Prioritising urological surgery in the COVID-19 Era: A global reflection on guidelines

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Education

Prioritising

Urological

Surgery

in

the

COVID-19

Era:

A

Global

Reflection

on

Guidelines

Stavros

Gravas

*

,

Georges

Fournier

,

Mototsugu

Oya

,

Duncan

Summerton

,

Roberto

Mario

Scarpa

,

Piotr

Chlosta

,

Ioannis

Gkialas

,

Li-Ping

Xie

,

Nur

Rasyid

,

Damien

Bolton

,

Reynaldo

Gomez

,

Laurence

Klotz

,

Sanjay

Kulkarni

,

Simon

Tanguay

,

Jean

de

la

Rosette

,

on

behalf

of

the

SIU

Board

of

Directors

a_{DepartmentofUrology,FacultyofMedicine,SchoolofHealthSciences,UniversityofThessaly,Larissa,Greece;}b_{DepartmentofUrology,HopitaldelaCavale}

Blanche,UniversityofBrest,Brest,France;c_{DepartmentofUrology,KeioUniversitySchoolofMedicine,Tokyo,Japan;}d_{DepartmentofUrology,University}

HospitalsofLeicesterNHSTrust,Leicester,UK;e_{DepartmentofUrology,UniversitàCampusBiomedico,Rome,Italy;}f_{DepartmentofUrology,Jagiellonian}

University_—MedicalCollege,Krakow,Poland;g_{DepartmentofUrology, AnticancerHospitalofAthens}

“AgiosSavvas_”,Athens,Greece;h_Departmentof

Urology,First AffiliatedHospital, ZhejiangUniversitySchoolofMedicine,Hangzhou,China;i_{DepartmentofUrology, Facultyof Medicine,Universitas}

Indonesia,CiptoMangunkusumoGeneralHospital,Jakarta,Indonesia;j_{DepartmentofUrology,AustinHealth,Heidelberg,VIC,Australia;}k_Universidad

AndresBello,HospitaldelTrabajador,Santiago,Chile; l_{DivisionofUrology,Sunnybrook HealthSciences Centre,Toronto,Ontario,Canada;} m_Kulkarni

ReconstructiveUrologyCenter,Pune,India;n_{DepartmentofSurgery,DivisionofUrology,McGillUniversity,Montreal,QC,Canada;}o_{DepartmentofUrology,}

FacultyofMedicine,IstanbulMedipolUniversity,Istanbul,Turkey a v a i l ab l e a t w w w . s c i e n c e d i r e c t . c o m

j o u r n a l h o m e p a g e : w w w . e u r o p e a n u r o l o g y . c o m / e u fo c u s

Articleinfo Articlehistory:

AcceptedJune9,2020

AssociateEditor:MalteRieken

Keywords: Coronavirus COVID-19 Guidelines Pandemic Practicemanagement

Severeacuterespiratory

syndromecoronavirus2

Urology

Abstract

Background: Determining whethermembersfollow guidelines,includingguidelines prepared to help direct practice management during the coronavirus disease2019 (COVID-19)pandemic,isanimportantgoalformedicalassociations.

Objective: Todeterminewhetherpracticeofurologistsisinlinewithguidelinesforthe management of commonurologicalconditions duringtheCOVID-19pandemic pro-ducedbyleading(inter)nationalurologicalassociations.

Design,setting,andparticipants: Self-selectedurologistscompletedavoluntarysurvey availableonlinefromMarch27toApril11,2020anddistributedgloballybytheSociété Internationaled’Urologie.

Outcomemeasurementsandstatisticalanalysis: Responsestotwosurveyquestionson the(1)managementof14commonurologicalproceduresand(2)priorityscoringof 10commonurologicalprocedureswereevaluatedbypracticesettingandgeographical regionusingchi-squareandone-wayanalysisofvarianceanalyses,respectively.

