Where do Urologists Stand in the Era of Novel Coronavirus-2019 Disease

Thomas Hughes; Hui Ching Ho; Shahrokh F. Shariat; Bhaskar Kumar Somani

Disclosures

Curr Opin Urol. 2020;30(4):610-616. 

In This Article

Oncological Diseases

Renal Cancer and Upper Urinary Tract Cancer

Renal cell carcinoma (RCC) usually presents late with up to 30% having metastatic disease on initial diagnosis and is therefore associated with high mortality[22] Table 2. However, if diagnosed early, active surveillance and delaying treatment up to three months in stage T1 RCC does not worsen prognostic outcomes. Ablative treatments could be considered for cT1a tumours rather than surgical intervention.[23] Stage T2 RCC with scheduled nephrectomy could be considered to be postponed for one month with considerations of patient and tumour characteristics.[23] Stage T3 and above RCC, especially those extending into the inferior vena cava are aggressive tumours requiring prompt treatment. They may be more technically challenging, associated with a longer length of stay and higher risk of postoperative complications like requiring haemodialysis and ICU admission.[24] Hence, treatment need not be delayed for Stage T3+ RCC but careful counselling of risks are required.

Delaying surgery in low-grade nonmuscle-invasive uppertract urothelial carcinoma (UTUC) for up to three months does not affect survival outcome.[25,26] However, delaying radical nephroureterectomy in high-grade invasive UTUC is associated with a significant progression of disease.[27]

Bladder Cancer

Two-thirds of bladder cancer cases are nonmuscle-invasive bladder cancer (carcinoma in situ, Ta and T1).[28] High-grade T1 bladder cancer is associated with a high risk of recurrence and understaging at transurethral resection of bladder cancer (TURBT).[29] Cases that are clinically deemed to be T1 should be prioritized for TURBT because of the risk of muscle-invasive bladder cancer (MIBC). Delaying treatment of MIBC by three months is associated with worse overall survival rates.[30] Similarly, delaying radical cystectomy by more than 10 weeks after neoadjuvant chemotherapy is associated with worse overall survival.[31] However, radical cystectomy is a major operation and the median length of stay is seven days even on an enhanced recovery after surgery pathway and ICU admission may be required.[32,33] The stage and grade of tumour and the availability of postoperative high-care bed should guide cystectomy procedures. Patients who are cisplatin-eligible should be offered this even more actively than before. Cisplatin ineligible MIBC should be offered a radical cystectomy within 12 weeks.

Prostate Cancer

A watch and wait approach is often adopted for many patients with prostate cancer. Postponing radical prostatectomy has not been associated with increased risk of biochemical or clinical recurrence of prostate cancer in those with low or intermediate-risk groups.[34] Even in high-risk disease, the risk of recurrence increased only after 12 months, suggesting radical prostatectomy can be considered to be postponed.[34,35] Other treatment modalities including radiotherapy and androgen deprivation therapy should be considered with the multidisciplinary team.[36] Some centres have stopped performing prostate biopsies during the outbreak.[37] Additional consideration should be given to performing transperineal prostate biopsy under fusion MRI guidance scan as opposed to transrectal prostate biopsies for diagnostic purposes as SARS-CoV-2 RNA has been identified in 29% of faecal samples in patients with COVID-19 and may be a potential route for transmission of infection.[38]

Testicular Cancer

Delayed presentation, diagnosis and orchidectomy of testicular cancer is associated with higher rates of mortality from testicular cancer.[39,40] Orchidectomy also serves the purpose of providing tissue for diagnosis and risk stratification to determine further management including chemotherapy.[41] Inguinal orchidectomy for testicular cancer can be performed as a day case procedure, reducing pressure on beds.[42] Therefore, radical orchidectomy is high priority and should be performed whenever possible.

Emergency Urology Service

In the event that pressures on hospital resources by the COVID-19 pandemic are so great that high-priority malignancy operations have to be delayed, an emergency service must be maintained to provide surgery for 'life-or-limb' cases. This may mean that more innovative management options are pursued. In certain situations, surgery is mandated, such as debridement of Fournier's gangrene, exploration and fixation of testicular torsion or drainage of urosepsis.

In urinary retention as a result of BPH for example, a urethral catheter should be used to relieve the obstruction. Similarly, renal colic should be managed conservatively wherever possible. However, in cases of an infected and obstructed kidney, decompression and intravenous antibiotics are indicated. Urosepsis associated with nephrolithiasis can be associated with severe illness and even death with ICU admission required in as many as 18% of patients[43] Decompression can be facilitated with either ureteric stenting or percutaneous nephrostomy. Careful consideration should be given to which procedure is chosen as nephrostomy under local anaesthetic can spare a ventilator.[44] In centres with suitable experience, ureteric stenting under local anaesthetic in the outpatient setting can be considered.[45] Definitive stone surgery can then be postponed for a few weeks.

Laparoscopic Procedures

The Royal College of Surgeons[46] and Society of American Gastrointestinal and Endoscopic Surgeons[47] advise caution when performing laparoscopic surgery due to limited evidence of the risk posed by COVID-19. The potential exposure to aerosolized biological fluid carried within surgical smoke or while removing trocars or surgical specimens can result in an explosive release of smoke, risking COVID-19 aerosol exposure. Although it can potentially be mitigated by the use of smoke filters, smoke extraction devices and use of PPE.

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