Treatment of urological conditions in the era of covid
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COVID-19 has put tremendous pressure on the existing healthcare system. While , all resources are being diverted for COVID-19 treatment, Urology should put in effort for the same, meanwhile treating patients for their emergent urological problems. This presentation discusses the Dos and Donts of urological practice in the hero of COVID-19
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Treatment of urological conditions in the era of covid
- 1. Urological surgical procedures in the COVID -19 era Dr Santosh K Senior Resident ,AIIMS BBSR
- 2. Triage of urologic surgeries during the COVID-19 pandemic • Demand for ventilator-level care for COVID- 19 cases • Scarce resource – PPE, Testing , Man Power, Beds , ICU backup • American College of Surgeons- Cancellations of elective surgeries Urological procedures Elective Emergency
- 3. ELECTIVE VS EMERGENCY • Elective - “vague” ; open to interpretation • Elective procedures be delayed until the strain is decreased • Cases are not been well defined - Context dependent Effects of delaying surgery Capacity and demand
- 4. General considerations • All patients should receive preoperative screening for COVID-19 • Only emergency surgeries are to be done • Lap/robotic surgeries are to be avoided • If lap is used: one way insufflators, low pressure, Ultra low penetrating air filter and intelligent smoke evacuation systems to be used • Ultrasonic shears are to be avoided • Fecal and urinary transmission is possible- due care is must • Minimal staff in the OR SAGES and EAU robotic urology section
- 5. Office based procedures Procedure Indication Recommendation Comments Diagnostic cystoscopy Gross hematuria Consider performing full evaluation without delay Diagnostic yield in finding bladder cancer or upper tract malignancy is high Microscopic hematuria with risk factors Consider delaying evaluation up to 3 months unless patient is symptomatic Diagnostic yield for urinary tract malignancy is high in this setting compared to asymptomatic patients, especially when multiple risk factors are present Microscopic hematuria without risk factors Delay evaluation for 3 months or longer as necessary Risk of urinary tract malignancy in a diverse patient cohort with asymptomatic microscopic hematuria is low Katz EG et al. The Journal of Urology;Mar2020
- 6. Procedure Indication Recommendation Comments Surveillance cystoscopy • Assessment of response to treatment • surveillance of high risk NMIBC within 6 months of initial diagnosis Consider performing evaluation without delay. There is a high risk of recurrence and/or progression within the first 6 months of diagnosis • Assessment of response to treatment • surveillance of high risk NMIBC beyond 6 months of initial diagnosis Consider delaying evaluation up to 3 months. High risk patients with stable disease may be at lower risk for relapse • Assessment of response to treatment • surveillance of low/intermediate risk NMIBC, regardless of when diagnosis was made Delay evaluation for 3-6 months Tumor recurrence in this group is low Katz EG et al. The Journal of Urology;Mar2020
- 7. Procedure Indication Recommendation Comments Induction intravesical BCG/chemotherapy High risk or intermediate NMIBC bladder cancer Should be prioritized for treatment significant benefit by reducing disease recurrence and progression Maintenance intravesical BCG/chemotherapy High risk NMIBC Stop maintenance therapy and reevaluate The utility/need in 3 months While maintenance therapy is important, the most significant benefit from intravesical treatment is likely during the induction course Intermediate risk NMIBC Delay indefinitely Katz EG et al. The Journal of Urology;Mar2020
- 8. Procedure Indication Recommendation Comments Prostate biopsy Risk factors for high risk prostate cancer • PSA>20 • PSADT< 6 months • DRE suspicious nodule • local or systemic symptoms Attempt to obtain MRI initially Delay biopsy up to 3 months If performing biopsy, suggest transperineal biopsy, if possible, to minimize infectious risks and fecal exposure Delay in diagnosis by 3 months is unlikely to change long-term oncologic outcome No risk factors for high risk prostate cancer routine biopsy for established patients on active surveillance Delay 3-6 months. Delay in diagnosis by 3-6 months is unlikely to change long-term oncologic outcome Katz EG et al. The Journal of Urology;Mar2020
