The document discusses surgical treatment of genitourinary cancers during the COVID-19 pandemic at a high-volume cancer center in Southern Italy. Through careful patient selection, strict safety protocols, and hospital reorganization, the center was able to maintain surgical treatment flow for urological cancers. A multidisciplinary team prioritized 93 cancer surgeries from March-April 2020, performing 40.8% robotically. Outcomes were similar to the prior year. One patient developed postoperative COVID-19 but recovered. The experience shows timely cancer treatment can continue safely during pandemics with appropriate measures.

1. ForPeerReview
AVOIDING DISRUPTION OF SURGICAL TREATMENT OF
GENITOURINARY CANCERS DURING THE EARLY PHASE OF
COVID-19 PANDEMIC
Journal: BJU International
Manuscript ID BJU-2020-1031.R2
Manuscript Type: Comment
Date Submitted by the
Author:
n/a
Complete List of Authors: Quarto, Giuseppe; 12Istituto Nazionale Tumori, Fondazione G Pascale,
Urology
Grimaldi, Giovanni; National Cancer Institute IRCCS Pascale Foundation,
Urology
Castaldo, Luigi; National Cancer Institute IRCCS Pascale Foundation,
Urology
Izzo, Alessandro; 12Istituto Nazionale Tumori, Fondazione G Pascale,
Urology
Muscariello, Raffaele; National Cancer Institute IRCCS Pascale
Foundation, Urology
Franzese, Dario; National Cancer Institute IRCCS Pascale Foundation,
Urology
Desicato, S. ; National Cancer Institute IRCCS Pascale Foundation,
Urology
Crocerossa, Fabio; Virginia Commonwealth University, Department of
Urology
Del Prete, Paola; National Cancer Institute IRCCS Pascale Foundation,
Urology
Carbonara, Umberto; Virginia Commonwealth University, Division of
Urology; Università degli Studi di Bari, Division of Urology
Autorino, Riccardo; VCU Medical Center Main Hospital, Surgery (Urology)
Perdonà, Sisto; 12Istituto Nazionale Tumori, Fondazione G Pascale,
Urology
Keywords:
COVID-19, Bladder cancer, Genitourinary cancer, Prostate cancer,
Robotic surgery, Kidney cancer
Abstract:
With appropriate health network and hospital re-organization,
multidisciplinary collaboration, careful patient selection, and adoption of
safety protocols, the flow of uro-oncological surgical procedures can be
safely preserved during the COVID-19 era. This translates into a timely
and effective treatment of genitourinary cancer patients. In this
scenario, robotic surgery should be considered in Centers with high
volume and surgical expertise.
BJU International

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1 BJU Int Comment
2
3 AVOIDING DISRUPTION OF TIMELY SURGICAL
4 MANAGEMENT OF GENITOURINARY CANCERS DURING
5 THE EARLY PHASE OF COVID-19 PANDEMIC
6
7 Giuseppe Quarto1, Giovanni Grimaldi1, Luigi Castaldo1, Alessandro Izzo1,
8 Raffaele Muscariello1, Sonia De Sicato1, Dario Franzese1, Fabio Crocerossa2, Paola Del Prete1
9 Umberto Carbonara2, Riccardo Autorino2, Sisto Perdonà1
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11 1Uro-Gynecological Department, Fondazione "G. Pascale" IRCCS, Naples, Italy;
12 2Division of Urology, VCU Health, Richmond, VA, USA
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17 *Corresponding author
18 Riccardo Autorino MD PhD
19 Director Urologic Oncology
20 Associate Professor of Urology
21 VCU Health
22 Richmond, VA, USA
23 ricautor@gmail.com
24
25 References: 11
26 Word count: 1443 (excluding abstract, references and legends)
27 Keywords: Bladder cancer; COVID-19; Kidney cancer; Penile cancer; Prostate cancer; Testicular
28 cancer, robotic surgery
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1 As of mid-June 2020, over 8,000,000 confirmed SARS-CoV-2 (COVID-19) cases and 460,000
2 deaths have been recorded with USA, UK and Italy being among the most affected countries for a variety
3 of reasons. This sudden, dramatic, and unexpected surge of the pandemic resulted in hospital
4 overcrowding and shortage of intensive care unit (ICU) beds, creating a global crisis at different levels in
5 health care systems worldwide1. Thus, there has been an immediate need to respond in a timely manner to
6 this unexpected scenario on a national and international level by re-allocating and optimizing resources,
7 structures, equipment, and personnel. As many other specialties, Urology has been impacted at different
8 levels2,3. A decline in number of elective surgeries was observed across the country, with peaks of over
9 94% reduction in most affected regions4. Outpatient clinics have been largely shifted to virtual consults5.
