Comparative analysis of partial versus radical nephrectomy for renal cell carcinoma: Is oncologic safety compromised during nephron sparing in higher stage disease?

Objectives: Over the past 20 years, the utility of partial nephrectomy (PN), compared to radical nephrectomy (RN), for the management of localized renal cell carcinoma (RCC) has progressively increased, particularly for larger and more complex masses. We sought to compare the recurrence-free survival (RFS) outcomes of PN versus RN in a single-institution cohort. Methods: Between 2002 and 2017, 228 patients underwent RN or PN for lcT1a-T2b, N0M0 RCC at a single tertiary referral center, performed by five surgeons. The clinical end point result was (local or distant) RFS. Univariate and multivariate (cox regression) models were used to evaluate the association between type of surgery (PN vs. RN) and RFS, in the overall cohort and in a subgroup of patients with cT1b. Results: The median age was 59 (interquartile range [IQR] 48-66), and the median tumor size was 4.5 cm (IQR 3-7). There were 128 PN and 100 RN. Over a median follow-up of 4.2 years (IQR 2.2-6.9), the Kaplan-Meier analysis showed no significant RFS difference between PN and RN (logrank P = 0.53). On multivariate analysis, pathologic stage ≥T2a, Fuhrman Grade ≥3, and chromophobe histology were associated with a worse RFS. PN was not significantly associated with diminished RFS (Hazard ratio [HR] 1.78, 95% confidence interval [CI] 0.74-4.3, P = 0.199) in the overall cohort compared to RN. However, in the cT1b subgroup, PN was associated with a significant increase in recurrence compared to RN (HR = 12.4, 95% CI 1.45-133.4, P = 0.038). Conclusions: Our institutional data highlight the possibility of compromise in RFS for clinically localized RCC treated with PN compared to RN, particularly for larger and more complex masses. These data raise concern, especially in light of the nonproven association of survival benefit of PN over RN, warranting future randomized prospective studies for further evaluation.

Adjusting the duration of androgen deprivation therapy (ADT) based on nadir PSA for high risk localized prostate cancer patients treated with definitive external beam radiation therapy and ADT.

BACKGROUND: A nadir Prostate-Specific Antigen (nPSA) of 0.06 ng/mL has been shown to be a strong independent predictor of biochemical recurrence-free survival (bRFS) in patients with intermediate or high-risk (HR) prostate cancer treated with definitive external beam radiation therapy (RT) and androgen deprivation therapy (ADT). We aimed to examine the association between the duration of ADT and bRFS in HR localized prostate cancer, based on nPSA. METHODS: Between 1998 and 2015, 204 patients with HR localized prostate cancer were identified. Of them, 157 patients (77.0%) reached the desired nPSA of < 0.06 ng/mL (favorable group), while 47 (23.0%) did not (unfavorable group). Duration of ADT varied among patients depending on physician preference, patient tolerance, and/or compliance. Survival outcomes were calculated using Kaplan-Meier methods and predictors of outcomes using multi-variable cox regression model. RESULTS: In the favorable group, ADT for at least 12 months lead to superior bRFS compared to ≤ 9 months of ADT (P = 0.036). However, no significant difference was seen when examining the value of receiving ADT beyond 12, 18, or 24 months, respectively. On univariate analysis for bRFS, the use of ADT for at least 12 months was significant (P = 0.012) as well as time to nadir PSA (tnPSA), (≤ 6 vs > 6 months); (P = 0.043). The presenting T stage was borderline significant (HR 3.074; 95% CI 0.972-9.719; P = 0.056), while PSA at presentation, Gleason Score and age were not. On multivariate analysis, the use of ADT for 12 months (P = 0.012) and tnPSA (P = 0.037) remained significant. In the unfavorable group, receiving ADT beyond 9 and 12 months was associated with improved bRFS (P = 0.044 and 0.019, respectively). However, beyond 18 months, there was no significant difference. CONCLUSION: In HR localized prostate cancer patients treated with definitive RT and ADT, the total duration of ADT may be adjusted according to treatment response using nPSA. In patients reaching a nPSA below 0.06 ng/mL, a total of 12 months of ADT may be sufficient, while in those not reaching a nPSA below 0.06 ng/mL, a total duration of 18 months is required.