- 9. Procedure Indication Recommendation Comments Cystoscopy and ureteral stent removal Indwelling ureteral stent after ureteroscopy Consider performing without delay Risk of encrustation, UTIs, ongoing symptoms requiring ER visit or hospital admission, retained/forgotten stent should be minimized Exchange of chronic foley/suprapubic catheter Indwelling catheter Extend exchange intervals for additional 2-4 weeks if no history of encrusted catheter, difficult exchange, recurrent UTIs Urodynamics Evaluation of lower urinary tract dysfunction Delay for 3-6 months Pessary cleaning/exchange SUI, pelvic organ prolapse (POP) Delay for up to 3 months if no evidence of vaginal wall erosion or ulceration Risk of rectovaginal or vesicovaginal fistula Katz EG et al. The Journal of Urology;Mar2020
- 10. ONCOLOGY Stensland et al . European urology
- 24. Systemic Therapy in Patients with Urological Cancers • Cancer patients - higher risk of death from COVID-19 • Systemic therapy- • Neo- adjuvant • Adjuvant • Palliative • Lengthy, Multiple visits to hospital • Risk of exposure to COVID-19 during hospital visits • risk/benefit ratio to be considered • favor not giving therapy if the survival benefits are modest or unproven • neoadjuvant therapy may delay the need for surgery/radiotherapy is they are interrupted Silke Gillessen et at; European urology
- 25. Factors affecting the Protocols • Clinical scenarios vary from country to country • Single Protocol - not universally acceptable • Stage of the pandemic • Local health care capacity • Risk of infection to the individual • Status of the cancer • Comorbidities • Age • Details of the treatment
- 26. Goals and Priorities • Most relevant- Minimize potential exposure to COVID-19 by reducing hospital visits • Regimens with a clear survival advantage should be prioritized • Curative treatments remain mandatory-use of growth factors and prophylactic antibiotics to avoid / minimize hospitalization • Treatments that have only shown a palliative effect for patients who are symptomatic require careful discussion • Others requiring consideration of the risk/benefit ratio
- 27. • Palliative treatments -dose intensity that avoids febrile neutropenia • suboptimal dosing to be avoided • If neutropenia occurs – reduce dose for each episode • Prophylactic antibiotics - Recommended • steroids -avoided / reduced for antiemesis where possible
- 29. Take Home Message • Exponential increase in number of COVID -19 cases • Health care facilities are overwhelmed • Minimal urological cases burden needed • Urgency to be decided on case to case basis • Maintain Optimal work force
Editor's Notes
- As hospitals begin bracing for the possibility of surge demand for ventilator-level care for COVID 19 cases, the possibility of having to cancel elective surgeries to increase access to care is real.
- 1Lahey Hospital and Medical Center, Institute of Urology 11 2University Hospitals Cleveland Medical Center, Case Western Reserve School of Medicine 3Vanderbilt University Medical Center, Department of Urology
- Initial phase of the pandemic, when incidence is increasing exponentially and the upcoming pressure on health care resources is unknown
- AR = androgen receptor; CTx = chemotherapy; ICI = immune checkpoint inhibitor; IMDC = International Metastatic Renal Cell Carcinoma Database Consortium; IV = intravenous. a Oral VEGF-targeted therapy rather than IV ICIs may be attractive as it requires less health care interactions and resources. b Younger cancer patients and those without comorbidities may be at lower risk, which should be considered. c Neoadjuvant chemotherapy may be helpful in bridging time to surgery in cases in which elective surgery is not possible. d Regimens with a longer interval (4-weekly nivolumab or 6-weekly pembrolizumab) should be used where possible. e Palliative CTx was tested with a specific number of cycles. The risk associated with stopping before this has not been assessed, nor of the principles of delaying chemotherapy. There are subgroups of prostate and urothelial cancer patients for whom continuing CTx to the full number of cycles may be associated with more risk than benefit. Patients will need to participate in this discussion. f Assuming similar efficacy between the regimens