European Urology

CONSIDERATIONS IN THE TRIAGE OF UROLOGIC SURGERIES DURING THECOVID-19 PANDEMIC

--Manuscript Draft--

Manuscript Number: EURUROL-D-20-00380

Article Type: Editorial

Keywords: COVID-19; elective surgery; pandemic response

Corresponding Author: David Canes, MDLahey ClinicBurlington, MA United States

First Author: Kristian D Stensland, MD, MPH

Order of Authors: Kristian D Stensland, MD, MPH

Todd M. Morgan, MD

Alireza Moinzadeh, MD, MHL

Cheryl T. Lee, MD

Alberto Briganti, MD, PhD

James Catto, MB, ChB, PhD, FRCS

David Canes, MD

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March 15, 2020 1

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CONSIDERATIONS IN THE TRIAGE OF UROLOGIC SURGERIES DURING THE COVID-19 3

PANDEMIC 4

Kristian D. Stensland MD MPH1; Todd M. Morgan MD2; Alireza Moinzadeh MD MHL1; Cheryl T. 5

Lee MD3; Alberto Briganti MD PhD4; James Catto MB ChB PhD FRCS5; David Canes MD1 6

7

1 Division of Urology, Lahey Hospital and Medical Center 8

2 Department of Urology, University of Michigan; 9

3 The Ohio State University; 10

4 Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Vita-Salute San 11

Raffaele University, Milan, Italy; 12

5 Academic Urology Unit, The University of Sheffield 13

14

As hospitals begin bracing for the possibility of surge demand for ventilator-level care for COVID-15

19 cases, the possibility of having to cancel elective surgeries to increase access to care is real. 16

Many hospitals, and the American College of Surgeons, are recommending cancellations of 17

elective surgeries. [1] The term “elective” in this setting is inherently vague and open to 18

interpretation. As a result, urologists and hospitals throughout the world will have to make their 19

own difficult decisions about which surgeries should continue under the current circumstances. 20

While hospital systems and/or governments may request that “elective procedures” be delayed 21

until the strain on the hospital system from COVID-19 is decreased, the characteristics of an 22

“elective” procedure in urology are context dependent and have not been well defined in the 23

current crisis. 24

25

Lessons learned from Singapore, Asia and some European countries will be important in helping 26

us respond to these challenging demands.[2] The choice of urgent or emergent surgeries that 27

should still occur will depend upon capacity and demand, but must also be counterbalanced by 28

the effects of delaying surgery. This is particularly true for patients with urological cancers and 29

complicated stones. Urologists can help by decreasing the demand for ventilators, personal 30

protective equipment, and other critical hospital and human resources by minimizing surgeries 31

without compromising patient outcomes whenever possible. As a community, we must also weight 32

the impact of non-surgical therapies such as systemic chemotherapy, which will leave patients at 33

greater risk for contracting and potentially succumbing to COVID-19. 34

Manuscript

35

Will the global pandemic change the short term progression and/or mortality rates for aggressive 36

urologic cancers? And will this affect the in-hospital mortality and complication rates of frail 37

patients with aggressive genito-urinary malignancies? Prior data on delays to care are the best 38

current guide by which we can begin to select cases to prioritize in the face of acutely decreased 39

resources and diversion of operative resources to care for COVID-19 patients. 40

41

We have put together preliminary recommendations in that regard and discuss the rationale for 42

these difficult decisions. These suggestions were curated with input from multiple departments in 43

the United States and Europe. In general, consideration should be made for non-surgical 44

treatments when available or deferral of surgery until demand for ventilators and inpatient beds 45

fall, where possible. 46

47

The following is a suggested list of surgeries that should be prioritized if COVID-19 surges warrant 48

cancellation of most elective surgery. These recommendations, which can be applied in the 49

current and any future situation where ventilators and other operating room resources are scarce, 50

prioritize moving forward with cases where evidence suggests that even short term delays may 51

affect patient survival. Secondarily, we suggest alternatives for the management of common 52

urgent or emergent urologic procedures that may spare the use of ventilators, and consider the 53

use and impact of common urologic treatments on patients during an infectious outbreak. Finally, 54

while we do not incorporate patient age and frailty into these recommendations, the risk of a post-55

operative COVID-19 infection and its potential impact on a patient’s post-operative course should 56

also be considered. 57

58

As with all guidelines, these recommendations must be tailored to locally available resources and 59

situations. This document reflects preliminary expert opinion from this group, and by no means 60

should these recommendations be considered rigid or all-encompassing. It is our hope that this 61

preliminary evidence and opinion may provide a starting point for discussions to continue at a 62

local level. Further, it is also possible for other surgical service lines to use these urology 63

recommendations as a framework in creating their own specialty specific recommendations. 64

