Objective: To determine if a precise 5-point nerve-spare (NS) scoring system at the time of robot-assisted radical prostatectomy (RARP) correlates with post-operative erectile function recovery (EFR). Patients and methods: From 2014 to 2018, 277 patients underwent RARP by a single surgeon. NS quality was recorded as: grade 1, non-NS; grade 2, <50%; grade 3, 50%; grade 4, 75%; grade 5, ⩾95%. EFR rates were compared using Fisher’s exact test or Pearson’s chi-square test at 3–24 months, grouped based on the degree of NS: 1 = bilateral full NS (grade 5); 2 = bilateral NS with one good NS (⩾grade 4); 3 = unilateral good NS; 4 = incremental NS (grade 3); 5 = partial neurovascular bundle (NVB) resection (grade 2); 6 = complete NVB resection (grade 1). Results: At 24 months, EFR defined as Sexual Health Inventory for Men (SHIM) score ⩾17 was 75%, 55%, 41%, 23%, 12% and 0% for groups 1–6, respectively ( p = 0.001). EFR defined as spontaneous erection sufficient for intercourse with or without PDE5i was 60%, 58%, 40%, 33%, 0% and 11% for groups 1–6, respectively ( p < 0.001). Conclusion: A precise anatomic NS scoring system at RARP allows good prognostication of EFR, which may inform patient counselling and erectile dysfunction management. Level of evidence: 4

Objective: To produce comprehensive and detailed benchmarking data allowing surgeons and patients to compare practice against, by using all recorded radical prostatectomies across a 3-year period in England. Patients and methods: The British Association of Urological Surgeons (BAUS) manages the radical prostatectomy (RP) Complex Operations Database. Surgical departments upload data which they can review and amend before lockdown and data cleansing. Analysis of 2016–2018 data held on the BAUS Complex Operations Database was performed for 21,973 patients undergoing RP in England, producing procedure-specific benchmarking data. General linear models were used to assess differences in patient selection between different operative modalities. Analysis involved assessment of case selection, operative decisions and outcomes, case volume and pathological outcomes. Results: Using national Hospital Episode Statistics, the BAUS RP dataset was estimated 91% complete. Median age was 65 and 96% were American Society of Anesthesiologists (ASA) Grades 1–2. Over 80% had RP performed in a high-volume centre (>100 annual RPs) and 88% had Gleason grade group (GGG) ⩾2 disease on biopsy. Robotic-assisted RP (RARP), laparoscopic RP (LRP) and open RP (ORP) were performed in 85%, 7.2% and 7.7% of cases, respectively. Patient and disease characteristics differed across surgical modalities. Transfusion rates were 0.14% in RARP, 0.38% in LRP and 1.8% in ORP. Increased positive surgical margin (PSM) rates were observed with increasing prostate-specific antigen (PSA), GGG and T-stage, with comparable PSM rates across surgical modalities. Lymph node dissection was performed more commonly in high-risk cases (cT3, PSA > 20, GGG ⩾ 4). Pathological upstaging was common. Median length of stay was 1, 2 and 3 days for RARP, LRP and ORP, respectively. ORP had Clavien–Dindo complications ⩾3 and unplanned hospital readmissions. Conclusion: This analysis has enabled the first set of UK national RP standards to be produced allowing procedure, patient and disease-specific national, centre and individual comparisons. The present degree of service centralisation, operative modalities, and specific aspects of surgical practice can be observed. Level of evidence: 2b

Objective: This study aimed to determine the effect of template transperineal (TTP) compared to transrectal (TR) biopsy on surgical and functional outcomes after robotic-assisted radical prostatectomy (RARP). Methods: From 2014 to 2018, 280 patients underwent RARP by a single surgeon. Of these, 184 had TR, and 96 had TTP biopsy. Primary outcomes were continence and erectile function recovery (EFR) rates up to 24 months postoperatively. Secondary outcomes comprised positive margin rates and markers of a difficult operation, including operative time, estimated blood loss (EBL), urethral preservation quality and ability to perform planned nerve-sparing surgery. Results: The median age was greater in the TTP group (64 vs. 62 years, p=0.028). The proportions of men with preoperative erectile dysfunction and men undergoing nerve-sparing surgery were not different between groups. Operative time, EBL, urethral preservation quality, proportion of men undergoing intended nerve-sparing procedure, positive margin rates and continence recovery rates were not different among the groups. At 24 months, men in the TR group had a higher EFR rate on univariate analysis ( p=0.036), and multivariate analysis ( p=0.03). Conclusion: TTP biopsy was not associated with markers of a more difficult RARP or worse oncological and continence recovery outcomes but did appear to impact upon long-term rates of EFR. Level of evidence: Level 4.

