The COVID-19 pandemic has indeed led to an unprecedented emergency scenario embracing all aspects of healthcare, including Urology.1-6 As such, virtually all Urological Centres have been forced to prioritize surgical interventions, in an effort to optimize the available healthcare resources and minimize the risk of hospital-acquired infection. Such a process has started early in Italy.2
Recently, a panel of experts from Europe and the US have proposed a scheme for the triage of the urological procedures that should be prioritized, taking into account the aggressiveness of each disease, the impact of delays to care, and the availability of alternative treatment modalities.6
Of note, major cancer surgery represents a large and demanding proportion of practice in most Urological Cancer Centres. Nonetheless, the exact burden of these major urological cancer procedures is still unknown, as the impact of such recommendations on urological practice.
To fill these gaps, we selected the patients undergoing elective major surgery for prostate, urothelial and kidney cancer during a 12- months period (2018 or 2019) at our three high-volume Academic Centres (San Luigi Hospital in Turin, San Raffaele Hospital in Milan and Careggi Hospital in Florence, all performing >500 major cancer procedures/year).
Based on the scheme proposed by Stensland et al for the triage of urological cancer surgery during the COVID-19 pandemic,6 we considered as “high-priority” surgery in our analysis the following interventions: radical cystectomy (RC), radical nephroureterectomy (RNU), nephrectomy (NEP) for cT2 and cT3+ disease, and radical prostatectomy (RP) for locally advanced prostate cancer (as defined by the EAU Guidelines).
We did not include in our analysis of other major cancer surgeries listed by Stensland et al,6 such as post-chemotherapy RPLND for testicular cancer, adrenalectomy for suspected ACC or tumors >6cm, and clinically invasive or obstructing penile or urethral cancers, is less often performed and usually referred to highly specialized Centres.
Overall, 2,387 patients were included. Of these, 771 (32.3%) were classified as high-priority (Figure 1, ref).1 Stratified by cancer type, the relative contribution of RNU, NEP, RP, and RC to the high-priority procedures was 12.6%, 17.3%, 33.9%, and 36.2%, respectively.
While >90% of high-priority RPs were performed with minimally-invasive surgery (MIS), for all other cancers this percentage ranged between 40% (for RC) and 61% (for high-priority NEP).
Using an ASA® score >3 as a surrogate metrics, we also assessed the burden of patients undergoing high-priority major cancer surgeries with a higher perioperative risk (and potentially longer hospitalization, need for postoperative monitoring in intensive care units, etc.). In our cohort, 26.4% of high-priority patients had an ASA® score >3. Patients undergoing RC contributed the most to this cohort (50%). Stratifying by procedure, 14% of patients undergoing high-priority RP were ASA >3, while this proportion was 26% for NEP, 32.0% for RNU, and 36% for RC.
Our study provides key findings that may contextualize the ongoing recommendations5,6 on the triage of uro-oncologic surgeries during the COVID-19 pandemic.
First, we found that in times of emergency two out of three (67.8%) elective major uro-oncological surgeries can be postponed. Second, our study highlights the critical value of proper selection of surgical candidates in the COVID-19 period, considering that more than one out of four patients (26.2%) requiring high-priority major surgery had a higher pre-operative risk (ASA score >3).
While many other factors related to both patients and healthcare scenarios might impact on surgical indications and decision-making, our real-life data offer the Urology Community and policymakers insights to adapt the management strategies for the inflow of uro-oncological patients in light of the reduced resources caused by the COVID-19 pandemic.
Written by: Riccardo Campi,1,2 Daniele Amparore,3 Sergio Serni,1,2 Francesco Porpiglia3
On behalf of all co-authors
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi University Hospital, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy.
- Campi R, Amparore D, Capitanio U, et al. Assessing the Burden of Nondeferrable Major Uro-oncologic Surgery to Guide Prioritisation Strategies During the COVID-19 Pandemic: Insights from Three Italian High-volume Referral Centres. Eur Urol. 2020. [Epub ahead of print] doi:10.1016/j.eururo.2020.03.054.
- Ficarra V, Novara G, Abrate A, et al. Urology practice during COVID-19 pandemic. Minerva Urol Nefrol. 2020 [Epub ahead of print] doi: 10.23736/S0393-2249.20.03846-1.
- Porpiglia F, Checcucci E, Amparore D, et al. Slowdown of urology residents' learning curve during COVID-19 emergency. BJU Int. 2020 doi: 10.1111/bju.15076. [Epub ahead of print]
- Amparore D, Claps F, Cacciamani GE, et al. Impact of the COVID-19 pandemic on urology residency training in Italy. Minerva Urol Nefrol. 2020 doi: 10.23736/S0393-2249.20.03868-0. [Epub ahead of print]
- Ribal MJ, Cornford P, Briganti A, et al. EAU Guidelines Office Rapid Reaction Group: An organisation-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era. Eur Urol 2020. In Press. Available at: https://www.europeanurology.com/covid-19-resourceEAU
- Stensland KD, Morgan TM, Moinzadeh A, et al. Considerations in the triage of urologic surgeries during the COVID-19 pandemic. Eur Urol 2020 [In Press]; available at: https://www.europeanurology.com/covid-19-resource
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