This document provides preliminary recommendations for prioritizing urologic surgeries during the COVID-19 pandemic. It suggests prioritizing surgeries where delays may affect patient survival, such as for aggressive urologic cancers. It also suggests alternatives to surgeries that may spare ventilator use, and considers how common urologic treatments may impact patients during an outbreak. The recommendations are meant to help decrease demands on critical hospital resources while avoiding compromised patient outcomes whenever possible. Local tailoring is still needed based on available resources and situations.

1. European Urology
CONSIDERATIONS IN THE TRIAGE OF UROLOGIC SURGERIES DURING THE
COVID-19 PANDEMIC
--Manuscript Draft--
Manuscript Number: EURUROL-D-20-00380
Article Type: Editorial
Keywords: COVID-19; elective surgery; pandemic response
Corresponding Author: David Canes, MD
Lahey Clinic
Burlington, MA United States
First Author: Kristian D Stensland, MD, MPH
Order of Authors: Kristian D Stensland, MD, MPH
Todd M. Morgan, MD
Alireza Moinzadeh, MD, MHL
Cheryl T. Lee, MD
Alberto Briganti, MD, PhD
James Catto, MB, ChB, PhD, FRCS
David Canes, MD
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Title Dr.
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6. March 15, 20201
2
CONSIDERATIONS IN THE TRIAGE OF UROLOGIC SURGERIES DURING THE COVID-193
PANDEMIC4
Kristian D. Stensland MD MPH1
; Todd M. Morgan MD2
; Alireza Moinzadeh MD MHL1
; Cheryl T.5
Lee MD3
; Alberto Briganti MD PhD4
; James Catto MB ChB PhD FRCS5
; David Canes MD1
6
7
1
Division of Urology, Lahey Hospital and Medical Center8
2
Department of Urology, University of Michigan;9
3
The Ohio State University;10
4
Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Vita-Salute San11
Raffaele University, Milan, Italy;12
5
Academic Urology Unit, The University of Sheffield13
14
As hospitals begin bracing for the possibility of surge demand for ventilator-level care for COVID-15
19 cases, the possibility of having to cancel elective surgeries to increase access to care is real.16
Many hospitals, and the American College of Surgeons, are recommending cancellations of17
elective surgeries. [1] The term “elective” in this setting is inherently vague and open to18
interpretation. As a result, urologists and hospitals throughout the world will have to make their19
own difficult decisions about which surgeries should continue under the current circumstances.20
While hospital systems and/or governments may request that “elective procedures” be delayed21
until the strain on the hospital system from COVID-19 is decreased, the characteristics of an22
“elective” procedure in urology are context dependent and have not been well defined in the23
current crisis.24
25
Lessons learned from Singapore, Asia and some European countries will be important in helping26
us respond to these challenging demands.[2] The choice of urgent or emergent surgeries that27
should still occur will depend upon capacity and demand, but must also be counterbalanced by28
the effects of delaying surgery. This is particularly true for patients with urological cancers and29
complicated stones. Urologists can help by decreasing the demand for ventilators, personal30
protective equipment, and other critical hospital and human resources by minimizing surgeries31
without compromising patient outcomes whenever possible. As a community, we must also weight32
the impact of non-surgical therapies such as systemic chemotherapy, which will leave patients at33
greater risk for contracting and potentially succumbing to COVID-19.34
Manuscript

7. 35
Will the global pandemic change the short term progression and/or mortality rates for aggressive36
urologic cancers? And will this affect the in-hospital mortality and complication rates of frail37
patients with aggressive genito-urinary malignancies? Prior data on delays to care are the best38
current guide by which we can begin to select cases to prioritize in the face of acutely decreased39
resources and diversion of operative resources to care for COVID-19 patients.40
41
We have put together preliminary recommendations in that regard and discuss the rationale for42
these difficult decisions. These suggestions were curated with input from multiple departments in43
the United States and Europe. In general, consideration should be made for non-surgical44
treatments when available or deferral of surgery until demand for ventilators and inpatient beds45
fall, where possible.46
47
The following is a suggested list of surgeries that should be prioritized if COVID-19 surges warrant48
cancellation of most elective surgery. These recommendations, which can be applied in the49
current and any future situation where ventilators and other operating room resources are scarce,50
prioritize moving forward with cases where evidence suggests that even short term delays may51
affect patient survival. Secondarily, we suggest alternatives for the management of common52
urgent or emergent urologic procedures that may spare the use of ventilators, and consider the53
use and impact of common urologic treatments on patients during an infectious outbreak. Finally,54
while we do not incorporate patient age and frailty into these recommendations, the risk of a post-55
operative COVID-19 infection and its potential impact on a patient’s post-operative course should56
also be considered.57
58
As with all guidelines, these recommendations must be tailored to locally available resources and59
situations. This document reflects preliminary expert opinion from this group, and by no means60
should these recommendations be considered rigid or all-encompassing. It is our hope that this61
preliminary evidence and opinion may provide a starting point for discussions to continue at a62
local level. Further, it is also possible for other surgical service lines to use these urology63
recommendations as a framework in creating their own specialty specific recommendations.64
65