Resultsandlimitations: Therewere2494respondentsfrom76countries.Oncological conditions were prioritised over benign conditions, and benign conditions were deferredwhenfeasibleandsafe.Oncologicalconditionswiththegreatestmalignant potentialwereprioritisedoverlessaggressivecancers.RespondentsfromEuropewere leastlikelytopostponeandmostlikelytoprioritiseconditionsidentifiedbyguidelines asbeingofthehighestpriority.Respondents’priorityscoringofurologicalprocedures closelymatchedtheprioritiesassignedbyguidelines.Themainlimitationofthisstudyis thatrespondentswereself-selected,andaccesstothesurveywaslimitedbylanguage andtechnologybarriers.

*Correspondingauthor.DepartmentofUrology, FacultyofMedicine,SchoolofHealthSciences, UniversityofThessaly,Larissa,Greece.Tel.:+302413502983.

E-mailaddress:sgravas2002@yahoo.com(S.Gravas).

https://doi.org/10.1016/j.euf.2020.06.006

1. Introduction

Guidelinesaredevelopedthroughevaluationandsynthesis

ofthebest availabledata,ideallyincludingavailable

ran-domisedcontrolledtrialsandmeta-analyses,andrankedby

qualityofevidence.On rareoccasions,however,

practice-changing events occur that necessitate the provision of

guidancetohealthcaresystemsintheabsenceofdata.

Suchaneventisthecoronavirusdisease2019

(COVID-19) pandemic in2020, whichnecessitated rapid practice

changeinordertominimisethespreadofthesevereacute

respiratory syndrome coronavirus 2 (SARS-CoV-2) virus

amongpatientsandhealthcareworkers,andtoensurethat

adequateresourcesareavailabletotreatanunprecedented

influxofCOVID-19patients.Toprovideguidancetohealth

careprofessionals globally,medical associationsprepared

anddisseminatedguidelinesforpatients’carerapidly

dur-ingtheCOVID-19pandemic.Intheabsenceofdatatoguide

decision making, theseguidelines were developed based

largelyon expertconsensus. TheEuropeanAssociationof

Urology (EAU) Guidelines Office commissioned a Rapid

Reaction Group to facilitate the development of adapted

guidelinestoassisturologistsinternationally.TheAmerican

Urological Association took a different approach and

adoptedthe more general American College of Surgeons

(ACS)guidelines.

Wehypothesisedthaturologistsworldwidehave

chan-gedtheirpatients’managementduetoCOVID-19.Ouraim

wastoassess whethercurrentpractice isinlinewiththe

COVID-19guidelines.Thiswillclarifywhetherthepresent

guidelineshavepracticalutilityintheclinicalsetting,asthe

pandemicmayinfluence medicalpracticeformonthsand

possiblyyears. Suchinformation canprovide insightinto

the development of useful and effective guidelines for

futurepandemicsandglobalemergencies.

2. Patientsandmethods

Thisstudyisananalysisofasurveydevelopedandconductedbythe SociétéInternationaled’Urologie(SIU).Itincludesmultiple-choice ques-tionsaboutrespondentdemographicsandgeneralpracticechangein responsetoCOVID-19,aswellasquestionsabouteducationalneedsand concern about contracting COVID-19. These are reported separately because they represent different domains. This analysis specifically addressesresponsestoquestionsabouttheapproachtoand prioritisa-tionofspecificprocedures(ie,questions11and12).Thefullsurveyhas beenpublished[1]andisavailableasAppendix1athttp://www.mdpi. com/2077-0383/9/6/1730/s1.

ThesurveywasopenedonMarch27,2020andclosedonApril11, 2020.ItwasadministeredonlineusingtheAventriplatform.Thesurvey wasdistributedviae-mailto15252contacts(membersand nonmem-bersofSIU)fromtheSIUeNewsmailingdistributionlist.No compensa-tionwasofferedforitscompletion.Allresponseswereanonymous.

InordertofacilitatetheanalysisoftheimpactofCOVID-19onhealth caresettingsasitspreadfromeasttowest,respondentsweregrouped into the following regions:East/Southeast Asia andnearby regions, West/SouthwestAsiaandnearbyregions,Europe,Africa,NorthAmerica, andSouthAmerica.Thelistofcountriesincludedineachregionhasbeen presentedinanotherpublication[1]andisavailableasAppendix2at http://www.mdpi.com/2077-0383/9/6/1730/s1.