The R.E.N.A.L score's relevance in determining perioperative and oncological outcomes: a Middle-Eastern tertiary care center experience.

Objective: The aim of this study is to evaluate the significance of the R.E.N.A.L nephrometry scoring system in predicting perioperative and oncological outcomes and determining the surgical approach of choice for kidney tumors.Patients and Methods: Our study retrospectively reviewed outcomes from the year 2002 to 2017. Mann-Whitney U test was used to compare continuous variables and chi-square test was used to compare categorical variables. Kaplan-Meier estimates and multivariable cox proportional hazard regression were performed to determine an association between the different R.E.N.A.L categories and disease recurrence or mortality. Results: A total of 325 patients underwent kidney surgery The most common R.E.N.A.L score category in our cohort study was intermediate (41.2%), followed by low, (33.2%) and high (25.5%). Patients with a high R.E.N.A.L score had worse perioperative outcomes compared to those with a low R.E.N.A.L score. High R.E.N.A.L score patients were 3 times more likely to receive blood transfusions compared to those with a low R.E.N.A.L score (19.4% vs 6.3%, p = 0.018), and a statistically significant longer hospital length of stay was also observed between the two groups (median 4.5 vs 4 days, p = 0.0419). In addition, the only predictor of disease recurrence or mortality was a high R.E.N.A.L score (Hazard Ratio (HR) 3.65, 95% Confidence Interval (CI) 1.05-12.7, p = 0.041). Conclusion: Our study sheds light on the use of R.E.N.A.L nephrometry score in predicting perioperative, postoperative, and oncological outcomes. Such findings may play a role in optimizing surgical approaches and pre-operative patient counseling.

Management of Patients with Advanced Prostate Cancer: Report from the Advanced Prostate Cancer Consensus Conference 2021.

BACKGROUND: Innovations in treatments, imaging, and molecular characterisation in advanced prostate cancer have improved outcomes, but various areas of management still lack high-level evidence to inform clinical practice. The 2021 Advanced Prostate Cancer Consensus Conference (APCCC) addressed some of these questions to supplement guidelines that are based on level 1 evidence. OBJECTIVE: To present the voting results from APCCC 2021. DESIGN, SETTING, AND PARTICIPANTS: The experts identified three major areas of controversy related to management of advanced prostate cancer: newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC), the use of prostate-specific membrane antigen ligands in diagnostics and therapy, and molecular characterisation of tissue and blood. A panel of 86 international prostate cancer experts developed the programme and the consensus questions. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The panel voted publicly but anonymously on 107 pre-defined questions, which were developed by both voting and non-voting panel members prior to the conference following a modified Delphi process. RESULTS AND LIMITATIONS: The voting reflected the opinions of panellists and did not incorporate a standard literature review or formal meta-analysis. The answer options for the consensus questions received varying degrees of support from panellists, as reflected in this article and the detailed voting results reported in the Supplementary material. CONCLUSIONS: These voting results from a panel of experts in advanced prostate cancer can help clinicians and patients to navigate controversial areas of management for which high-level evidence is scant. However, diagnostic and treatment decisions should always be individualised according to patient characteristics, such as the extent and location of disease, prior treatment(s), comorbidities, patient preferences, and treatment recommendations, and should also incorporate current and emerging clinical evidence and logistic and economic constraints. Enrolment in clinical trials should be strongly encouraged. Importantly, APCCC 2021 once again identified salient questions that merit evaluation in specifically designed trials. PATIENT SUMMARY: The Advanced Prostate Cancer Consensus Conference is a forum for discussing current diagnosis and treatment options for patients with advanced prostate cancer. An expert panel votes on predefined questions focused on the most clinically relevant areas for treatment of advanced prostate cancer for which there are gaps in knowledge. The voting results provide a practical guide to help clinicians in discussing treatment options with patients as part of shared decision-making.

