key: cord-0785533-44j30wdf authors: Stroman, L; Cathcart, P; Lamb, A; Challacombe, B; Popert, R title: A cross‐section of UK prostate cancer diagnostics during the COVID‐19 era ‐ a shifting paradigm? date: 2020-09-27 journal: BJU Int DOI: 10.1111/bju.15259 sha: 772b238b22c22db8d9da834f4e3240aac4effbc4 doc_id: 785533 cord_uid: 44j30wdf The prostate cancer diagnostic pathway accounts for over 50,000 prostate biopsies each year. (1) In an attempt to minimise the transmission of the COVID‐19 virus, during the height of the COVID‐19 many outpatient and procedural attendances were kept to a minimum in an attempt to safeguard patients and healthcare workers alike. Prostate MRI was offered in 99% of centres prior to the COVID-19 crisis. During the pandemic 14 (13%) centres stopped performing prostate MRI altogether. 39 (37%) continued to offer MRI for the same indications as prior to the pandemic while 48 (46%) offered prostate MRI to selected high risk patient groups only. Other answers were provided by 3 (3%) centres; one stated that they offered MRI to all patients except patients >70 years old while another stated they were booking all patients for MRI but patients were being cancelled due to reduced access to radiology services (Graph 1). Prior to COVID-19, centres were offering varying forms of biopsy with more than one form of biopsy offered in most centres; Local anaesthetic transperineal (LATP) biopsy was offered in 68 (67%), general anaesthetic (GATP) biopsy in 85 (81)% and local anaesthetic transrectal ultrasound guided (LATRUS) biopsy in 83 (79%). Of the centres that were offering that method of biopsy prior to COVID, LATP was continued to be offered more (80%) than GATP (36%) or LATRUS (40%) (Graph 2). Most centres that continued biopsy during the COVID-19 pandemic did so only on selected higherrisk patients. Of all centres that responded to the survey LATP was offered for higher risk patients in 43 (41%), GATP in 23 (22%), LATRUS in 22 (21%). However, some centres continued to offer biopsies in the same method as prior to the pandemic; LATP 13 (12%), GATP 9 (9%) and LATRUS 12 (11%) (Graph 3). Pre-biopsy testing and isolation Some 39% of centres required a negative COVID test and self-isolation prior to general anaesthetic (GA) biopsies (either TP or TRUS) and 12% for local anaesthetic (LA) biopsies (TP or TRUS). Some centres advised patients to self-isolate prior to their procedure but without COVID-19 testing; 43% Accepted Article for GA biopsies and 34% for LA biopsies. No isolation or testing was performed for 27% of centres offering GA and 45% offering LA (Graph 4). We observed variation in the reported PPE use for biopsy procedures; centres performing LATP used PPE for aerosol generating procedures (defined as filtering facepiece 3 (FFP3) mask, fluid repellent or surgical gown, gloves and eye protection) in 37%, PPE for inpatient care (defined as fluid repellent mask, apron, gloves and eye protection) in 33% and PPE for non-aerosol generating procedures (defined as fluid repellent mask, fluid repellent or surgical gown, gloves and eye protection) in 31% while this varied for GATP (64%, 11%, 25% respectively) and LATRUS (50%, 39%, 11% respectively) (Graph 5). Comparative rates of GATP and LATRUS biopsy both fell during the pandemic, probably related to the perceived higher risks of virus transmission through faeces and/or possible exacerbation of asymptomatic upper airway colonisation with intubation and general anaesthetic. It is also possible that TRUS biopsy use reduced as it is thought to pose a higher risk of post-procedural sepsis than the transperineal approach (1) (3), an important concern during the early stage of the pandemic when intensive care beds were carefully protected. BAUS guidance recommended that both TRUS and any general anaesthetic procedure should be kept to a minimum during the COVID-19 pandemic. (4) There is also an argument that due to the protracted nature of prostate cancer that withholding all prostate biopsies may have been reasonable during the peak of the COVID-19 pandemic although it seems as though most centres were continuing diagnostic biopsy in some form. The TREXIT plan to move away from transrectal biopsy and introduce LATP biopsy throughout the UK started in 2019. (5) There