COVID-19 and Global Urologic Surgery Disruptions - Bertrand Tombal and Neal Shore

Recorded March 24, 2020

Amid the escalating COVID-19 crisis across the globe, Alicia Morgans speaks with Neal Shore and Bertrand Tombal who share the urologist's perspective on the impact of the crisis on their patients and their capacity to give care. Dr. Tombal calls in from Belgium; where he speaks to the effect of total confinement in the country and how GU-oncology and urology surgeries have been reconfigured as hospitals are forced to adjust to an influx of COVID positive patients. Dr. Tombal also addresses delays for surgeries, and when exceptions to this rule must be made when patient survival is dependent on the surgical procedure.   Dr. Shore describes the situation in South Carolina and the work being done to flatten the curve leveraging telemedicine. He also addresses the lack of personal protective equipment available, and how elective appointments in outpatient and inpatient settings are being delayed for as long as possible. Both Dr. Shore and Dr. Tombal consider the long term impact of this uncertain time on all levels of cancer and urologic care.

Biographies:

Bertrand Tombal, MD, Ph.D., Professor and Chairman, Cliniques Universitaires Saint-Luc, Brussels, Belgium.

Neal Shore, MD, Medical Director for the Carolina Urologic Research Center, Myrtle Beach, South Carolina, USA.

Alicia Morgans, MD, MPH Associate Professor of Medicine in the Division of Hematology/Oncology at the Northwestern University Feinberg School of Medicine in Chicago, Illinois.


Read the Full Video Transcript

Alicia Morgans: Hi, this is Alicia Morgans, GU medical oncologist, and Associate Professor of Medicine at Northwestern University. I am so appreciative to have here with me today, Dr. Neal Shore, and Dr. Bertrand Tombal, who are joining us to share the global urologist's perspective on the unprecedented COVID-19 pandemic, as we as GU oncologists try to deal with the situation. Dr. Shore is joining us as the Director of the Carolina Urologic Research Center in South Carolina, and Dr. Bertrand Tombal is joining us from Belgium where he is the Chairman of the Division of Urology, and a Professor of Urology there in Brussels. Thank you so much for being here with me today, gentlemen.

Bertrand Tombal: Great pleasure.

Neal Shore: Thank you.

Alicia Morgans: Wonderful. So why don't we start with you, Bertrand, just sharing what your experience has been in Belgium, in the middle of Europe as you face this COVID-19 pandemic in your practice?

Bertrand Tombal: Here in Belgium, we started the COVID-19 crisis a little bit more than that three weeks ago. As you know, Italy has been quite severely hit, and we could observe that from the outside. So by chance, our house authority very rapidly started a confinement procedure. We are now on day 11 of total confinement. And for a country of 11 million we have roughly, I would, say 250-300 new hospitalizations every day, and we have like 30 to 40 deaths every day. As for the urology and the uro-oncology, because we could get organized very early on, most large hospitals have actually separated the OR into a COVID-19 positive and negative zone. So, so far we could actually maintain most of the, I would say, large surgeries like cystectomy, nephrectomy, testis cancer.

But we had to take a decision for, I would say, more a case like prostate cancer, we have stopped any prostate cancer activity in terms of surgery like 10 days ago and we have started also to have phone conferences. So I think that's getting organized. Our national society has issued a recommendation for the surgical management of GU cancer. So recommending that any procedure that could be delayed would be delayed. And for instance, we have stopped the robotic program. I don't know, I would be very curious to see what Neal thinks about that.

But actually they were concerned about, could we secure full sterilization of the robot after the procedure because in an OR where you do surgery in a with a COVID-19 patient you need to use a so-called stage three reconditioning. So we've been stopping the robot program. So today we did a partial nephrectomy open, which I didn't remember how to do. So that's where we stayed now. For the rest, most of the activity has been stopped. We've stopped doing prostate biopsies. The MRI machines have been slowing down also. So it's like we're making a total pause for prostate cancer. It looks like we're going to wait another six weeks before we treat prostate cancer again. For the other cancers, that's still okay.

