Delphi consensus on ex vivo fluorescence confocal microscopy in robot-assisted radical prostatectomy

Area of Science:

• Uro-oncology
• Surgical pathology
• Medical imaging

Background:

• Positive surgical margins (PSMs) in robot-assisted radical prostatectomy (RARP) are linked to increased prostate cancer recurrence and the need for further treatment.
• Intraoperative frozen section is not routinely feasible for PSM detection.
• Ex vivo fluorescence confocal microscopy (FCM) presents a promising, rapid alternative, but its clinical application requires standardization and further evidence.

Purpose of the Study:

• To establish international expert consensus on the clinical application, workflow, and research priorities for ex vivo fluorescence confocal microscopy (FCM) during RARP.
• To provide a framework for the safe integration of FCM into RARP procedures.

Main Methods:

• A modified Delphi process, adhering to the RAND/UCLA Appropriateness Method and ACCORD checklist, was employed.
• Thirty-two international urology and pathology experts participated in a hybrid consensus meeting following literature review and online sessions.
• Forty-four evidence-based items were anonymously voted on to achieve consensus (≥80% agreement).

Main Results:

• Consensus was reached on 24 of 44 items (55%). Key agreements include risk-adapted FCM use (97%), its role as an adjunct for nerve-sparing decisions (87%), preference for en-face imaging (82%), and a 30-minute reporting time (85%).
• Endorsement of formal certification for image interpretation (83%), standardized reporting of positive margin length (82%), and feasibility of remote reporting (84%).
• Large PSMs (>3 mm) in high-risk cases necessitate complete neurovascular bundle resection (96%).

Conclusions:

• This Delphi consensus establishes a structured framework for intraoperative FCM use in RARP, outlining indications, workflow standards, and training needs.
• Further multicenter studies are crucial to evaluate the oncological and functional outcomes of FCM and to develop standardized implementation pathways.