Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.

Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.

Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.

Study Type – Prognosis (retrospective cohort) Level of Evidence 2b OBJECTIVE To determine the effect of an upgrade in Gleason score between initial prostate biopsy and final prostatectomy specimen on the risk of postoperative biochemical recurrence. PATIENTS AND METHODS A total of 1629 patients with paired biopsy and radical prostatectomy histology were identified from two prospectively recorded prostate cancer databases. Information on key clinical and pathological characteristics as well as prostate‐specific antigen follow‐up was recorded. Patients who experienced an upgrade in their Gleason score were compared with corresponding patients with concordant tumours of the lower and higher grade. Kaplan–Meier curves and multivariate models were generated to examine the impact of Gleason score upgrade on the risk of postoperative biochemical recurrence. RESULTS Overall, 466 patients (28.6%) experienced an upgrade in their Gleason score post radical prostatectomy, in 88.4% of cases involving a change in a single Gleason score point. Patients upgraded from Gleason 6 (3 + 3) to Gleason 7 (3 + 4) had pathological characteristics that were very similar to Gleason 7 (3 + 4) concordant tumours, with an identical risk of biochemical recurrence. In contrast, patients upgraded from Gleason score 6 (3 + 3) to Gleason 7 (4 + 3) had tumours with pathological characteristics intermediate between the two concordant groups, which was mirrored by their risk of biochemical recurrence. Patients with Gleason 7 tumours who experienced a change in the predominant pattern from 3 + 4 to 4 + 3 had tumours that resembled Gleason 7 (4 + 3) concordant tumours, with a similar risk of biochemical recurrence. In contrast, patients upgraded from Gleason 7 to Gleason >7 had tumours with intermediate pathological characteristics, and a risk of biochemical recurrence that was significantly different to concordant tumours of the lower and higher grade. In multivariate models, a change in Gleason score was an independent predictor of biochemical recurrence in the preoperative setting only. Although a difference in Gleason score was an independent predictor of recurrence in concordant tumours in models based on postoperative variables, an upgrade in Gleason score in discordant tumours was not, with differences in co‐segregated adverse pathological characteristics being more predictive. CONCLUSIONS Patients experiencing an upgrade in their Gleason score between biopsy and final specimen exhibit significantly more aggressive pathological features than corresponding concordant tumours, and a higher risk of biochemical recurrence post radical prostatectomy. As Gleason score can be more accurately assessed preoperatively than other prognostic tumour features, continued effort is required to identify those most at risk of upgrading, and to refine biopsy strategies to reduce sampling error.

Background With among the lowest urologist per population ratios in Europe, the demand for urology specialist review in Ireland far exceeds supply. Lower urinary tract symptoms (LUTS) account for a significant number of referrals. The traditional paradigm of every patient being reviewed in a consultant-led clinic is unsustainable. New models of care with nurse-led clinics represent an opportunity to optimise limited resources. Methods Existing long-waiting male LUTS referrals were triaged to a specialist nurse-led LUTS clinic. After urology CNS assessment, charts were reviewed by a consultant urologist and a plan formulated. Relevant data were prospectively collected and analysed. Results Fifty-eight new male patients with LUTS were seen over a 6-month period with an average waiting time of 15.8 months. Patients were assessed with uroflowmetry, IPSS and DRE. Mean age was 64, IPSS 14.5, Qmax 18.3 ml/s and PVR 89 ml. Thirty patients (52%) were discharged directly with lifestyle modification and medical therapy. Twenty-eight patients (48%) required one or more further investigations and subsequent review; 11 had flexible cystoscopy, 4 had urodynamics, 5 had prostate MRI, and 2 patients were listed for surgery (TURP and circumcision). The remaining 10 patients were for review post trial of lifestyle modifications and/or medical treatment. After review/investigations, 4 more patients were discharged. A total of 32 patients (55%) were discharged or listed for surgery after initial assessment. This total increased to 62% after a second review/investigations. Conclusion Introduction of a CNS-led LUTS clinic has significantly reduced the number of patients requiring follow-up in general urology clinics, representing a quality improvement in service provision. Supplementary Information The online version contains supplementary material available at 10.1007/s11845-020-02428-8.