Alicia Morgans: So before we jump to Neal because I think this robot question is a really interesting one. Just to clarify, it sounds like you're still doing surgeries where survival is imminently linked with that surgery. So for example, a bladder cancer, you cannot delay that.

Bertrand Tombal: The clear recommendation was that if you have any form of data suggesting that a delay would hurt the patient because you know the problem is that we don't know how long we will be delayed, and we don't know what is going to be our capacity to catch up after that. Because it's going to be impossible to work more than the allocated time, so we decided that we would keep, for instance, lung surgery is maintained. So we decided to maintain oncological surgery as long as we have enough anesthetists to do so, and just suppress those we believe honestly there is no hurry. So that was a very interesting discussion.

Alicia Morgans: So for prostate, even for a high-grade prostate, are you doing ADT or something with a plan to then delay, or what are you doing?

Bertrand Tombal: In Belgium, we have a miracle drug. It's called bicalutamide 150, and actually no later than yesterday, we also had a Gleason 9-10 that was scheduled for prostatectomy, the patient was anxious, the GU were anxious. So we said, okay, no worry, we're going to start you under a little bit of bicalutamide 150 daily, which is actually in my country still a recognized indication actually. And we're going to postpone this guy because once again that would eventually allow us to postpone this guy a little bit later. So because we start now making a plan, not knowing the date, or are we going to catch up, because like my hospital usually is 30% internal medicine. Now, 75% of the rooms are occupied with a patient with an indomethacin problem. The urology department is usually two floors. We have one common floor with the gynecologist now, so that's the problem. It's not only the duration of the crisis but how long is it going to take to get these patients going home and free the bed for surgery again. So it's really, really a concern. So we keep doing oncological surgery as long as we can.

Alicia Morgans: And it sounds like you're operating on patients who have COVID-19, or is this an exposure? You have this COVID-19 plus and the COVID-19 minus?

Bertrand Tombal: Yeah, for the COVID-19 plus, like yesterday we did a 27-year-old teacher who was infected so he was positive on the PCR testing, not having any symptoms showed up Friday with a large tumor, testis cancer. We did the orchiectomy today.

Alicia Morgans: Wow. Well, I-

Bertrand Tombal: And we have a COVID-19 OR.

Alicia Morgans: Wow. Well, I need to give Neal an opportunity to jump in because I could just keep asking questions. This is fascinating. Dr. Shore, what are your thoughts and what are you doing, and how do things look in South Carolina as compared to what's going on in Belgium?

Neal Shore: Yeah, so it is a little bit different. We are located almost at the midway point between New York and Florida. And so we're not an epicenter, but yet our case base and our infectivity rate keep increasing daily, and the modeling suggests that's going to continue for several more weeks without a doubt. And some of the things that are really now becoming very important when you're not in an epicenter area perhaps as parts of Europe are and New York and Washington and parts of California is to make sure that the education and the fidelity to the importance of social distancing is presented on a regular basis. So I like acronyms. And one of the things that we've started within the last two weeks is this concept of PPS, which is to protect the patients, to protect the team, the healthcare team, which is becoming a real challenge in different parts of the world. And then the S in the PPS is sustaining economic viability. And all of this encompasses all aspects of healthcare delivery.

So you could be in a metropolitan area or rural suburban area, you could be any part of the globe and you can be academic or community. And I think what a lot of folks have been concerned about, well they're saying, well, we're going to flatten this curve, and the flattening of the curve presupposes economic shutdowns, economic dislocation, and a delay before we finally see the Zenith of infectivity. So some have argued, oh, don't do that and accept the marked increase of infectivity as well as the increase in mortality and hospitalization. I think what people weren't realizing what that argument and I think it's the wrong argument clearly, is that it would completely overrun our healthcare systems, the issues around equipment, personal protective equipment, PPE, an important acronym now that's flooding all the literature. This is causing enormous strain in the healthcare system both in urology practices, in academia as well as in the community.