Purpose: The COVID-19 pandemic has caused 1.4 million deaths globally and is associated with a 3-4 times increase in 30-day mortality after a fragility hip fracture with concurrent COVID-19 infection. Typically, death from COVID-19 infection occurs between 15 and 22 days after the onset of symptoms, but this period can extend up to 8 weeks. This study aimed to assess the impact of concurrent COVID-19 infection on 120-day mortality after a fragility hip fracture. Methods: A multi-centre prospective study across 10 hospitals treating 8% of the annual burden of hip fractures in England between 1st March and 30th April, 2020 was performed. Patients whose surgical treatment was payable through the National Health Service Best Practice Tariff mechanism for "fragility hip fractures " were included in the study. Patients' 120-day mortality was assessed relative to their peri-operative COVID-19 status. Statistical analysis was performed using SPSS version 27. Results: A total of 746 patients were included in this study, of which 87 (11.7%) were COVID-19 positive. Mortality rates at 30-and 120-day were significantly higher for COVID-19 positive patients relative to COVID-19 negative patients (p < 0.001). However, mortality rates between 31 and 120-day were not significantly different (p = 0.107), 16.1% and 9.4% respectively for COVID-19 positive and negative patients, odds ratio 1.855 (95% CI 0.865-3.978). Conclusion: Hip fracture patients with concurrent COVID-19 infection, provided that they are alive at day-31 after injury, have no significant difference in 120-day mortality. Despite the growing awareness and concern of "long-COVID " and its widespread prevalence, this does not appear to increase medium-term mortality rates after a hip fracture. (C) 2021 Chinese Medical Association. Production and hosting by Elsevier B.V.

Introduction: Proximal femoral fracture is common with a high mortality (7% mortality at 30 days). Accurate determination of mortality risk allows better consenting, clinical management and expectation management. Our study aim was to develop a prognostic tool to predict 30-day mortality after proximal femoral fracture, among patients treated within a dedicated hip fracture unit. Materials and methods: We collected data from our hospital concerning 2210 patients with 2287 proximal femoral fractures. The clinical parameters of 97 patients who died within 30 days of surgery were analysed. We used logistic regression to determine if the parameters' relationship with 30-day mortality was statistically significant or not. The statistically significant parameters were used to create a prognostic model for predicting 30-day mortality. Results: The 5 independent predictors of 30-day mortality were gender, age, admission source, preoperative Abbreviated Mental Test Score (AMTS) and American Society of Anesthesiologists Score (ASA). The highest risk was for males >85 years, admitted from institutional care, with low preoperative mental test score and high ASA grade. Using these predictors, we formulated the G4A score. The Hosmer-Lemeshow 'goodness of fit' test showed good concordance between observed and predicted mortality rates. Conclusions: We recommend the use of the G4A score to predict 30-day mortality after surgery for proximal femoral fracture, particularly within dedicated hip fracture units. Further research is needed to establish whether the findings of this study are applicable on a national scale.

Abstract Introduction: Secondary pelviureteral junction obstruction (PUJO) may be defined as one or more of recurrent symptoms, renographic obstruction, and renal function deterioration after prima...

Abstract Introduction Open fractures are associated with increased infection rates and the evidence shows timely administration of prophylactic antibiotics within one hour of injury improves the outcomes. Method A multi-cycle audit was carried out retrospectively for patients presenting to Brighton and Sussex University Hospitals NHS Trust (BSUH) with an open limb fracture in 2018-2020. Targeted teaching was carried out for orthopaedic trainees, prompt posters created and alterations to the trauma clerking proforma were implemented. Results In first cycle, 48 (92.3%) out of total 52 patients were prescribed antibiotics prior to definitive surgical management, with a mean time to administration of 271 minutes. Of these, 41 (78.8%) received prescriptions according to BSUH guidelines. The use of STAT ‘once-only’ prescriptions was found to significantly reduce the mean time to administration for 154 minutes. In second cycle, all of 29 patients (100%) were prescribed antibiotics prior to definitive surgical management, with a reduced mean time to administration (233 minutes). Of these, 26 (89.7%) received prescriptions according to BSUH guidelines, and a significantly greater proportion received initial STAT prescriptions (51.7% vs. 15.4%). Conclusions This quality improvement project has demonstrated the successful implementation of targeted changes to improve the attainment of BOAST 4 guidelines.

Traditionally, men referred for investigation of raised prostate specific antigen (PSA) could expect to be investigated via blind TRUS biopsy. In recent years, the availability of pre-biopsy imaging with multi-parametric magnetic resonance imaging (mp-MRI) has allowed urology centres to improve their triage and care of this patient cohort. The ability to identify discrete lesions for more accurately targeted TRUS, stream patients with anterior lesions for trans-perineal biopsy, and of course to prevent those with no evidence of clinically significant prostate cancer from being subjected to unnecessary procedures has proved pre-biopsy mp-MRI a valuable tool in the assessment and diagnosis of prostate cancer. Our service recently audited the impact of the introduction of mp-MRI on our prostate cancer assessment pathway. An analysis of the outcomes of 1558 referrals over a 2-year period, and found that pre-biopsy imaging has resulted in a marked reduction in unnecessary procedures and more accurate targeting of lesions, leading to improved outcomes for patients.