10 Interestingly, emergency rooms witnessed a significant decrease in hospital attendance for urological
11 emergencies6. Urologic surgical training has been negatively impacted7. The management of cancer
12 patients pose exceptional challenges in this scenario, given their immunosuppressed status and increased
13 risk of virus transmission. In the uro-oncology field, timely patient selection based on priority criteria for
14 surgical treatment has been advocated8.
15 We read with great interest the report from the Martini Clinic, a renowned high-volume center
16 for prostate cancer surgery in Germany9, where favorable outcomes could be obtained without
17 implementing rigorous screening measures, and by only applying strict protective hygiene standards. We
18 agree with the authors that, albeit remarkable, their experience might not applicable to countries with
19 different demographics, health systems, hospital resources (including ICU bed availibility), and testing
20 capabilities. In this regard, some key differences between Germany and Italy might explain the different
21 impact of the virus. As of April 20th, 2020, over 180,000 cases and 24,114 deaths had been recorded in
22 Italy, most of which in Northern Italy, with Lombardy being the leading region (over 66,000 cases and
23 12,376 deaths at that time point). Southern Italy was in general less affected, with Campania region
24 recording over 4,000 cases and only 309 deaths. According to the Robert Koch Institute, the average age
25 of those who tested positive for coronavirus in Germany was 47 years old, compared to 63 years old in
26 Italy. German had high testing rates early in the pandemics, which may have contributed to lower death
27 rates. Moreover, Germany was very meticulous tracking the contacts of those testing positive and
28 quarantined those individuals. This was not the case in Northern Italy, especially in the early phase.
29 Another key factor is the number of hospital beds in Germany, a total of 497,000 for general and acute
30 care (by contrast, the UK has 101,255). A recent survey by the OECD found that before the crisis
31 Germany had 33.9 ICU beds per 100,000 people, compared with 9.7 in Spain and 8.6 in Italy.
32 We would like to describe our experience matured at a high-volume cancer center in Southern
33 Italy during the peak of the early phase of COVID-19 pandemic, and to illustrate how a planned re-
34 organization of the hospital and local (regional) health care system allowed to avoid major disruption of
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1 most commonly performed uro-oncologic surgical procedures during this period. We looked at the
2 surgical procedures for urologic cancers performed at Fondazione "G. Pascale" IRCCS (Naples, Italy)
3 from March 2nd to April 20th2020. A workflow was established with the aim of optimize outcomes and
4 minimize risk of transmission. Each case was evaluated by a multidisciplinary team consisting of a
5 urologic surgeon, a genitourinary medical oncologist, and an anesthesiologist. Intervention priorities were
6 determined based on the severity of the disease, its risk of its progression, also considering length of time
7 in the waiting lists, disease related symptoms, and anesthesiologic risk, to minimize the risk of admission
8 to the ICU unit. At the time of pre-hospitalization, before being subjected to further consultations, all
9 patients were assessed by means of nursing triage so that body temperature was measured, presence of
10 COVID-19 symptoms were ruled out, as well as possible contact with COVID-19 positive patients in the
11 previous 15 days. Starting April 1st, 2020, rapid blood testing was made available to verify the presence of
12 IgG-IgM. Asymptomatic COVID-19 +ve patients were quarantined home.
13 In general, robotic surgery was preferred over open surgery whenever possible to minimize
14 surgical invasiveness and morbidity and minimize hospital stay. In the ward and in the OR, use of
15 appropriate PPE was strictly adopted, similarly to what was implemented at Martini Cinic9. All patients
16 had surgical masks, and all health care workers were provided with FFP2 masks (the European
17 counterpart of N95 in the US). Anesthesia team members were also wearing face shields in addition to
18 FFP2 masks, and intubations were being performed with glidescope assistance, and using a protective
19 plastic intubation. Moreover, steps were taken to minimize CO2 release, including use of filtered
20 insufflation systems allowing to work with low pressure (<10 mmHg) pneumoperitoneum.
