key: cord-0807578-nu0dte6k
authors: Quarto, Giuseppe; Grimaldi, Giovanni; Castaldo, Luigi; Izzo, Alessandro; Muscariello, Raffaele; De Sicato, Sonia; Franzese, Dario; Crocerossa, Fabio; Del Prete, Paola; Carbonara, Umberto; Autorino, Riccardo; Perdonà, Sisto
title: Avoiding disruption of timely surgical management of genitourinary cancers during the early phase of COVID‐19 pandemic
date: 2020-07-13
journal: BJU Int
DOI: 10.1111/bju.15174
sha: cf0c6026f97680bcdfe0e25f423664bdde85f5a7
doc_id: 807578
cord_uid: nu0dte6k

As of early July 2020, over 10,000,000 confirmed SARS‐CoV‐2 (COVID‐19) cases and 500,000 deaths have been recorded worldwide. This dramatic surge of the pandemic resulted in hospital overcrowding and shortage of intensive care unit (ICU) beds, creating a global crisis in health care systems. As many other specialties, Urology was impacted at different levels. A decline in number of elective surgeries was observed, with peaks of over 94% reduction in most affected regions. Outpatient clinics were largely shifted to virtual consults. Interestingly, there was a significant decrease in hospital attendance for urological emergencies. Urologic surgical training was negatively impacted.

DR. RICCARDO AUTORINO (Orcid ID : 0000-0001-7045-7725)

As of early July 2020, over 10,000,000 confirmed SARS-CoV-2 (COVID-19) cases and 500,000 deaths have been recorded worldwide. This dramatic surge of the pandemic resulted in hospital overcrowding and shortage of intensive care unit (ICU) beds, creating a global crisis in health care systems 1 . As many other specialties, Urology was impacted at different levels 2, 3 . A decline in number of elective surgeries was observed, with peaks of over 94% reduction in most affected regions 4 . Outpatient clinics were largely shifted to virtual consults 5 . Interestingly, there was a significant decrease in hospital attendance for urological emergencies 6 . Urologic surgical training was negatively impacted 7 .

In the uro-oncology field, timely patient selection based on priority criteria for surgical treatment was advocated 8 . We enjoyed reading the report from the Martini Clinic, a renowned high-volume center for prostate cancer surgery, where favorable outcomes were obtained without implementing rigorous screening measures, and by only applying strict protective hygiene standards 9 . Albeit remarkable, their experience might not applicable to countries with different demographics, health systems, hospital resources, and testing capabilities. In this regard, some key differences between Germany and Italy are notable. As of April 20th, 2020, over 180,000 cases and 24,114 deaths had been recorded in Italy, most of which in Northern Italy, with Lombardy being the leading region (over 66,000 cases and 12,376 deaths at that time point). Southern Italy was in general less affected, with Campania region recording over 4,000 cases and only 309 deaths. German had high testing rates early in the pandemics, which may have contributed to lower death rates. Moreover, Germany was very meticulous in tracking the contacts of those testing positive. This was not the case in Northern Italy, especially in the early phase. Another key factor was the number of hospital beds in Germany, a total of 497,000 for general and acute care (by contrast, the UK has 101,255). A recent OECD survey found that before the crisis Germany had 33.9 ICU beds per 100,000 people, compared with 9.7 in Spain and 8.6 in Italy.

We would like to describe our experience matured at a high-volume cancer center in Southern Italy during the early phase of COVID-19 pandemic, and to illustrate how a planned re-organization of Accepted Article the hospital and regional health care system allowed avoiding major disruption of most commonly performed uro-oncologic surgical procedures. We looked at the surgical procedures for urologic cancers performed at Fondazione "G. Pascale" IRCCS (Naples, Italy) from March 2 nd to April 20 th 2020. A workflow was established to optimize outcomes and minimize risk of transmission. Each case was evaluated by a multidisciplinary team consisting of a urologic surgeon, a genitourinary medical oncologist, and an anesthesiologist. Intervention priorities were determined based on disease severity, risk of progression, length of time in the waiting lists, disease-related symptoms, and anesthesiology risk. At the time of pre-hospitalization, all patients were assessed by means of nursing triage so that body temperature was measured, presence of COVID-19 symptoms were ruled out, as well as possible contact with positive patients. Starting April 1 st , 2020, rapid blood testing was available to verify presence of IgG-IgM. Asymptomatic COVID-19 +ve patients were quarantined home.

Use of appropriate PPE was strictly adopted. All patients had surgical masks, and all health care workers were provided with FFP2 masks ("N95" in the US). Anesthesia team members were also wearing face shields, and intubations were being performed with glidescope assistance, and using a protective plastic intubation. Moreover, steps were taken to minimize CO 2 release during robotic procedures, including use of filtered insufflation systems and low pressure pneumoperitoneum.

Overall, 93 patients underwent a urologic surgical procedure, and 38 of which (40.8%) done robotically. Mean patient age was 65yo (mean ASA score 2). The most common procedure was TURB (22 cases; 23%) whereas radical prostatectomy was the most common robotic procedure (18% of total). A similar number of procedures, 96 overall, of which 31 robotic (30%), had been performed in the same period of 2019. Overall, there were no differences in terms of surgical outcomes between the two time periods. Only one radical cystectomy patient developed fever, reduced oxygen saturation, and lymphocytopenia on postoperative day 3. Chest x-ray and oropharyngeal swab confirmed COVID-19. He was transferred to a COVID-19 hospital within the regional health care system where he was discharged home after 3 weeks with two consecutive negative testing. Patient did not suffer respiratory sequalae.

Healthcare in Italy is organized on a regional basis. In our region (Regione Campania), with a population of about 5.8 million people, regional health system was restructured to create "COVID hospitals" for acute management of COVID-19 patients. Selected hospitals were provided with "purposebuilt" wards specifically reserved for COVID-19 patients, but they could still offer, to a limited capacity, elective (mostly emergent) cases. Ours was the only "COVID-free" regional cancer center. This allowed an optimal triage of incoming patients, with the possibility of transferring those testing positive to "COVID hospitals", thus avoiding disruption of a timely management of non-COVID cancer cases (Figure 1) . In general, we preferred robotic over open surgery to minimize surgical morbidity and

This article is protected by copyright. All rights reserved minimize hospital stay. To date no transmission of the virus has been proven during laparoscopic procedures, and this remains open for debate, as recently pointed out by the Society of Robotic Surgery 10 .

There are both similarities and differences between our experience and that reported by Würnschimmel et al 9 . As discussed, there was a different impact of the pandemic in Germany versus Italy. While the Martini Clinic is a University-affiliated private clinic dedicated to prostate cancer treatment, our hospital is a public "free standing" cancer center where all genitourinary malignancies are treated. Our German colleagues did not perform COVID-19 screening initially on routine basis, but rather relied on patient history prior to admission, whereas we adopted in-hospital screening for asymptomatic patients early on. In this regard, we implemented initially oropharyngeal swab (RT-PCR) swab, and soon after antibody (IgG/IgM) blood test, whereas we did not use CT chest as screening tool 11 .

Overall, our experience shows that appropriate health network and hospital re-organization, multidisciplinary collaboration, careful patient selection, and adoption of safety protocols, allow to safely preserve the flow of uro-oncological surgical procedures during this COVID-19 era. This translates into a timely and effective treatment of genitourinary cancer patients.

None

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Martini-Klinik experience on prostate cancer surgery during the early phase of COVID-19

Society of Robotic Surgery Review: Recommendations Regarding the Risk of COVID-19 Transmission During Minimally Invasive Surgery

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This article is protected by copyright. All rights reserved