Positive surgical margins (PSMs) after robot-assisted radical prostatectomy (RARP) increase the risk of prostate cancer recurrence, often requiring salvage treatments that may compromise functional recovery. Intraoperative frozen section can detect PSM but is not feasible as a routine approach in most settings. Ex vivo fluorescence confocal microscopy (FCM) provides a rapid, real-time alternative, though evidence remains limited and knowledge gaps persist. This international Delphi consensus aimed to define expert recommendations on the clinical application of and workflow and research priorities for the safe integration of FCM during RARP.
A modified Delphi process was conducted following the RAND/UCLA Appropriateness Method and reported according to the ACCORD checklist. In total, 32 international experts in urology and pathology participated in a hybrid consensus meeting after structured literature review and preparatory online sessions. Forty-four evidence-based multiple-choice items across patient selection, image acquisition, and surgical management domains were developed and anonymously voted on via a secure online platform. Consensus was predefined as ≥80% agreement among respondents.
Consensus was achieved for 24 of 44 items (55%). Key agreements included a risk-adapted use of FCM (97%), its role as an adjunct to magnetic resonance imaging for nerve-sparing decisions (87%), adoption of en-face imaging as the preferred FCM technique (82%), and a maximum reporting time of 30 min (85%). The panel endorsed formal certification for image interpretation (83%), standardized reporting of positive margin length (82%), and feasibility of remote intra-institutional reporting (84%). Larger (>3 mm) PSM in high-risk cases warranted complete neurovascular bundle resection (96%).
This consensus provides a structured framework for the intraoperative use of FCM during RARP, defining its indications, workflow standards, and training requirements. Future multicentre studies are needed to assess its oncological and functional impact and to establish standardized implementation pathways.
BJU international. 2026 Jun 10 [Epub ahead of print]
Edoardo Beatrici, Mario de Angelis, Ricardo Almeida-Magana, Tarek Al-Hammouri, Cristian Fiori, Federico Piramide, Andrei Plopeanu, Nicola Frego, Riccardo Schiavina, Attilio Barretta, Anna Silvanto, Renu S Eapen, Ravi Barod, Jon Oxley, Elio Mazzone, Mathias Winkler, Nikhil Mayor, Kris Van Der Steen, Rui Farinha, Stefania Ferretti, Giampaolo Bianchi, Natali Rodriguez Peñaranda, Riccardo Autorino, Jihad Kaouk, Ruben Olivares, Christopher J Weight, Nicolas A Soputro, Luca Reggiani Bonetti, Albino Eccher, Maria Chiara Sighinolfi, Vincenzo Cavarra, Francesco Pepillo, Anthony G Gallagher, Declan G Murphy, Peter Wiklund, Freddie C Hamdy, Stefano Puliatti, Alexandre Mottrie, Greg Shaw, Ruben De Groote
ORSI Academy, Melle, Belgium., Department of Urology, University College London NHS Foundation Trust, London, UK., Division of Urology, San Luigi Gonzaga Hospital, Orbassano (Turin), Italy., Department of Microscopic Morphology-Pathology, ANAPATMOL Research Center, 'Victor Babeș' University of Medicine and Pharmacy of Timisoara, Timisoara, Romania., Division of Urology, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy., Department of Pathology, University College London Hospitals NHS Foundation Trust, London, UK., Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia., Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK., Department of Histopathology, North Bristol Hospitals Trust, Bristol, UK., Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy., Department of Surgery and Cancer, Imperial College London, London, UK., Department of Urology, Imperial College Healthcare National Health Service (NHS) Trust, London, UK., Department of Pathology, AZORG Hospital Aalst, Aalst, Belgium., Department of Urology, University Hospital of Modena, Modena, Italy., University of Modena and Reggio Emilia, Modena, Italy., Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio, USA., Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, University Hospital of Modena, Modena, Italy., Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy., Urology Department, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA., Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.