What Experts Think About Prostate Cancer Management During the COVID-19 Pandemic: Report from the Advanced Prostate Cancer Consensus Conference 2021.

Patients with advanced prostate cancer (APC) may be at greater risk for severe illness, hospitalisation, or death from coronavirus disease 2019 (COVID-19) due to male gender, older age, potential immunosuppressive treatments, or comorbidities. Thus, the optimal management of APC patients during the COVID-19 pandemic is complex. In October 2021, during the Advanced Prostate Cancer Consensus Conference (APCCC) 2021, the 73 voting members of the panel members discussed and voted on 13 questions on this topic that could help clinicians make treatment choices during the pandemic. There was a consensus for full COVID-19 vaccination and booster injection in APC patients. Furthermore, the voting results indicate that the expert's treatment recommendations are influenced by the vaccination status: the COVID-19 pandemic altered management of APC patients for 70% of the panellists before the vaccination was available but only for 25% of panellists for fully vaccinated patients. Most experts (71%) were less likely to use docetaxel and abiraterone in unvaccinated patients with metastatic hormone-sensitive prostate cancer. For fully vaccinated patients with high-risk localised prostate cancer, there was a consensus (77%) to follow the usual treatment schedule, whereas in unvaccinated patients, 55% of the panel members voted for deferring radiation therapy. Finally, there was a strong consensus for the use of telemedicine for monitoring APC patients. PATIENT SUMMARY: In the Advanced Prostate Cancer Consensus Conference 2021, the panellists reached a consensus regarding the recommendation of the COVID-19 vaccine in prostate cancer patients and use of telemedicine for monitoring these patients.

MRI/US fusion transperineal versus transrectral biopsy of prostate cancer: Outcomes and complication rates, a tertiary medical center experience in the Middle East.

OBJECTIVE: To report on the outcomes of transperineal versus transrectal magnetic resonance imaging/ultrasound fusion biopsy of the prostate including detection of clinically significant cancer and complications. This is the first and largest series in the Middle East. MATERIAL AND METHODS: Between May 2019 and June 2020, 145 patients with suspicious lesions on magnetic resonance imaging underwent magnetic resonance imaging/ultrasound fusion prostate biopsy at our center. Transperineal biopsy was performed under light sedation, while transrectal biopsy patients had a periprostatic block for anesthesia. Clinically significant cancer was defined as Gleason ≥3+4 Results: In all, 98 transperineal biopsies and 47 transrectal magnetic resonance imaging/ultrasound fusion prostate biopsies were done. Patients had similar prebiopsy parameters (transperineal vs. transrectal): median age (64.5 vs. 66 years; P=.68), median prostate-specific antigen value (7.5 vs. 7.5; P=.42), and median prostate volume (51 vs. 52.5; P=.83). Those that underwent transperineal biopsy had fewer average total number of cores compared to transrectal ultrasound-guided biopsy (11 vs. 13; P=.025) fewer average number of random cores (3 vs. 6; P < .0001), and the detection rate of clinically significant cancer was similar between the groups (44% vs. 48.9%; P=.57). No difference in hematuria, retention, and sepsis rate requiring admission (1 vs. 2; P=.2) was observed. However, more patients had urinary tract infection in the transrectal ultrasound-guided biopsy group compared to transperineal biopsy group (5 vs. 1; P=.006) that were treated with antibiotics on outside basis. CONCLUSION: Magnetic resonance imaging/ultrasound transperineal fusion biopsy has similar detection rate of clinically significant cancer compared to transrectal ultrasound-guided biopsy with less urinary tract infection post biopsy.

High rates of advanced prostate cancer in the Middle East: Analysis from a tertiary care center.