65

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ONCOLOGY

Condition Recommended

Surgeries Rationale

Average Length of Stay

Bladder cancer

● Cystectomy for MIBC, regardless of receipt of neoadjuvant chemotherapy

● Cystectomy for CIS refractory to 3rd Line therapy

● Delaying cystectomy for MIBC by 90 days increases pN+ rate[3], decreases overall and progression free survival [4], and higher pathologic stage[5]

● 5-8 days (US) [6,7]

● TURBT for suspected cT1+ bladder tumors

● cT1 tumors are understaged in up to 50% of cases, presenting significant risk of missed MIBC[8]

● Outpatient procedure

Testicular cancer

● Orchiectomy for suspected testicular tumors

● Post-chemotherapy RPLND

● Favor chemotherapy or radiation rather than RPLND when clinically appropriate

● Limited data on survival with delay to orchiectomy[9]; however, orchiectomy is an outpatient procedure with potential overall survival benefit and should be prioritized[10]

● To spare a ventilator and

inpatient stay (RPLND), radiation post-orchiectomy can be encouraged when surveillance is not an option. Chemotherapy use should be balanced by concern for immunosuppression and increased risk of COVID-19 infection/sequelae

● Orchiectomy: outpatient procedure

● RPLND: 4-6 days (open) [11] 1-3 days (minimally invasive)[12]

Kidney cancer

● Nephrectomy for cT3+ tumors, including all patients

● More advanced renal tumors, particularly with associated vein thrombi,

● Nephrectomy: 3 days[14]

with renal vein and/or IVC thrombi

● Planned partial or radical nephrectomy for cT1 masses should be delayed or other forms of ablative approaches should be considered in selected patients

may progress rapidly and create more complicated surgeries and adversely affect survival and/or surgical morbidity.[13]

● IVC Thrombectomy: 5-10 days[15]

● Planned partial or radical nephrectomy for cT2 should be considered for delay based upon patient specific considerations, such as age, morbidity, symptoms, and tumor growth rate

● For cT1-2 (stage I-II) masses, delaying surgery by 3 months has not been associated with decreased CSS or OS.

● 1-2 days (minimally invasive)

● 2-4 days (open) [16]

Prostate cancer

● Most prostatectomies should be delayed

● Shared decision making to consider radiation therapy for NCCN High risk disease

● Surgery for NCCN high risk if patient is ineligible for radiation

● Selected high risk patients as well as those with intermediate or low risk cancer should be delayed

● Surgery for NCCN high risk may be considered depending on patient age and disease risk. However, given the availability of other treatment modalities, these surgeries may receive lower prioritization than others on this list (as delay of treatment up to 12 months, even for high risk disease, may not alter operative outcomes, cancer specific mortality, or other outcomes).

● Biochemical recurrence rates may be higher in high risk men who delay definitive treatment, but there is not a clear cut-off time for this treatment benefit.[17–19]

● 0-2 days[20]

UTUC ● Nephroureterectomy ● 3 month delay to surgery ● 1-4 days[23]

for high grade and/or cT1+ tumors

for UTUC has been associated with disease progression for all patients, and with CSS for patients with muscle invasive disease.[9,21]

● Early stage, particularly invasive, has a high risk of being understaged.[22]

Adrenal tumors

● Adrenalectomy for suspected ACC, or tumors >6cm

● Consider delay of adrenalectomy for less suspicious adrenal masses (<6cm, favorable imaging characteristics)

● Adrenal masses larger than 6 cm are much more likely to harbor carcinoma.