To determine whether responses to the survey reflect currently available guidelines for adaptation ofpractice during the COVID-19 pandemic,severalleadingguidelinesinEnglishlanguagewereevaluated andsummarisedbykeyrecommendations(Tables1and2)[2–10]. 2.1. Statisticalanalysis

Participantsindicatedwhethertheymanageeachof14common uro-logicalproceduresbypostponingit,performingitasinthepast,usingan alternativetechnique(eg,minimallyinvasiveprocedure,chemotherapy, orradiotherapy),includingitinthesurgicalprioritylist,orreferringitto anothercentre.Omnibuschi-squaretestswereusedtocomparewhether the managementofthese14 proceduresvariedamong geographical regionsandpracticesettings.Thestatisticalsignificancethresholdfor these analyses was Bonferroni corrected for multiple comparisons, yieldingacriticalalphathresholdof0.004.

Statisticallysignificantdifferencesofclinicalinterestwerefurther explored by calculating,for each cell in each contingency table,its adjusted standardised residual.Conceptually, these arethe Z-trans-formeddifferencesbetweentheexpectedpercentageforthatcellunder thenullhypothesisandtheobservedpercentage[11].Byexaminingthe adjustedstandardisedresiduals,wedeterminedwhichobservedcells showedahigher/lowerpercentagethanexpected.Thestatisticalsigni fi-cance threshold forthe adjustedstandardised residualswithin each contingencytablewasBonferronicorrectedforthenumberofresiduals calculatedwithinthattable;thisyieldedathresholdofZ=2.94 (corre-sponding toanalphaof0.003) foreachprocedurecrossedwith the practicesettingfactorandathresholdofZ=3.14(correspondingtoan alphaof0.002)foreachprocedurecrossedwiththeregionfactor.

Participantsalsoratedthepriorityof10commonurological proce-duresonascaleof1(lowestpriority)to10(highestpriority).Omnibus one-wayanalysesofvariance(ANOVAs)andfollow-uppairwise com-parisonswereusedtocomparethepriorityratingsofthese10procedures amonggeographicalregionsandpracticesettings.Theone-wayANOVAs were Bonferroni corrected for multiple comparisons, yielding an adjustedalphalevelof0.005.Thepairwisecomparisonswithineach one-wayANOVAwerealsoBonferronicorrected,yieldingalpha thresh-oldsof0.017forcomparisonswithinthepracticesettingand0.003for comparisonswithinaregion.AnalysiswasconductedusingSPSSversion 26.0(IBMCorp.,Armonk,NY,USA).

Conclusions: Prioritisationandmanagementofurologicalproceduresduringthe COVID-19pandemicareinlinewithcurrentguidelines.Thegreatestagreementwasreportedin Europe.Observeddifferencesmayberelatedtolimitedresourcesinsomesettings.

Patientsummary: Whendecidinghowbest totreat patientsduring thecoronavirus disease 2019 (COVID-19) pandemic, urologists are taking into account both expert recommendationsandtheavailabilityofimportantlocalresources.

©2020EuropeanAssociationofUrology.PublishedbyElsevierB.V.Allrights reserved. EUROPEAN UROLOGYFOCUS 6(2020)1 104–1 1 10 1105

3. Results

3.1. Managementofcommonurologicalconditions

Atotalof2494urologistsfrom76countriescompletedthe

survey.Theresponseratewas16.35%.Althoughthiswasa

self-selected, nonrepresentative, nonprobability sample,

thelargenumberofparticipantsandtheirrepresentation

fromaroundtheworldallowsustodrawinferencesabout

urologistsbroadly.