OBJECTIVES: Prostate cancer incidence is increasing in the Middle East (ME); however, the data of stage at the diagnosis and treatment outcomes are lacking. In developed countries, the incidence of de novo metastatic prostate cancer ranges between 4% and 14%. We hypothesized that the rates of presentation with advanced disease are significantly higher in the ME based on clinical observation. This study aims to examine the stage at the presentation of patients with prostate cancer at a large tertiary center in the ME. METHODS: After Institutional Review Board approval, we identified the patients diagnosed with prostate adenocarcinoma and presented to a tertiary care center between January 2010 and July 2015. Clinical, demographic, and pathological characteristics were abstracted. Patients with advanced disease were stratified according to tumor volume based on definitions from practice changing clinical trials. Descriptive and Kaplan-Meier survival analysis was used. RESULTS: A total of 559 patients were identified, with a median age at the diagnosis of 65 years and an age range of 39-94 years. Median prostate-specific antigen (PSA) at the presentation was 10 ng/ml, and almost a quarter of the men (23%) presented with metastatic disease. The most common site of metastasis was the bone (34/89, 38%). High-volume metastasis was present in 30.3%, 9%, and 5.2% of the cohort based on STAMPEDE, CHAARTED, and LATITUDE trial criteria, respectively. CONCLUSION: This is the first report showing the high proportion of men from ME presenting with de novo metastasis. This could be due to many factors, including the highly variable access to specialist multidisciplinary management, lack of awareness, and lack of PSA screening in the region. There is a clear need to raise the awareness about prostate cancer screening and early detection and to address the rising burden of advanced prostate cancer affecting men in the ME region.

Use of Bariatric Ports in 4-Arm Robotic Partial Nephrectomy: A Comparative Study With the Standard 3-Arm Technique.

Objectives We aim to compare the outcomes of a 3-arm versus a 4-arm robotic assisted partial nephrectomy (RAPN) using the da Vinci Si model; as well as, illustrate the deployment of long ports to decrease arm collision during the 4-arm approach. Patients and Methods Results of RAPN in a Middle Eastern tertiary referral center from August 2013 to December 2017 are reported. Comparison between 3 versus 4-arm robotic approaches was done in regards to patient and tumor characteristics, operative parameters, and postoperative outcomes. Statistical analysis was performed with the Student's t-test and chi-squared test. Results Forty consecutive 3-arm RAPNs and 40 consecutive 4-arm RAPNs were retrospectively evaluated. Differences in tumor complexity between the two groups were statistically insignificant. Similarly, surgical margin positivity, mean ischemia time, estimated blood loss, length of hospital stay, and mean change in serum creatinine were statistically insignificant between the two groups. Mean operative time was significantly shorter by 42 minutes in the 4-arm vs 3-arm group (p=0.01). Conclusions The addition of a 4th arm in RAPN can be of benefit in centers that still rely on the da Vinci Si model. The ease of hilar dissection, retraction, and surgeon independence instigated a statistically significant decrease in operative time with 4-arm use.

Comparative analysis of histopathological subtypes of renal cell carcinoma in the Middle East compared to other world regions.

INTRODUCTION: Renal cell carcinoma (RCC) has various histopathological tumor subtypes which have a significant implication on the oncological outcome of these patients. We aimed to evaluate the distribution of RCC subtypes presenting at a tertiary care center in the Middle East, in comparison to the distribution reported in different geographic areas worldwide. METHODS: A retrospective chart review was conducted on all patients who underwent partial or radical nephrectomy for RCC at the American University of Beirut Medical Center between January 2012 and January 2018. Data on histologic subtypes were compiled and compared to representative series from different continents. RESULTS: One hundred and seventy-nine patients with RCC were identified, of whom 122 (68.2%) were classified as clear cell, 30 (16.8%) as papillary, 17 (9.5%) as chromophobe, and 10 (5.6%) as unclassified. When compared to other regions of the world, this Middle Eastern series demonstrated a higher prevalence of the chromophobe subtype compared to Western populations (9.5% in the Middle East vs. 5.3% in the US and 3.1% in Europe) and a lower prevalence of clear cell subtype (68.2% in the Middle East vs. 78.7% in the US and 85.8% in Europe). Conversely, there was a higher prevalence of papillary RCC in the Middle East (16.8%) compared to North America (13.1%, 95% confidence interval [CI]: 12.7-13.6), Europe (11.1%, 95% CI: 10.0-12.1), and Australia (10.2%). The prevalence of chromophobe and clear cell RCC in the Middle East was similar to that reported in South America. CONCLUSIONS: The distribution of RCC subtypes in this Middle Eastern cohort was significantly different from that reported in the Western hemisphere (Europe and the US) but similar to that reported in South America and Australia. These findings may point to a possible genetic predisposition underlying the global variation in distribution.