And for our organization here we have and have had several very vibrant and busy ambulatory surgery centers, a very active and busy clinical research department in addition to our clinical department. And so we're taking all these steps to, as I said, protect patients, protect the healthcare team and to work on sustaining our economic viability, which is in the longterm obviously of significant consequence. As Bertrand mentions, once we get through this we have to adjust to the potential huge surgeon capacity that'll be required from all the delayed procedures. And as it regards treatment, diagnostics, surgical interventions, we have clearly started a very dramatic prioritization of only oncologic patients that need immediate attention and as well as patients in acute pain and other acute emergency needs.

So all elective meetings in the clinic, in research, in outpatient and inpatient hospitalization are all being delayed for as long as possible. And it's a very interesting dynamic and argument amongst urologists, medical oncologists, internists, and radiation oncologists, the whole multi-disciplinary team. And I've actually been fascinated in my discussions and my feedback from what I'm hearing throughout the United States and even globally, we all aren't singing from the same page book, but I think it's a work in evolution and like with most things, they have to be tapered to the specific environment in which you're working. So Bertrand's question about closing down the robotic platform, we have not done that yet, that hasn't been discussed. It's interesting, I've just learned from him. We may have to start doing that. We're certainly prioritizing and thinking about more important ways to work with our hospital systems, the ones that are near each other and compete. Obviously ambulatory surgery centers.

Alicia Morgans: So I agree with you Neal because I have not... Now, I'm a medical oncologist, so I don't work with robots in that way. I just envy you guys as you get to do those cool surgeries in the OR. But that is the first that I've heard of that. And as I think about prostatectomies and I think about when this pandemic may die down, we don't know when that's going to happen. And at least in the US as I understand a majority of prostatectomies are actually occurring through a robotic approach with some saying, and again, I'm not a urologist so I don't know the details of this, but I have heard that it is not every young urologist who comes out of training who knows how to do an open prostatectomy. And again, I could be wrong.

But if this ends up being a more sustained issue, certainly we'll have to understand how to clean the robots. But I could imagine this causing some challenges in the US as we try to go from the way that these surgeries are commonly done back to different strategies and different approaches. Even Bertrand you mentioned, you're doing a partial nephrectomy perhaps in a way that you haven't done it for years to this point. So relearning these old strategies or learning them for the first time, it seems maybe something in our future. Am I thinking about this correctly, guys?

Bertrand Tombal: Yeah, but that's, I mean clearly it shows how much we have become dependent of these technologies, and that we do not anticipate a situation where for a reason which is just a lack of evidence more than evidence against using it that we are taking decisions and we still confronted to the patient. Also, I think one of the problems is that this crisis it's everybody says, okay it's a pandemic, but it's not synchronous everywhere. And we see that in Europe, where countries have taken a different, like the Netherlands are still believing in that spontaneous immunization and full saturation of the healthcare system, where the UK started like this and now is going into... So that uncertainty about what we are facing is probably will prolong the crisis and my worry now is not how to deal today is, how are we going to deal with the huge backlog of patients that we're going to create, explaining why we tried to do as much as we can now.

Neal Shore: In the spirit of understanding old-school use of a surgical scalpel is a good reason why we can't get rid of baby boomer surgeons like myself and Bertrand. So, but another thing is technology has had some really great advantages. You mentioned it earlier, Alicia, about telehealth or telemedicine. We've ramped up in that dramatically. And so not only is it protecting patients and protecting the healthcare team by keeping the social distancing and therefore 'flattening the curve', but it's allowing us to effectively delay surgeries and reassure patients. Many patients need a lot of reassurance because understandably, they're not science-based, they're not medicine-based.

So now that we're having an ability to see them remotely, and because at least just here in the US we've relaxed dramatically the barriers to doing telemedicine, we can delay elective surgeries even if they're big and needed cancer surgeries, because, let's remember, major surgeries have an increased risk of complications and they further drain the healthcare system when we're still trying to understand where the peak will be in hospitalization and inpatient ventilator use, et cetera, for the COVID crisis. So I think even for patients who can reasonably wait several weeks to have their cystectomy, their prostatectomy, their nephrectomy, there's always exceptions and those have to be judged individually and with the right panels. Telemedicine allows us to optimize that.