8. 66
ONCOLOGY
Condition
Recommended
Surgeries
Rationale
Average Length of
Stay
Bladder
cancer
● Cystectomy for MIBC,
regardless of receipt
of neoadjuvant
chemotherapy
● Cystectomy for CIS
refractory to 3rd
Line
therapy
● Delaying cystectomy for
MIBC by 90 days
increases pN+ rate[3],
decreases overall and
progression free survival
[4], and higher
pathologic stage[5]
● 5-8 days (US)
[6,7]
● TURBT for suspected
cT1+ bladder tumors
● cT1 tumors are
understaged in up to
50% of cases,
presenting significant
risk of missed MIBC[8]
● Outpatient
procedure
Testicular
cancer
● Orchiectomy for
suspected testicular
tumors
● Post-chemotherapy
RPLND
● Favor chemotherapy
or radiation rather
than RPLND when
clinically appropriate
● Limited data on survival
with delay to
orchiectomy[9];
however, orchiectomy is
an outpatient procedure
with potential overall
survival benefit and
should be prioritized[10]
● To spare a ventilator and
inpatient stay (RPLND),
radiation post-
orchiectomy can be
encouraged when
surveillance is not an
option. Chemotherapy
use should be balanced
by concern for
immunosuppression and
increased risk of COVID-
19 infection/sequelae
● Orchiectomy:
outpatient
procedure
● RPLND: 4-6
days (open) [11]
1-3 days
(minimally
invasive)[12]
Kidney
cancer
● Nephrectomy for
cT3+ tumors,
including all patients
● More advanced renal
tumors, particularly with
associated vein thrombi,
● Nephrectomy: 3
days[14]

9. with renal vein and/or
IVC thrombi
● Planned partial or
radical nephrectomy
for cT1 masses
should be delayed or
other forms of ablative
approaches should
be considered in
selected patients
may progress rapidly
and create more
complicated surgeries
and adversely affect
survival and/or surgical
morbidity.[13]
● IVC
Thrombectomy:
5-10 days[15]
● Planned partial or
radical nephrectomy
for cT2 should be
considered for delay
based upon patient
specific
considerations, such
as age, morbidity,
symptoms, and tumor
growth rate
● For cT1-2 (stage I-II)
masses, delaying
surgery by 3 months has
not been associated with
decreased CSS or OS.
● 1-2 days
(minimally
invasive)
● 2-4 days (open)
[16]
Prostate
cancer
● Most prostatectomies
should be delayed
● Shared decision
making to consider
radiation therapy for
NCCN High risk
disease
● Surgery for NCCN
high risk if patient is
ineligible for radiation
● Selected high risk
patients as well as
those with
intermediate or low
risk cancer should be
delayed
● Surgery for NCCN high
risk may be considered
depending on patient
age and disease risk.
However, given the
availability of other
treatment modalities,
these surgeries may
receive lower
prioritization than others
on this list (as delay of
treatment up to 12
months, even for high
risk disease, may not
alter operative
outcomes, cancer
specific mortality, or
other outcomes).
● Biochemical recurrence
rates may be higher in
high risk men who delay
definitive treatment, but
there is not a clear cut-off
time for this treatment
benefit.[17–19]
● 0-2 days[20]
UTUC ● Nephroureterectomy ● 3 month delay to surgery ● 1-4 days[23]