Does a Positive Surgical Margin After Nephron Sparing Surgery Affect Oncological Outcome in Renal Cell Carcinoma? A Systematic Review and Meta-analysis.

We systematically evaluated the impact of positive surgical margins (PSM) on oncological outcomes after partial nephrectomy for renal cell carcinoma. Forty-two studies comprising 101,153 subjects were included and five distinct meta-analyses were performed. PSM was associated with increased risk of local recurrence (hazard ratio (HR) 6.11-high certainty), metastasis (HR 3.29-moderate certainty), overall relapse (HR 2.25-high certainty), overall mortality (HR 1.30-moderate certainty), and may be associated with increased cancer-specific mortality (HR 1.91-low certainty). Patients with PSM should be counseled for the possibility of additional surgery, novel adjuvant therapies, and more rigorous surveillance.

Treatment of Localized and Locally Advanced, High-Risk Prostate Cancer: A Report From the First Prostate Cancer Consensus Conference for Developing Countries.

PURPOSE: To generate and present survey results on important issues relevant to treatment and follow-up of localized and locally advanced, high-risk prostate cancer (PCa) focusing on developing countries. METHODS: A panel of 99 PCa experts developed more than 300 survey questions of which 67 questions concern the main areas of interest of this article: treatment and follow-up of localized and locally advanced, high-risk PCa in developing countries. A larger panel of 99 international multidisciplinary cancer experts voted on these questions to create the recommendations for treatment and follow-up of localized and locally advanced, high-risk PCa in areas of limited resources discussed in this article. RESULTS: The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion and not on a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations considered cost-effectiveness as well as the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. Results were tabulated in real time. CONCLUSION: The voting results and recommendations presented in this article can guide physicians managing localized and locally advanced, high-risk PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for treatment of localized and locally advanced, high-risk PCa in developing countries have not been defined, this article will serve as a point of reference when confronted with this disease.

Consensus on Prostate Cancer Treatment of Localized Disease With Very Low, Low, and Intermediate Risk: A Report From the First Prostate Cancer Consensus Conference for Developing Countries (PCCCDC).

PURPOSE: A group of international urology and medical oncology experts developed and completed a survey on prostate cancer (PCa) in developing countries. The results are reviewed and summarized, and recommendations on consensus statements for very low-, low-, and intermediate-risk PCa focused on developing countries were developed. METHODS: A panel of experts developed more than 300 survey questions of which 66 questions concern the principal areas of interest of this paper: very low, low, and intermediate risk of PCa in developing countries. A larger panel of 99 international multidisciplinary cancer experts voted on these questions to create the recommendations for treatment and follow-up for very low-, low-, and intermediate-risk PCa in areas of limited resources discussed in this manuscript. RESULTS: The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion not a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations consider cost-effectiveness and the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. The results were tabulated in real time. CONCLUSION: The voting results and recommendations presented in this document can be used by physicians to support management for very low, low, and intermediate risk of PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for treatment for very low, low, and intermediate risk of PCa in developing countries have not been developed, this document will serve as a point of reference when confronted with this disease.

Genitourinary Interventions in Autosomal Dominant Polycystic Kidney Disease: Clinical Recommendations for Urologic and Transplant Surgeons.