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Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Due to sampling error, the Gleason score of clinically localized prostate cancer is frequently underestimated at the time of initial biopsy. Given that this may lead to inappropriate surveillance of patients with high‐risk disease, there is considerable interest in identifying predictors of significant undergrading. Recently PSAD has been proposed to be an accurate predictor of subsequent upgrading in patients diagnosed with Gleason 6 disease on biopsy. We examined the predictive characteristics of PSAD in patients with low‐ and intermediate‐risk disease on biopsy subsequently treated with radical prostatectomy. We found that although PSAD was a significant predictor of upgrade of biopsy Gleason 6 and 3 + 4 = 7 tumours, it failed to predict upgrading in patients with Gleason 7 tumours taken as a whole. When we explored reasons for this discrepancy, we found that the amount of PSA produced per unit tumour volume decreased with increasing Gleason score, thereby diminishing the predictive value of PSAD. OBJECTIVES To analyse the performance of PSA density (PSAD) as a predictor of Gleason score upgrade in a large cohort stratified by Gleason score. We and others have shown that an upgrade in Gleason score between initial prostate biopsy and final radical prostatectomy (RP) pathology is a significant risk factor for recurrence after local therapy. PATIENTS AND METHODS Patients undergoing RP with matching biopsy information were identified from two prospective databases. Patients were analysed according to the concordance between biopsy and final pathology Gleason score in three paired groups: 6/>6, 3 + 4/>3 + 4, 7/>7. Receiver‐operating characteristic (ROC) curves were generated stratified by Gleason score, and the area under the curve (AUC) calculated. Logistic regression models were fitted to identify significant predictors of tumour upgrade. RESULTS From 1516 patients, 435 (29%) had an upgrade in Gleason score. ROC analysis showed a decline in AUC with increasing biopsy Gleason score, from 0.64 for biopsy Gleason score 6, to 0.57 for Gleason score 7. In logistic regression models containing pretreatment variables, e.g. clinical stage and number of positive cores, for Gleason score 6 and 3 + 4, PSAD was the strongest predictor of subsequent tumour upgrade (odds ratio [OR] 1.46, 95% confidence interval [95% CI] 1.18–1.83, P= 0.001 and OR 1.37, 95% CI 1.14–1.67, P= 0.002, respectively). Surprisingly, in tumours upgraded from Gleason score 7 to >7, PSAD was not predictive even on univariable analysis, whereas clinical stage and number of positive cores were significant independent predictors. To explore the relationship between serum PSA and Gleason score, tumour volume was calculated in 669 patients. There was a strong association between Gleason score and tumour volume, with the median volume of Gleason score 7 and Gleason score >7 tumours being approximately twice and four‐times that of Gl...

What ' s known on the subject? and What does the study add? The Gleason score of prostate cancer is frequently underestimated at the time of diagnostic biopsy, although the contribution of sampling error to its incidence is unknown.We show that under-graded tumours are signifi cantly smaller that tumours concordant for the higher grade, indicating that incomplete tumour sampling plays a signifi cant role in Gleason score assignment error. OBJECTIVE• To determine the infl uence of tumour and prostate gland volumes on the underestimation of prostate cancer Gleason score in diagnostic core biopsies. PATIENTS AND METHODS• Patients undergoing radical prostatectomy with matched diagnostic biopsies were identifi ed from a prospectively recorded database.• Tumour volumes were measured in serial whole-mount sections with image analysis software as part of routine histological assessment.• Differences in various metrics of tumour and prostate volume between upgraded tumours and tumours concordant for the lower or higher grade were analysed. RESULTS• In all, 684 consecutive patients with Gleason score 6 or 7 prostate cancer on diagnostic biopsy were identifi ed.• Of 298 patients diagnosed with Gleason 6 tumour on biopsy, 201 (67.4%) were upgraded to Gleason 7 or higher on fi nal pathology. Similarly, of 262 patients diagnosed with Gleason 3 + 4 = 7 prostate cancer on initial biopsy, 60 (22.9%) were upgraded to Gleason score 4 + 3 = 7 or higher.• Tumours upgraded from Gleason 6 to 7 had a signifi cantly lower index tumour volume (1.73 vs 2 mL, P = 0.029), higher calculated prostate volume (41.6 vs 39 mL, P = 0.017) and lower relative percentage of tumour to benign glandular tissue (4.3% vs 5.9%, P = 0.001) than tumours concordant for the higher grade.• Similarly, tumours that were Gleason score 3 + 4 on biopsy and upgraded on fi nal pathology to 4 + 3 were signifi cantly smaller as measured by both total tumour volume (2.3 vs 3.3 mL, P = 0.005) and index tumour volume (2.2 vs 3, P = 0.027) and occupied a smaller percentage of the gland volume (6.3% vs 8.9%, P = 0.017) compared with tumours concordant for the higher grade.• On multivariate analysis, lower prostate weight (hazard ratio 0.97, 95% confi dence interval 0.96 -0.99, P < 0.001) and larger total tumour volume (hazard ratio 1.87, 95% confi dence interval 1.4 -2.6, P < 0.001) independently predicted an upgrade in Gleason score from 6 to 7. In tumours upgraded from biopsy Gleason 3 + 4, only higher index tumour volume (hazard ratio 3.1, 95% confi dence interval 1.01 -9.3, P = 0.048) was a signifi cant predictor of upgrading on multivariate analysis. CONCLUSIONS• Under-graded tumours are signifi cantly smaller than tumours concordant for the higher grade, indicating that incomplete tumour sampling plays a signifi cant role in Gleason score assignment error.