Bertrand Tombal: Yeah. And also one of the interesting questions is we have absolutely no idea what is going to be the impact of delaying these surgeries. So this is something we try at least in the academic center it's not easy, but to flag these patients and hopefully benchmark in a few years, we may actually learn from that bad experience, nobody knows. Are we going to see, and it is the same a little bit for you in medical oncology, are we going to see an increase in mortality in like six months, one year from now for prostate cancer? Once again, it's going to take five years, but that that's going to be very interesting.

Alicia Morgans: I agree. And something that we as a community need to put together and to review. There are certainly registries that are being formed that are centered here in the US that are trying to go international that can help us pull together information from COVID-19 patients. But just to reflect back on something you mentioned a few minutes ago Bertrand, you operated on a patient who had to testicular cancer who was completely asymptomatic and was COVID-19 positive and you put that patient in a separate operating suite as is appropriate and you still cared for that patient who had an emergent need. We in the United States to my knowledge at least for a majority of centers are not currently testing asymptomatic patients who could be walking into our clinics in medical oncology, could be walking into our ORs and this is not because we don't wish to have the data, this is actually because we don't at this point have guidance and test availability that allows us to do that for whatever reason. And it's something that we all, I think hope to change.

But this could be an issue for us in the United States and in other places around the world where we don't have that test availability where we aren't able to sequester or at least separate outpatients with COVID-19 from others. And it's something that I see as a problem within our medical oncology clinics as well as our urology practices. And I don't know if either of you has any thoughts on that other than, I mean certainly Bertrand, I think you would encourage us to test these patients and I think we would like to do that. But any other comments or guidance as we struggle with this?

Bertrand Tombal: The rule we have is that anybody who is entering the hospital for more than a simple outpatient visit, or a CT, is actually tested, okay? For instance, the testis cancer patient was... The scrub was made on Sunday, we had the result by Monday. And so we could decide that we would do this, we could eventually decide not to do the surgery. I mean, but then we decided to do the surgery. But in an environment which is there to protect the staff as you know, for anesthesiologist intubations and any form of aerosolization is extremely dangerous. So that's how we sort that out. I mean, we want to protect also the people and also the personnel, because that can spread very rapidly. We want to avoid a weak point in the confinement chain, and so we're now testing everybody before they enter the hospital if possible.

Alicia Morgans: Yeah, of course. Neal, what are your thoughts?

Neal Shore: Yeah, I love the potential to do ubiquitous testing. We are way, way behind here in this country. I'm not aware that in any of the facilities that I'm involved with nor anywhere in the country yet that we've adopted that policy because we've had a dearth of testing available. That is how we will get to a full understanding of the infectivity rate and then a better understanding ultimately of the mortality rate. So I think we're moving in that direction. That's clearly been the goal I think of the CDC in the United States. I do think that all of these issues that have been brought up are going to allow for much greater learnings for future care.

I think for now urologists, in particular, are thinking about basic things such as simple viral hygiene and precautions as well as the impact not only on their patients but on the healthcare team. And as I said earlier, and we didn't get too much into it, but is the economic sustainability here, and this is obviously the looming issue that keeps us fearful in the future because as Bertrand said, we are going to see a back load or pent up surgical volume of cases that are being delayed, we'll see a pent up infusion volume in medical oncology clinics as well.

Alicia Morgans: Well, I sincerely appreciate your time. I know we could talk about this for a lot longer, and I will make sure that we schedule to talk with both of you in a few weeks so we can try to flush some of these issues out a little bit more thoroughly and with a little bit more time and distance since our initial conversation. Hopefully, things will have moved in a better direction. But I as I said, appreciate your time, appreciate your expertise and hope that this conversation will help guide those in the US or around the world as we try to make some smart choices for our patients. Thank you both.