Autosomal dominant polycystic kidney disease is the fourth most common single cause of end-stage renal disease worldwide with both renal and extrarenal manifestations, resulting in significant morbidity. Approaches to the management of this disease vary widely, with no broadly accepted practice guidelines. Herein, we reviewed the various surgical and interventional management options that are targeted toward treating the symptoms or addressing the resulting kidney failure. Novel treatment modalities such as celiac plexus blockade and renal denervation appear to be promising in pain relief; however, further studies are lacking. Renal cyst decortication seems to have a higher success rate in targeting cyst-related pain compared with aspiration only. In terms of requiring major surgical intervention, such as need and timing of native nephrectomy, there are several considerations when deciding on transplantation with or without a pretransplant native nephrectomy. Patients who are not candidates for native nephrectomy may consider transcatheter arterial embolization. Based on our review of the contemporary indications for genitourinary interventions in the management of autosomal dominant polycystic kidney disease, we propose an algorithm that depicts the decision-making process on assessing the indications and timing of native nephrectomy in patients with end-stage renal disease awaiting transplant.

Cystectomy vs. bladder preservation after neoadjuvant chemotherapy in muscle-invasive bladder cancer: A tertiary medical center experience.

BACKGROUND: Radical cystectomy (RC) remains the standard of care for muscle-invasive bladder cancer (MIBC). Because of the higher overall risks associated with RC, particularly in the elderly patients with multiple comorbidities, other less invasive bladder preservation strategies have been considered. METHODS: This is a retrospective chart review of patients diagnosed with MIBC, pT2-4N0-2M0, at the American University of Beirut Medical Center between 2007 and 2017. RESULTS: 98 patients, 85 (86.7%) males and 13 (13.3%) females, were included. Of the 98 patients, 19 (19.3%) patients were treated with upfront CRT, 35 (35.7%) were treated with upfront RC and 44 (45%) were treated with NAC. 26 (26.5%) patients underwent RC after NAC and 18 (18.4%) received CRT after NAC. The mean overall survival (OS) for the different treatment modalities was 69.4, 60.4, 56.1 and 44.2 months for RC, CRT, RC post-NAC and CRT post-NAC, respectively (p = 0.83). The median disease-free survival (DFS) was 29, 22, 21 and 16 months for RC, CRT, RC post-NAC and CRT post-NAC, respectively (p = 0.49). Patients with pT3/T4 had a higher risk of death by 3.335 folds compared to pT2 (95% CI [1.321-8.422], p<0.05). CONCLUSIONS: No difference was noted in the OS and DFS between the groups who underwent RC post-NAC and CRT post-NAC. These findings further support the possibility of bladder preservation after the treatment with NAC for MIBC. The pathologic T stage at diagnosis is an important prognostic factor regardless of treatment modality.

A large bi-lobed classic renal angiomyolipoma with vena caval extension.

Renal angiomyolipomas (AMLs) are the most common benign renal tumors encountered, and composed of 3 components: mature adipose tissues, smooth muscles, and blood vessels. Mostly asymptomatic and discovered incidentally, the classic type of AMLs rarely extend to involve great vessels. Radiological confirmation of such lesions is paramount for diagnosis and planned intervention. Management of AMLs is based on clinical presentation and varies from active surveillance to invasive surgical interventions. A case of sizeable classic AML with extension to inferior vena cava is presented here, with successful tumor resection performed after complete liver mobilization. A literature review and a summary of similar cases are also presented. A multidisciplinary approach is required for proper and precise radiological diagnosis to achieve an adequate surgical resection, which might sometimes be complicated and complex, as in this current case.

Management of Patients with Advanced Prostate Cancer: Report of the Advanced Prostate Cancer Consensus Conference 2019.