AsseeninFigure1,nononcologicalprocedures(ie,benign

conditions, surgery forbenign prostatichyperplasia [BPH],

urodynamics,stonemanagement,andcystoscopy)were

post-poned ormanagedvia alternativeoptionsmoreoftenthan

oncologicalprocedures(ie,prostaticbiopsy,radical

prostatec-tomy,retroperitoneallymphnodedissection[RPLND],radical/

Table1–SummaryofEAU[2],BAUS[5–10],andUSANZ[4]guidelinerecommendationsforprioritisationofnononcologicalurological proceduresa,b_. EAUguidelines Priority(1) BAUSguidelines Stages(2) USANZguidelines Urgentintervention(3)

Urodynamics Low 1 Defer

BPHsurgery Low 1 Defer

Otherbenignconditionsc

Low 1 Defer

Removalofadouble-Jstent LowtoIntermediatebasedon double-J–relatedsymptoms

Delayifpossible Defer

Stonemanagement (withoutinfection)

Fromlowtohighbasedon symptoms

1(ElectiveURSandPCNL) 3(URSwithstentorureteric stones)

Forsymptomaticstones

Cystoscopy Macroscopichaematuria:high F/Uwithouthaematuria:from Lowtointermediatebasedon riskgroup

1 F/Uforhigh-riskgroup

Diagnosticwhenabnormal radiologyorabnormal cytology

ACS=AmericanCollegeofSurgeons;BAUS=BritishAssociationofUrologicalSurgeons;BPH=benignprostatichyperplasia;EAU=EuropeanAssociationof Urology;F/U=follow-up;PCNL=percutaneousnephrolithotomy;TVT=tension-freevaginaltape;URS=ureteroscopy;USANZ=UrologicalSocietyofAustralia andNewZealand.

a

ACSguidelinesarenotincludedbecausetheydidnotrefertospecificprocedures.

b _{1—EAUpriorities:low,clinicalharmveryunlikelyifpostponedfor6mo;intermediate,notrecommendedtopostponefor>3mo;high,thelasttocancel,}

preventdelayof>6wk;emergency,cannotbepostponedfor>24h.2—BAUSstages:1,firstcancellations;2,secondarycancellations;3,lasttobecancelled;4, emergencycasesonly.3—USANZpriorities:conditionsthatmaywarranturgentsurgicalintervention;conditionsnotproposedwereconsidereddeferrable.

c

Varicocele,hydrocele,circumcision,TVTs,etc.

Table2–SummaryofEAU[2],BAUS[5–10],andUSANZ[4]guidelinerecommendationsforprioritisationofoncologicalurological proceduresa,b_. EAUguidelines priority(1) BAUSguidelines Stages(2) USANZguidelines Urgentintervention(3) TURofbladdertumour Fromlowtohighbasedon

haematuriaandriskgroup

2(lowrisk) 3(highrisk)

High-riskgroup Radicalcystectomy Intermediate 2(lowrisk)

3(highrisk)

Urgent(ideallypriorneoadjuvant chemotherapyanddelayinsurgery afterdiscussionwithmedical oncologists)

Nephroureterectomy Highforhigh-riskpatients 2(lowrisk) 3(highrisk)

Urgent(considerneoadjuvant chemotherapy)

Prostaticbiopsy Fromlowtohighbasedonriskfor PCa

1(GAtransperineal)

2(LAtransperinealforhighPSA)

Onlyforsuspiciousprostatelesions orPIRADS4/5onpriorMRI Radicalprostatectomy

(localisedPCa)

Intermediatebutcanbepostponed untilafterpandemic

Defernewpatients 2(RARPs)

Onlyforaproportionofhigh-riskPCa patients

Radical/partialnephrectomy Fromlowtohighbasedonclinical stage

1(partial) 3(timesensitive)

ForlargeRCCs>7cm,orcomplicated withvenousthrombus

Radicalorchidectomy/ penectomy

Emergency 3 Urgent

RPLND High Deferandofferchemotherapy Urgent(deferralifsuggestiveof slowlygrowingmatureteratoma) ACS=AmericanCollegeofSurgeons;BAUS=BritishAssociationofUrologicalSurgeons;EAU=EuropeanAssociationofUrology;GA=generalanaesthetic;LA= localanaesthetic;MRI=magneticresonanceimaging;PCa=prostatecancer;PIRADS=ProstateImagingReportingandDataSystem;PSA=prostate-specific antigen;RARP=robot-assistedradicalprostatectomy;RCC=renalcellcarcinoma;RPLND=retroperitoneallymphnodedissection;TUR=transurethral resection;USANZ=UrologicalSocietyofAustraliaandNewZealand.

