Overview of the Italian Experience in Surgical Management of Bladder Cancer During First Month of COVID-19 Pandemic - Beyond the Abstract

The COVID-19 pandemic still represents a challenge faced by whole healthcare systems. This paper analyzed the impact of the first wave of the outbreak on the management of bladder cancer (BC) patients. 

A survey containing 14 multiple choice questions focused on surgical activity related to BC and carried out in March 2019 and March 2020 was sent to 32 Italian centers during the first week of April 2020. The authors also interviewed medical staffing at these facilities: the total amount of urologists (including resident physicians) and percentage dedicated to COVID wards for each institute. Of the 32 centers, 28 answered. Several different statistical differences emerged comparing Lombardy hospitals and the rest of northern Italy in March 2020: number of operative blocks (OB) dedicated to urology (p=0.027); the number of surgical procedures per OB (p=0.018); the number of transurethral resection of bladder tumor (TURBT) (p=0.012); the number of hemostatic transurethral resection (hTUR) (p=0.010). These differences were not relevant considering Lombardy centers were included among the northern group. Lombardy was the only region where a consistent number of urologists were reassigned to COVID wards (p=0.003); four centers had no OB dedicated to urology (p=0.027). A statistically significant reduction of the amount of radical cystectomy (RC) was seen in Lombardy (p=0.036), as well as an increasing number of RC performed in the South (p=0.030). The total amount of RC remained the same in 2019 and 2020, as more centers performed these surgeries in 2020.

The survey data supports the findings of the most recent papers, showing a global reduction in the number of BC surgical procedures due to the prioritization given to COVID-19 patient management. However, we can admit that the reduction was not so significant if we look at the different regions, especially the Southern ones, where a lower number of COVID-19 cases was observed. These data demonstrate the significant efforts made by Italian urologists to proceed with urgent surgical procedures, despite the COVID-19 outbreak. In our opinion, the improvement of the management of patients may be optimized because of COVID-dedicated hospitals, in order to guarantee high-quality, timely, and safe treatments to oncological patients.

The topic is still of great interest given the persistence of the COVID-19 pandemic. In this regard, a plethora of articles have been written in the last months. The management of BC patients needs special attention as during a pandemic, it tends to be hard to strictly respect the follow-up times. In a recently published editorial, it was suggested the possibility to extend the times between cystoscopy in patients under active surveillance (AS) for non-muscle invasive bladder cancer (NMIBC). This suggestion is useful both for optimizing the management of outpatient-naïve patients and decreasing the risk of being infected by nosocomial COVID-19 for recovered BC patients. Unfortunately, the AS protocol is still only slightly applied in both Italy and all over the world.

Few authors evaluated the diversified impact, dividing the urology units between northern, central, and southern academic and non-academic centers and the access in Emergency Room (ER).

A review that analyzed the common features and risk factors of COVID-19 disease and BC has been recently published. As far as it concerns COVID-19, increased age, obesity, smoking and chronic underlying comorbidities (including diabetes mellitus) are factors associated with developing more severe disease. High-risk NMIBC progression and worse prognosis are also characterized by a higher incidence in patients with risk factors similar to COVID-19. Immune system response and inflammation have been found as a common hallmark of both diseases. Most severe cases of COVID-19 and high-risk NMIBC patients at higher recurrence and progression risk are characterized by innate and adaptive immune activation followed by inflammation and cytokine/chemokine storm.

In conclusion, urologists learned to adapt their work to the organizational changes due to the COVID-19 outbreak, as well as patients showed their worries about accessing the ER due to the fear of being infected with COVID-19. However, it is known that the delay in the BC diagnosis could lead to a worse prognosis and lower survival. At the moment, the most effective solution seems to be to create separate ER access for COVID-19 and non-COVID-19 affected patients. 

Written by: Roberto Contieri, MD, PhD,1 Carmen Maccagnano, MDRodolfo Hurle, MD1

  1. Department of Urology, Humanitas Clinical and Research Center− IRCCS, Milan, Italy
  2. Department of Surgery, Division of Urology, ASST Lariana, Nuovo Ospedale Sant’Anna, Italy

  1. Maccagnano, Carmen, Lorenzo Rocchini, Emanuele Montanari, Giario Natale Conti, Giovanni Petralia, Federico Dehò, Kadi-Ann Bryan, Roberto Contieri, and Rodolfo Hurle. "Overview of the italian experience in surgical management of bladder cancer during first month of COVID-19 pandemic." Archivio Italiano di Urologia e Andrologia 92, no. 4 (2020).
  2. Hurle, Rodolfo, and Carmen Maccagnano. "Active surveillance for recurrent low-grade non-muscle-invasive bladder cancer: Can we take any advantage from the COVID-19 crisis?." Arab Journal of Urology 18, no. 2 (2020): 65.
  3. Maccagnano, Carmen, Conti, Giario Natale, Ferro, Matteo, Hurle, Rodolfo et al. "Emergency Room Access During Pandemic: Can Urologist Learn Something From The COVID-19? An Italian Experience." Archives of Clinical and Experimental Surgery 9, Issue: 1.8-15.
  4. Maccagnano, Carmen, Lorenzo Rocchini, Emanuele Montanari, Giario Natale Conti, Roberto Contieri, Kadi-Anna Bryan, and Rodolfo Hurle. "Surgical Management of Bladder Cancer During First Month of COVID-19 Outbreak: Lessons Learned Across Italy." (2020).
  5. Busetto, Gian Maria, Angelo Porreca, Francesco Del Giudice, Martina Maggi, Daniele D'Agostino, Daniele Romagnoli, Gennaro Musi et al. "SARS-CoV-2 Infection and High-Risk Non-Muscle-Invasive Bladder Cancer: Are There Any Common Features?." Urologia Internationalis (2020): 1-13.
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