10. for high grade and/or
cT1+ tumors
for UTUC has been
associated with disease
progression for all
patients, and with CSS
for patients with muscle
invasive disease.[9,21]
● Early stage, particularly
invasive, has a high risk
of being
understaged.[22]
Adrenal
tumors
● Adrenalectomy for
suspected ACC, or
tumors >6cm
● Consider delay of
adrenalectomy for
less suspicious
adrenal masses
(<6cm, favorable
imaging
characteristics)
● Adrenal masses larger
than 6 cm are much
more likely to harbor
carcinoma.
● ACC progresses rapidly,
and achieving R0 at
surgery provides the
best chance of survival.
Delay may decrease
resectability and affect
survival. [24]
● 0-1 days[25]
Urethral /
Penile
Cancer
● Clinically invasive or
obstructing cancers
● Data for these rare
tumors are limited.
Preventing lymph node
metastases may spare
significant morbidity from
patients. Further, partial
penectomy can be an
outpatient procedure
which has a diminished
strain on hospital
resources.
● Outpatient
procedure
ENDOUROLOGY/STONE DISEASE
Stones ● For
obstruction/infection:
● Ureteral stent
insertion
● Consideration for
awake, bedside
ureteral stent under
local
● Consideration for
nephrostomy tube
● When possible, stents
can be placed at the
bedside which spares a
ventilator [26]
● Nephrostomy tubes can
be placed under local
anesthesia, sparing a
ventilator.
● If neither option is
possible, an obstructed
or infected upper tract is
● Outpatient
procedure
(unless
concurrent
infection)

11. an emergency requiring
intervention.
Indwelling
ureteral stent
● Delay most
procedures
● Most stents left in place
even up to 6-12 months
can have simple stent
removal, and endoscopic
management of stents is
possible in most patients
up to 30 months of
indwelling time.[27]
● Outpatient
procedure
BPH ● Delay BPH
procedures
(TURP,HOLEP, PVP
Laser, etc)
● Urinary obstruction can
be adequately treated
via urethral or
suprapubic catheter
without need for a
procedure under
anesthesia
● TURP: 1-2
days[28]
FEMALE UROLOGY/INCONTINENCE
Stress urinary
incontinence,
interstitial
cystitis,
overactive
bladder,
neurogenic
bladder
● Delay all procedures
Nerve
Stimulator In
Place
● Second stage nerve
stimulator placement
or removal
● Nerve stimulators with
externalized leads may
have a high rate of
infection if left in place
and should be either
internalized via second
stage or removed, either
of which can be
performed under local
anesthesia.
Outpatient
Procedure
RECONSTRUCTIVE SURGERY
Fistula with
pelvic sepsis
● If systemic
symptoms, diversion
either with
catheters/drains, or
formal fecal stream
● Fistula repairs are
resource intensive and
should be delayed when
possible.
● Variable

12. diversion
● Delayed definitive
repair unless clinical
conditions would
require immediate
repair.
Artificial
Urinary
Sphincter
Explants
● Infected explants,
only
● Infected sphincters may
progress rapidly to
systemic infection and
should be addressed
emergently
● Variable
URETHRAL STRICTURE
Urethral
Obstruction
● Delay all procedures ● Suprapubic tube
placement or Foley
catheter placement in
association with urethral
dilation or incision is
urgent in those with
impending or complete
lower urinary tract
obstruction.
● Outpatient
Procedure
PROSTHETIC SURGERY
Erectile
dysfunction
● Infected explants only ● Infected implants may
progress rapidly to
systemic infection and
should be addressed
emergently.
● Variable
GENERAL UROLOGY
Soft tissue
infection
● Acute infections only;
scrotal abscesses,
Fournier’s gangrene
● Variable
Ischemia ● Shunting for Priapism
● Testicular Detorsion /
Orchidopexy
● 1-3 days
Hemorrhage ● Clot evacuation for
refractory gross
hematuria
● 1-3 days

13. Trauma ● Penile / testicular
fracture repair
● Outpatient
Procedure
● Ureteral injury
● Bladder Perforation
● 1-3 days
TRANSPLANT
Renal
transplantatio
n
● Deceased donor
transplants only
● Live donor
transplants delayed
● Deceased donor
transplants should
proceed without delay.
● Live donor transplants
should be delayed, both
to spare resources and
to delay the requisite
immunosuppression on
the recipient, which may
lead to a greater impact
of COVID-19 infection.
● 4-8 days[29]
PEDIATRICS
Acute torsion ● Scrotal exploration,
orchidopexy
● Outpatient
Procedure
GU
obstruction
● Foley catheter /
suprapubic tube
placement
● Outpatient
Procedure
INFERTILITY
● Delay all procedures
67
68

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