists, radiation oncologist and imaging specialists practicing in Lebanon, Syria, Iraq, Kuwait and Saudi Arabia voted on a selection of consensus questions. An additional workshop to formulate resource-stratified consensus recommendations was held in March 2019. RESULTS: Variations in practice based on available resources have been proposed to form resource-stratified recommendations for imaging at diagnosis, initial management of localized prostate cancer requiring therapy, treatment of castration-sensitive/naïve advanced prostate cancer and treatment of castration-resistant prostate cancer. CONCLUSION: This is the first regional consensus on prostate cancer management from the Middle East. The following recommendations will be useful to urologists and oncologists practicing in all areas with limited access to specialist multi-disciplinary teams, diagnostic modalities and treatment resources.

General anaesthesia combined with bilateral paravertebral blockade (T11-T12-L1) vs general anaesthesia for bilateral varicocelectomy. A randomized double-blind clinical trial.

INTRODUCTION: Varicocelectomy is a common operation in urology associated with considerable postoperative pain. The aim of this prospective, randomized, double-blind study was to investigate whether a combination of general anesthesia and bilateral nerve stimulator guided paravertebral nerve blocks could provide better postoperative pain relief compared to general anesthesia in combination with placebo paravertebral nerve block. METHODS: Sixty patients scheduled for varicocelectomy were randomized prospectively. Thirty patients each in either the active group (general anaesthesia combined with nerve stimulator guided bilateral paravertebral block) or the control group (general anaesthesia combined with normal saline nerve stimulator guided bilateral paravertebral block). Postoperative pain was assessed by visual analogue scale scores at predetermined time intervals. RESULTS: The active group was found to have better postoperative pain-relief (p < 0.005), reduced need for analgesics (p < 0.05), and also a more rapid return to normal activities (p < 0.001) compared to control group. Higher surgeon and patient satisfaction (p < 0.001) were noted in the active group compared to the control group. CONCLUSION: Preoperative paravertebral blockade combined with general anesthesia showed significantly reduced postoperative pain scores and analgesic consumption, earlier return to normal activity and was associated with better patient and surgeon satisfaction during varicocelectomy surgery.