BJU InternationalEarly View Research Communication A nationwide trend away from radical prostatectomy for Gleason Grade Group 1 prostate cancer Joseph B. John, Corresponding Author Joseph B. John joseph.john3@nhs.net orcid.org/0000-0003-1736-3679 The Royal Devon and Exeter NHS Foundation Trust, Exeter, UK Correspondence: Joseph B. John, Department of Urology, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon EX2 5DW, UK. e-mail: joseph.john3@nhs.netSearch for more papers by this authorJohn Pascoe, John Pascoe The Royal Devon and Exeter NHS Foundation Trust, Exeter, UKSearch for more papers by this authorSarah Fowler, Sarah Fowler British Association of Urological Surgeons (BAUS), The Royal College of Surgeons, London, UKSearch for more papers by this authorThomas Walton, Thomas Walton Nottingham University Hospitals NHS Trust, Nottingham, UKSearch for more papers by this authorMark Johnson, Mark Johnson Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UKSearch for more papers by this authorBenjamin Challacombe, Benjamin Challacombe Guy’s and St Thomas’ NHS Foundation Trust, London, UKSearch for more papers by this authorAndrew J. Dickinson, Andrew J. Dickinson University Hospitals Plymouth, Plymouth, UKSearch for more papers by this authorJonathan Aning, Jonathan Aning North Bristol NHS Trust, Bristol, UKSearch for more papers by this authorJohn S. McGrath, John S. McGrath orcid.org/0000-0001-9416-9912 The Royal Devon and Exeter NHS Foundation Trust, Exeter, UKSearch for more papers by this author Joseph B. John, Corresponding Author Joseph B. John joseph.john3@nhs.net orcid.org/0000-0003-1736-3679 The Royal Devon and Exeter NHS Foundation Trust, Exeter, UK Correspondence: Joseph B. John, Department of Urology, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon EX2 5DW, UK. e-mail: joseph.john3@nhs.netSearch for more papers by this authorJohn Pascoe, John Pascoe The Royal Devon and Exeter NHS Foundation Trust, Exeter, UKSearch for more papers by this authorSarah Fowler, Sarah Fowler British Association of Urological Surgeons (BAUS), The Royal College of Surgeons, London, UKSearch for more papers by this authorThomas Walton, Thomas Walton Nottingham University Hospitals NHS Trust, Nottingham, UKSearch for more papers by this authorMark Johnson, Mark Johnson Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UKSearch for more papers by this authorBenjamin Challacombe, Benjamin Challacombe Guy’s and St Thomas’ NHS Foundation Trust, London, UKSearch for more papers by this authorAndrew J. Dickinson, Andrew J. Dickinson University Hospitals Plymouth, Plymouth, UKSearch for more papers by this authorJonathan Aning, Jonathan Aning North Bristol NHS Trust, Bristol, UKSearch for more papers by this authorJohn S. McGrath, John S. McGrath orcid.org/0000-0001-9416-9912 The Royal Devon and Exeter NHS Foundation Trust, Exeter, UKSearch for more papers by this author First published: 26 November 2021 https://doi.org/10.1111/bju.15656Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy IV (MP74)1 Apr 2020MP74-04 RADICAL PROSTATECTOMY FOR GLEASON 3+3 PROSTATE CANCER; WHO, HOW AND WHY? ANALYSIS OF THE BRITISH ASSOCIATION OF UROLOGICAL SURGEONS COMPLEX OPERATIONS DATABASE Joseph B. John*, John Pascoe, Sarah Fowler, Thomas Walton, Mark Johnson, Jonathan Aning, Benjamin Challacombe, and John S. McGrath Joseph B. John*Joseph B. John* More articles by this author , John PascoeJohn Pascoe More articles by this author , Sarah FowlerSarah Fowler More articles by this author , Thomas WaltonThomas Walton More articles by this author , Mark JohnsonMark Johnson More articles by this author , Jonathan AningJonathan Aning More articles by this author , Benjamin ChallacombeBenjamin Challacombe More articles by this author , and John S. McGrathJohn S. McGrath More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000960.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is a risk of overtreating low-grade prostate cancer (PCa) with radical prostatectomy (RP). A preference for active surveillance for localised Gleason 3+3 disease was advocated in the 2018 UK National Prostate Cancer Audit. This reflects the peri-operative risks of major pelvic surgery and the common longer-term functional sequelae following RP. Objectives: To understand modern RP practices in England for Gleason 3+3 PCa, describing the patient, indication, procedure, and outcomes. METHODS: BAUS manage the complex operations database for RP. Seventy data fields are uploaded by surgical departments, pertaining to patient, disease, surgical, pathological and outcome descriptors. Surgeons can review and amend their data before lockdown and data cleansing. Analysis of all 21,973 RPs recorded in England from 2016-18 was performed to identify 2,627 cases of Gleason 3+3 disease diagnosed pre-operatively. RESULTS: The BAUS RP dataset for England (2016-18) was deemed to be 91% complete, using Hospital episode statistics (HES) as the comparator. Gleason 3+3 patients accounted for 12% of RPs. Median patient age was 63 (IQR 57 – 68), and 89% of patients were ASA 1-2. Median PSA was 7.0 (IQR 5.1 – 10.4). Pre-operative clinical T-stages of 1, 2, 3 and 4 were recorded in 24%, 62%, 11% and 0.04% respectively. Intermediate-risk disease was present in 52% (pre-operative T stage ≥2b and/or PSA ≥10). Primary treatment of cancer was the indication in 70%, and 28% had previously been under active surveillance. RARP was the chosen surgical modality in 80%. Bilateral and unilateral nerve spare was performed in 53% and 19% respectively. Post-operative 3+3 disease was confirmed in 28%, whilst 52% had 3+4 disease and 7% had 4+3 disease. Post-operative histological upstaging occurred in 40%, and downstaging in 7%. Median LOS was 1 day, and transfusion rate was 0.3%. Clavien-Dindo 3-4 complications were reported in 0.8% of patients. In-hospital mortality was zero. CONCLUSIONS: Decisions to proceed to RP for Gleason 3+3 PCa in England are commonly justified by pre-operative factors indicating intermediate or high-risk disease (PSA ≥10, ≥T2b), and by post-operative upstaging or upgrading. In addition to PSA and T stage, factors that might lead a surgeon to perform RP for a patient with locally-confined Gleason 3+3 disease include, but are not limited to, patient preference, high disease volume, MRI suggesting a higher-grade lesion, and prostate capsule proximity. Peri-operative outcome data indicate that RP in this cohort is safe. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1132-e1132 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph B. John* More articles by this author John Pascoe More articles by this author Sarah Fowler More articles by this author Thomas Walton More articles by this author Mark Johnson More articles by this author Jonathan Aning More articles by this author Benjamin Challacombe More articles by this author John S. McGrath More articles by this author Expand All Advertisement PDF downloadLoading ...