BACKGROUND: Innovations in treatments, imaging, and molecular characterisation in advanced prostate cancer have improved outcomes, but there are still many aspects of management that lack high-level evidence to inform clinical practice. The Advanced Prostate Cancer Consensus Conference (APCCC) 2019 addressed some of these topics to supplement guidelines that are based on level 1 evidence. OBJECTIVE: To present the results from the APCCC 2019. DESIGN, SETTING, AND PARTICIPANTS: Similar to prior conferences, experts identified 10 important areas of controversy regarding the management of advanced prostate cancer: locally advanced disease, biochemical recurrence after local therapy, treating the primary tumour in the metastatic setting, metastatic hormone-sensitive/naïve prostate cancer, nonmetastatic castration-resistant prostate cancer, metastatic castration-resistant prostate cancer, bone health and bone metastases, molecular characterisation of tissue and blood, inter- and intrapatient heterogeneity, and adverse effects of hormonal therapy and their management. A panel of 72 international prostate cancer experts developed the programme and the consensus questions. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The panel voted publicly but anonymously on 123 predefined questions, which were developed by both voting and nonvoting panel members prior to the conference following a modified Delphi process. RESULTS AND LIMITATIONS: Panellists voted based on their opinions rather than a standard literature review or formal meta-analysis. The answer options for the consensus questions had varying degrees of support by the panel, as reflected in this article and the detailed voting results reported in the Supplementary material. CONCLUSIONS: These voting results from a panel of prostate cancer experts can help clinicians and patients navigate controversial areas of advanced prostate management for which high-level evidence is sparse. However, diagnostic and treatment decisions should always be individualised based on patient-specific factors, such as disease extent and location, prior lines of therapy, comorbidities, and treatment preferences, together with current and emerging clinical evidence and logistic and economic constraints. Clinical trial enrolment for men with advanced prostate cancer should be strongly encouraged. Importantly, APCCC 2019 once again identified important questions that merit assessment in specifically designed trials. PATIENT SUMMARY: The Advanced Prostate Cancer Consensus Conference provides a forum to discuss and debate current diagnostic and treatment options for patients with advanced prostate cancer. The conference, which has been held three times since 2015, aims to share the knowledge of world experts in prostate cancer management with health care providers worldwide. At the end of the conference, an expert panel discusses and votes on predefined consensus questions that target the most clinically relevant areas of advanced prostate cancer treatment. The results of the voting provide a practical guide to help clinicians discuss therapeutic options with patients as part of shared and multidisciplinary decision making.

Robot-assisted radical prostatectomy in the Middle East: A report on the perioperative outcomes from a tertiary care centre in Lebanon.

OBJECTIVE: To report on the surgical, oncological and early functional outcomes of robot-assisted radical prostatectomy (RARP) at our tertiary care centre, as there is a scarcity of reports on outcomes of robotic surgery from the Middle East. PATIENTS AND METHODS: We reviewed the electronic health records for patients undergoing RARP between 2013 and 2019 at the American University of Beirut Medical Center. We collected patients' demographics and preoperative oncological factors including prostate-specific antigen (PSA), clinical oncological stage, and World Health Organization (WHO) grade. PSA persistence, biochemical recurrence (BCR) and positive surgical margin (PSM) were reported. Complications were categorised by Clavien-Dindo grade. Moreover, the postoperative oncological outcomes including the rates of adjuvant and salvage androgen-deprivation therapy (ADT) and external-beam radiation therapy (EBRT), chemotherapy, and metastasis were reported. Additionally continence and potency results were retrieved. RESULTS: For the designated period, 250 patients underwent RARP of which 182 (72.8%) underwent lymph node dissection. The median (interquartile range) anaesthesia time was 330 (285-371) min and the estimated blood loss was 200 (200-300) mL. The overall complication rate was 8%, with 2% Clavien-Dindo Grade III-IV complications. The PSM and BCR rates were 21.6% and 6.4%, respectively. Adjuvant ADT and EBRT was administered to 7.2% of the patients. Functional data was available for 112 patients. Continence was 68%, 82% and 97% of the patients at 3, 6 and 12 months, respectively. For 65 patients who had bilateral nerve sparing potency was 37%, 60% and 83% at 3, 6 and 12 months, respectively. CONCLUSION: This is the largest RARP series from the Middle East. The surgical, oncological and functional outcomes are consistent with those published in the literature. This confirms the safety and efficacy of applying robotic technology in our region during the implementation phase.Abbreviations: ADT: androgen-deprivation therapy; AJCC: American Joint Committee on Cancer; AUBMC: American University of Beirut Medical Center; BCR: biochemical recurrence; CPT: Current Procedural Terminology; EBRT external beam radiation therapy; IQR, interquartile ranges; LOS: length of stay; PLND: pelvic lymph node dissection; PSM: positive surgical margin; (O)(RA)RP, (open) (robot-assisted) radical prostatectomy.