Components of a safe cystectomy service during coronavirus disease 2019 in a high-volume centre

Objective:

Delivery of a safe cystectomy service is a multidisciplinary exercise. In this article, we detail the measures implemented at our institution to deliver a cystectomy service for bladder cancer patients during coronavirus disease 2019 (COVID-19).

Methods:

A ‘one-stop’ enhanced recovery clinic had been established at our hospital, consisting of an anaesthetist, an exercise testing service, urinary diversion nurses, clinical nurse specialists and surgeons. During COVID-19, we modified these processes in order to continue to provide urgent cystectomy safely for bladder cancer. We collected patients’ outcomes prospectively measuring demographic characteristics, oncological and perioperative outcomes, the presence of COVID-19 symptoms and confirmed COVID-19 test results.

Results:

From March to May 2020, 25 patients underwent radical cystectomy for bladder cancer. Twenty-four procedures were performed with robotic assistance and one open as part of a research trial. We instituted modifications at various multidisciplinary steps, including patient selection, preoperative optimisation, enhanced recovery protocols, patient counselling and perioperative protocols. Thirty-day mortality was 0%. The 30-day rate of Clavien ⩾3 complications was 8%. Postoperatively, none of the patients developed COVID-19 based on World Health Organization criteria and testing.

Conclusion:

We safely delivered a complex cystectomy service during the peak of the COVID-19 pandemic without any COVID-19-related morbidity or mortality.

Level of evidence:

Level 2b.

The evolution of image guidance in robotic-assisted laparoscopic prostatectomy (RALP): a glimpse into the future

OBJECTIVES

To describe the innovative intraoperative technologies emerging to aid surgeons during minimally invasive robotic-assisted laparoscopic prostatectomy.

METHODS

We searched multiple electronic databases reporting on intraoperative imaging and navigation technologies, robotic surgery in combination with 3D modeling and 3D printing used during laparoscopic or robotic-assisted laparoscopic prostatectomy. Additional searches were conducted for articles that considered the role of artificial intelligence and machine learning and their application to robotic surgery. We excluded studies using intraoperative navigation technologies during open radical prostatectomy and studies considering technology to visualize lymph nodes. Intraoperative imaging using either transrectal ultrasonography or augmented reality was associated with a potential decrease in positive surgical margins rates. Improvements in detecting capsular involvement may be seen with augmented reality. The benefit, feasibility and applications of other imaging modalities such as 3D-printed models and optical imaging are discussed.

CONCLUSION

The application of image-guided surgery and robotics has led to the development of promising new intraoperative imaging technologies such as augmented reality, fluorescence imaging, optical coherence tomography, confocal laser endomicroscopy and 3D printing. Currently challenges regarding tissue deformation and automatic tracking of prostate movements remain and there is a paucity in the literature supporting the use of these technologies. Urologic surgeons are encouraged to improve and test these advanced technologies in the clinical arena, preferably with comparative, randomized, trials.

Real-time assessment of learning curve for robot-assisted laparoscopic prostatectomy

INTRODUCTION

The learning curves analysed to date for robot-assisted laparoscopic prostatectomy are based on arbitrary cut-offs of the total cases.

METHODS

We analysed a large dataset of robot-assisted laparoscopic prostatectomies from a single centre between 2008 and 2019 for assessment of the learning curve for perioperative outcomes with respect to time and individual cases.

RESULTS

A total of 1,406 patients were evaluated, with mean operative time 198.08 minutes and mean console time 161.05 minutes. A plot of operative time and console time showed an initial decline followed by a near-constant phase. The inflection points were detected at 1,398 days (308th case) for operative time and 1,470 days (324th case) for console time, with a declining trend of 8.83 minutes and 7.07 minutes, respectively, per quarter-year (p<0.001). Mean estimated blood loss showed a 70.04% reduction between the start (214.76ml) and end (64.35ml) (p<0.001). The complication rate did not vary with respect to time (p=0.188) or the number of procedures (p=0.354). There was insufficient evidence to claim that the number of operations (p=0.326), D'Amico classification (p=0.114 for intermediate versus low; p=0.158 for high versus low) or time (p=0.114) was associated with the odds of positive surgical margins.