21 Overall, 93 patients underwent a urologic surgical procedure, and 38 of these were done
22 robotically (40.8%). Mean age of patients was 65yo with a mean ASA score of 2. The most common
23 procedure was TURB (22 cases; 23%) whereas radical prostatectomy was the most common robotic
24 procedure (18% of total). A similar number of procedures, 96 overall, of which 31 robotic (30%), had
25 been performed in the same period of 2019. Overall, there were no differences in terms of main surgical
26 outcomes (operative time, blood loss, length of stay, complication rates) between the two time periods.
27 Only one patient developed fever and reduced oxygen saturation on postoperative day 3 and was found to
28 have lymphocytopenia. Chest x-ray and oropharyngeal swab confirmed COVID-19. The patient had
29 undergone a radical cystectomy, and surgical course was uncomplicated except for this respiratory
30 complication. He was isolated and then transferred to a COVID-19 hospital within the regional health
31 care system where he was discharged home after 3 weeks with two consecutive negative testing. Patient
32 did not suffer respiratory sequalae and he is being followed as outpatient. The two patients who shared the
33 same room, as all the health care workers who had contact with the patient, tested negative.
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1 Risk identification and timely diagnosis and transfer of COVID-19+ or suspect patients allowed a
2 minimal impact on our surgical activity. Healthcare in Italy is organized on a regional basis. In our region
3 (Regione Campania), with a population of about 5.8 million people, it was decided to restructure the
4 regional health system and create “COVID hospitals” for the acute management of symptomatic COVID-
5 19 patients. Selected (major) hospitals were provided with “purpose-built” wards specifically reserved for
6 COVID-19 patients, but they could still offer, to a limited capacity, regular ward for elective (mostly
7 emergent) cases. Ours was the only “free standing” regional cancer center which was kept “COVID-free”.
8 This allowed an optimal triage of incoming patients, some of which referred from other hospitals, with the
9 possibility of immediately transferring those testing positive to “COVID hospitals”, thus avoiding
10 disruption of a timely management of non-COVID cancer cases (Figure 1).
11 In addition, a preference was given to robotic surgery whenever possibile to minimize hospital
12 stay as well as surgical team’s contact with patient's fluids. To date no transmission of the virus has been
13 described during laparoscopic procedures, and this remains open for debate, as recently pointed out in a
14 review by the Society of Robotic Surgery in this same journal10. It is also worth mentioning that the only
15 urologic emergency managed at our Center is obstructive uropathy secondary to oncological disease,
16 which is an additional element allowing to maintain pre-established workflow while minimizing the risk
17 of transmission.
18 There are both similarities and differences between our experience and that reported by
19 Würnschimmel et al9. As discussed, there has been a different impact of the pandemic in Germany versus
20 Italy. While the Martini Clinic is a University affiliated private clinic exclusively dedicated to prostate
21 cancer treatment, our hospital is a public “free standing” cancer center where all genitourinary
22 malignancies are treated. Our German colleagues initially did not perform COVID-19 screening on
23 routine basis, but rather relied on patient history prior to admission, whereas we adopted in-hospital
24 screening for asymptomatic patients early on. In this regard, we implemented initially oropharyngeal
25 swab (RT-PCR) swab, and soon after antibody (IgG/IgM) blood test, whereas CT chest, which has been
26 advocated as screening tool11, was not used.
27 Overall, our experience shows that appropriate health network and hospital re-organization,
28 multidisciplinary collaboration, careful patient selection, and adoption of safety protocols, allows to
29 safely preserve the flow of uro-oncological surgical procedures during this COVID-19 era. This translates
30 into a timely and effective treatment of genitourinary cancer patients. Moreover, in this scenario, robotic
31 surgery should be considered in Centers with high volume and surgical expertise.