has been a shift towards transperineal biopsy even before COVID-19; over the last 10 years transrectal biopsy has outnumbered transperineal with a 4:1 ratio however this has moved to a 2:1 ratio over the last 2 years. (1) Might the COVID-19 pandemic be the trigger that accelerates uptake of LATP perhaps leading to a permanent shift away from TRUS biopsy beyond the pandemic? MRI use in the UK is already a changing paradigm -99% stated they use MRI in prostate diagnostic pathway, while it has been reported that 25% of centres were not performing any pre- This article is protected by copyright. All rights reserved biopsy MRI in 2016, which reduced to 13% in 2018. (6) Will the uptake of LATP follow suit in the changing field of prostate diagnostics? Our survey has shown that large differences existed in pre-biopsy testing and isolation advice given to patients throughout the country. This is noteworthy in general anaesthetic biopsy where guidance exists from the four Royal Colleges of Surgeons (issued on 9 th April 2020) that all elective cancer patients should have been asymptomatic for at least 7 days prior to surgery, have been socially isolating for 14 days with shielding and have Covid-19 negative naso/oropharyngeal swabs within 48 hours of the procedure. (7) It was therefore surprising that only 39% of centres required a negative test prior to general anaesthetic biopsy. There is less national guidance on local anaesthetic procedures. Heterogeneity in PPE for local anaesthetic procedures (LATP and TRUS) probably reflects the perception that these are not aerosolgenerating procedures. Public Health England guidance states that non-aerosol generating procedures should be performed with fluid repellent mask, fluid repellent surgical gown, gloves and eye protection, while aerosol generating procedures require the same kit with an additional FFP3 mask. (8) There were no specific PPE guidance for local anaesthetic urological procedures such as prostate biopsy or flexible cystoscopy during the COVID-19 pandemic. This survey is strengthened by the large numbers of centres that responded within a short period of time at the peak of the COVID-19 pandemic. This is likely to give a good snapshot of practice during that time. It should be noted that there were relatively few responses from Scotland, Wales and Northern Ireland so the survey may not give an accurate a picture of practice outside England. In addition, regional incidence of COVID-19 is important and may explain some of the variance observed in PPE use and pre-procedural testing use and similarly changes may reflect the policy of a specific centre. The survey is limited as does not report the number of procedures performed nationally and is a 'snap-shot' over very short period of time. A national audit of method and numbers of diagnostic procedures following the pandemic would be required to delineate if COVID-19 has shifted the paradigm towards LATP biopsy permanently. Local anaesthetic transperineal prostate biopsy (LATP) was the preferred method of prostate biopsy by clinicians during the COVID-19 pandemic. More centres stopped GATP (64%) and TRUS (60%) than The clinical and financial implications of a decade of prostate biopsies in the NHS: analysis of Tamhankar AS Statista: Number of new coronavirus (COVID-19) cases in the United Kingdom (UK) since Comparison of complications after transrectal and transperineal prostate biopsy: a national population-based study COVID-19 strategy for the Interim Management of Prostate Cancer. s.l. : British Association of Urology Section of Oncology TREXIT 2020": why the time to abandon transrectal prostate biopsy starts now Prostate mpMRI in the UK: The State of the Nation Intercollegiate Guidance for Pre-Operative Chest CT imaging for elective cancer surgery during the COVID-19 Pandemic. Royal College of Surgeons of Edinburgh Recommended PPE for healthcare workers by secondary care inpatient clinical setting, NHS and independent sector. s.l. : Public Health England Number of centres surveyed offering prostate biopsy by indication and method during the COVID-19 pandemic Percentage of centres performing pre-procedure testing and isolation prior to local or general anaesthetic biopsy The authors have no relevant conflicts of interest.