BACKGROUND The rapid uptake of robotic surgery has largely been driven by the improved technical aspects of minimally invasive surgery including improved ergonomics, wristed instruments, and 3-dimensional vision. However, little attention has been given to the effect of physical separation of the surgeon from the rest of the operating team. PURPOSE The aim of this study was to examine in depth how this separation affected team dynamics and staff emotions. METHODS Robotic procedures were observed in 2 tertiary hospitals, and laparoscopic/open procedures were added for comparison; field notes were taken instantaneously. One-to-one interviews with theater team members were audio recorded and transcribed verbatim. Qualitative analysis was conducted via grounded theory approach using NVIVO11. RESULTS Twenty-nine participants (26 interviewed) were recruited to the study (11 females) and 134 (109 robotic) hours of observation were completed across gynecology, urology, and colorectal surgery.The following 3 main themes emerged with compounding factors identified: (a) communication challenge, (b) immersion versus distraction, and (c) emotional impact. Compounding factors included the following: individual and team experience, staffing levels, and the physical theater environment. CONCLUSIONS Our emergent theory is that "surgeon-team separation in robotic theaters poses communication challenges which impacts on situational awareness and staff emotions." These can be ameliorated by staff training, increased experience, and team/procedure consistency.

The published online version contains mistake, as the Fig. 1 legend should read "Kaplan-Meier survival curve for 30-day survival for 2020 cohort COVID-19 positive vs COVID-19 negative" whilst the Fig. 2 legend should read "Kaplan-Meier survival curve for 30-day survival 2020 COVID-19 negative group vs 2019 cohort".

Consent is a requirement for any medical or surgical intervention to be deemed appropriate. For such consent to be considered valid, it must be given voluntarily, by an individual with capacity, who has the appropriate information available to make an informed decision in line with their values. Following the Montgomery vs. Lanarkshire ruling in 2015, the legal basis from which informed consent is measured has changed. The law now reflects pre-existing professional guidelines, and advocates a patient-centred approach to informed consent. The previously paternalistic focus of informed consent, whereby it was deemed a matter for clinical judgement, has been firmly abandoned in favour of the provision of information pertaining to ‘material risks’, as determined by the significance attached to these risks by the patient themselves. This paper serves to provide an overview of consent within the medical profession, and gives an account of the implications of this landmark ruling.