● ACC progresses rapidly, and achieving R0 at surgery provides the best chance of survival. Delay may decrease resectability and affect survival. [24]

● 0-1 days[25]

Urethral / Penile Cancer

● Clinically invasive or obstructing cancers

● Data for these rare tumors are limited. Preventing lymph node metastases may spare significant morbidity from patients. Further, partial penectomy can be an outpatient procedure which has a diminished strain on hospital resources.

● Outpatient procedure

ENDOUROLOGY/STONE DISEASE

Stones ● For obstruction/infection:

● Ureteral stent

insertion

● Consideration for awake, bedside ureteral stent under local

● Consideration for

nephrostomy tube

● When possible, stents can be placed at the bedside which spares a ventilator [26]

● Nephrostomy tubes can be placed under local anesthesia, sparing a ventilator.

● If neither option is possible, an obstructed or infected upper tract is

● Outpatient procedure (unless concurrent infection)

an emergency requiring intervention.

Indwelling ureteral stent

● Delay most procedures

● Most stents left in place even up to 6-12 months can have simple stent removal, and endoscopic management of stents is possible in most patients up to 30 months of indwelling time.[27]

● Outpatient procedure

BPH ● Delay BPH procedures (TURP,HOLEP, PVP Laser, etc)

● Urinary obstruction can be adequately treated via urethral or suprapubic catheter without need for a procedure under anesthesia

● TURP: 1-2 days[28]

FEMALE UROLOGY/INCONTINENCE

Stress urinary incontinence, interstitial cystitis, overactive bladder, neurogenic bladder

● Delay all procedures

Nerve Stimulator In Place

● Second stage nerve stimulator placement or removal

● Nerve stimulators with externalized leads may have a high rate of infection if left in place and should be either internalized via second stage or removed, either of which can be performed under local anesthesia.

Outpatient Procedure

RECONSTRUCTIVE SURGERY

Fistula with pelvic sepsis

● If systemic symptoms, diversion either with catheters/drains, or formal fecal stream

● Fistula repairs are resource intensive and should be delayed when possible.

● Variable

diversion ● Delayed definitive

repair unless clinical conditions would require immediate repair.

Artificial Urinary Sphincter Explants

● Infected explants, only

● Infected sphincters may progress rapidly to systemic infection and should be addressed emergently

● Variable

URETHRAL STRICTURE

Urethral Obstruction

● Delay all procedures ● Suprapubic tube placement or Foley catheter placement in association with urethral dilation or incision is urgent in those with impending or complete lower urinary tract obstruction.

● Outpatient Procedure

PROSTHETIC SURGERY

Erectile dysfunction

● Infected explants only ● Infected implants may progress rapidly to systemic infection and should be addressed emergently.

● Variable

GENERAL UROLOGY

Soft tissue infection

● Acute infections only; scrotal abscesses, Fournier’s gangrene

● Variable

Ischemia ● Shunting for Priapism

● Testicular Detorsion / Orchidopexy

● 1-3 days

Hemorrhage ● Clot evacuation for refractory gross hematuria

● 1-3 days

Trauma ● Penile / testicular fracture repair

● Outpatient Procedure

● Ureteral injury ● Bladder Perforation

● 1-3 days

TRANSPLANT

Renal transplantation

● Deceased donor transplants only

● Live donor transplants delayed

● Deceased donor transplants should proceed without delay.

● Live donor transplants should be delayed, both to spare resources and to delay the requisite immunosuppression on the recipient, which may lead to a greater impact of COVID-19 infection.

● 4-8 days[29]

PEDIATRICS

Acute torsion ● Scrotal exploration, orchidopexy

● Outpatient Procedure

GU obstruction

● Foley catheter / suprapubic tube placement

● Outpatient Procedure

INFERTILITY

● Delay all procedures

67

68

References 69

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[16] Choi JE, You JH, Kim DK, Rha KH, Lee SH. Comparison of perioperative outcomes between 119 robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur 120 Urol 2015;67:891–901. https://doi.org/10.1016/j.eururo.2014.12.028. 121

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[29] McAdams-DeMarco MA, King EA, Luo X, Haugen C, DiBrito S, Shaffer A, et al. Frailty, 161 Length of Stay, and Mortality in Kidney Transplant Recipients: A National Registry and 162 Prospective Cohort Study. Ann Surg 2017;266:1084–90. 163 https://doi.org/10.1097/SLA.0000000000002025. 164