32
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1 References
2 1. Boccia S, Ricciardi W, Ioannidis JPA. What Other Countries Can Learn From Italy During the COVID-19
3 Pandemic [published online ahead of print, 2020 Apr 7]. JAMA Intern Med.
4 2020;10.1001/jamainternmed.2020.1447. doi:10.1001/jamainternmed.2020.1447
5 2. Puliatti S, Eissa A, Eissa R, et al. COVID-19 and urology: a comprehensive review of the literature. BJU
6 Int. 2020;125(6):E7‐E14. doi:10.1111/bju.15071
7 3. Ficarra V, Novara G, Abrate A, et al. Urology practice during COVID-19 pandemic. Minerva Urol Nefrol.
8 March 2020. doi:10.23736/S0393-2249.20.03846-1
9 4. Rocco B, Sighinolfi MC, Sandri M, et al. The dramatic COVID-19 outbreak in italy is responsible of a
10 huge drop in urological surgical activity: A multicenter observational study [published online ahead of
11 print, 2020 Jun 18]. BJU Int. 2020;10.1111/bju.15149. doi:10.1111/bju.15149
12 5. Patel S, Douglas-Moore J. A reflection on an adapted approach from face-to-face to telephone
13 consultations in our Urology outpatient department during the COVID-19 pandemic - a pathway for
14 change to future practice? BJU Int. 2020 May 29. doi: 10.1111/bju.15119. Epub ahead of print. PMID:
15 32469096.
16 6. Novara G, Bartoletti R, Crestani A, De Nunzio C, Durante J, Gregori A, Liguori G, Pavan N, Trombetta C,
17 Simonato A, Tubaro A, Ficarra V, Porpiglia F; Research Urology Network (RUN). Impact of COVID-
18 19 pandemic on the urologic practice in the emergency departments in Italy. BJU Int. 2020 May 14.
19 doi:10.1111/bju.15107. Epub ahead of print. PMID: 32407585.
20 7. Porpiglia F, Checcucci E, Amparore D, Verri P, Campi R, Claps F, Esperto F, Fiori C, Carrieri G, Ficarra
21 V, Mario Scarpa R, Dasgupta P. Slowdown of urology residents' learning curve during the COVID-19
22 emergency. BJU Int. 2020 Jun;125(6):E15-E17. doi: 10.1111/bju.15076. Epub 2020 Apr 28. PMID:
23 32274879.
24 8. Campi R, Amparore D, Capitanio U, et al. Assessing the Burden of Nondeferrable Major Uro-oncologic
25 Surgery to Guide Prioritisation Strategies During the COVID-19 Pandemic: Insights from Three Italian
26 High-volume Referral Centres. Eur Urol. April 2020. doi:10.1016/j.eururo.2020.03.054
27 9. Würnschimmel C, Maurer T, Knipper S, et al. Martini-Klinik experience on prostate cancer surgery during
28 the early phase of COVID-19 [published online ahead of print, 2020 May 18]. BJU Int.
29 2020;10.1111/bju.15115. doi:10.1111/bju.15115
30 10. Porter J, Blau E, Gharagozloo F, et al. Society of Robotic Surgery Review: Recommendations Regarding
31 the Risk of COVID-19 Transmission During Minimally Invasive Surgery [published online ahead of
32 print, 2020 May 8]. BJU Int. 2020;10.1111/bju.15105. doi:10.1111/bju.15105
33 11. Ai T, Yang Z, Hou H, et al. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019
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35 Radiology. 2020;200642. doi:10.1148/radiol.2020200642
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1 Figure 1. Implemented workflow to optimize surgical management of genitourinary cancer patients at a
2 COVID-free hospital (Istituto Nazionale Tumori IRCCS “Fondazione G. Pascale”, Naples, Italy).
3 Legends: GU=genitourinary; MD=multidisciplinary; PPE=Personal Protective Equipment
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Figure 1. Implemented workflow to optimize surgical management of genitourinary cancer patients at a
COVID-free hospital (Istituto Nazionale Tumori IRCCS “Fondazione G. Pascale”, Naples, Italy). Legends:
GU=genitourinary; MD=multidisciplinary; PPE=Personal Protective Equipment
338x190mm (96 x 96 DPI)
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