CONCLUSIONS

It takes about 300 cases and nearly 4 years to standardise operative and console times, with a requirement of around 80 cases per annum for a single surgical team in the initial years to optimise the outcomes of robot-assisted laparoscopic prostatectomy.

Laparoscopic partial nephrectomy for Juxtaglomerular apparatus tumour: A rare cause of hypertension

We report on the case of a partial nephrectomy for a Juxtaglomerular apparatus (JGA) tumour in a 28 year old female who presented with fatigue and symptomatic hypertension, and a normal serum renin level on pre-operative work-up.

Lower urinary tract symptoms - current management in older men

BACKGROUND

Lower urinary tract symptoms are a common problem in men and the incidence of these symptoms increases with age.

OBJECTIVE

This article provides an update on the evaluation and treatment of lower urinary tract symptoms in older men. In particular, we describe current nomenclature, diagnosis, the International Prostate Symptom Score, and currently available medical and surgical treatments as well as indications for referral to a urologist.

DISCUSSION

Lower urinary tract symptoms may be divided into voiding and storage, and men may present with a combination of the two symptom groups. Voiding symptoms include weak stream, hesitancy, and incomplete emptying or straining and are usually due to enlargement of the prostate gland. Storage symptoms include frequency, urgency and nocturia and may be due to detrusor overactivity. In elderly men who present with lower urinary tract symptoms, indications for early referral to a urologist include haematuria, recurrent infections, bladder stones, urinary retention and renal impairment. In uncomplicated cases, medical therapy can be instituted in the primary care setting. Options for medical therapy include alpha blockers to relax the smooth muscle of the prostate, 5 alpha reductase inhibitors to shrink the prostate, and antimuscarinics to relax the bladder. The International Prostate Symptom Score is beneficial in assessing symptoms and response to treatment. If symptoms progress despite medical therapy or the patient is unable to tolerate medical therapy, urological referral is warranted.

Bladder cancer--current management

BACKGROUND

Over 2000 cases of bladder cancer were diagnosed in Australia in 2005. Bladder cancer is a relatively common disease with high morbidity if left untreated. Bladder cancer is categorised as either 'nonmuscle invasive bladder cancer' or 'muscle invasive bladder cancer'. Treatment varies significantly for each type.

OBJECTIVE

This article provides an update on the presentation of bladder cancer, its risk factors, investigations and treatment, and discusses the role of chemotherapy as a neoadjuvant and adjuvant treatment.

DISCUSSION

Bladder cancer most commonly presents with microscopic or macroscopic haematuria. Evaluation is required of all patients with macroscopic haematuria, patients with persistent microscopic haematuria, and at risk patients with a single episode of microscopic haematuria. Evaluation consists of imaging, urine cytology and cystoscopy. Nonmuscle invasive bladder cancer patients can undergo tumour resection with adjuvant intravesical treatments, while muscle invasive bladder cancer patients are optimally treated with cystectomy and urinary diversion.

Androgen deficiency in the aging man

BACKGROUND

Androgen deficiency in the aging man is an area of considerable debate because a gradual decline in testosterone may simply be part of the normal aging process. However, there is an alternative view that androgen deficiency in the aging man may constitute a valid and underdiagnosed disorder.

OBJECTIVE

To discuss the aetiology, clinical features, diagnosis and management of androgen deficiency in the aging man.

DISCUSSION

Late onset hypogonadism has clinical features that overlap with both normal aging and some pathological conditions. It can only be diagnosed on the basis of both suggestive clinical features and clear biochemical evidence of testosterone deficiency. In this group of patients medication may play a role.