a

ACSguidelinesarenotincludedbecausetheydidnotrefertospecificprocedures.

b _{1—EAUpriorities:low,clinicalharmveryunlikelyifpostponedfor6mo;intermediate,notrecommendedtopostponefor>3mo;high,thelasttocancel,}

preventdelayof>6wk;emergency,cannotbepostponedfor>24h.2—BAUSstages:1,firstcancellations;2,secondarycancellations;3,lasttobecancelled;4, emergencycasesonly.3—USANZpriorities:conditionsthatmaywarranturgentsurgicalintervention;conditionsnotproposedwereconsidereddeferrable.

partialnephrectomy,nephroureterectomy,radicalcystectomy,

radialorchidectomy/penectomy,andbladder tumour

trans-urethralresection[TUR]). Thisapproach isinlinewith the

(inter)nationalguidelinerecommendations.

Chi-square analyses revealed significant variations in

responsefor eachprocedure bygeographicregion atp<

0.001(seeSupplementaryTable1).Follow-upexaminations

oftheadjustedstandardisedresidualsrevealedthat

respon-dentsfromEast/SoutheastAsiaconsistentlyreportedhigher

than expected rates of no change for all procedures. In

contrast,Europeanshadlowratesofnochangeforprostatic

biopsy, cystoscopy,urodynamics, BPH surgery, and

man-agementofkidneystonesandbenignconditions.

RespondentsfromEuropereportedhigherthanexpected

ratesofpostponementforproceduresdesignatedby

guide-linestobeoflowpriority(ie,allnononcologicalconditions

exceptforremovalofadouble-Jstent).

Forsevenof14proceduresdesignatedashigherpriority

byguidelines(ie,cystoscopy,bladdertumourTUR,

nephrec-tomy, nephroureterectomy, cystectomy, radial

orchidec-tomy/penectomy, andRPLND), Europeans reported lower

than expected rates of postponement and higher than

expected rates of inclusionon the priority list (data not

shown).

ForRPLND,referralstodedicatedcentreswerereported

athigherthanexpectedratesinEuropeandatlowerratesin

NorthandSouthAmerica.

Althoughtherewereanumberofstatisticallysignificant

differencesbypracticesetting,theseweredeemedtobenot

oftheoreticalinterestandarenotdiscussedfurther.

3.2. Prioritisationofcommonurologicalconditions

Figure2demonstratesthemedianandmeanpriorityscores

giventoeachofthe10commonurologicalproceduresby

respondents. Table 3liststherank order priorityof each

procedure,from1(mostimportant)to10(leastimportant),

amongrespondentsoverallaswellasbyregionandpractice

setting.

Surgeries for benignconditions wereranked lowestin

priority,followedbyBPHandmanagementofstone

condi-tionsnotassociatedwithinfection.Theseareinlinewith

theguidelinerecommendationspresentedinTables1and2,

which indicate that nononcology procedures should be

deferred,withlithiasisconsideredtobeofhigherpriority

thanBPH,dependingonclinicalcircumstances.

Among the oncological procedures, radical

prostatec-tomywasgiventhelowestpriority.Thisisalsoinlinewith

guidelines,whichindicatethatthissurgeryshouldbegiven

priorityonlyforhigh-riskpatients.

Notable regionaldifferences wereobserved for radical

cystectomy(F5,2192= 39.766;p < 0.001),

nephroureterec-tomy(F5,2281=29.113;p<0.001),TURforbladdertumour

(F5,2348 = 11.009; p < 0.001), and radical orchidectomy/

1% 1% 3% 4% 16% 22% 16% 1% 1% 1% 1% 1% 3% 4% 2% 3% 5% 4% 2% 3% 3% 10% 21% 8% 9% 14% 7% 5% 85% 80% 79% 64% 53% 37% 56% 46% 32% 30% 23% 22% 16% 16% 11% _13% 12% 18% 23% 31% 19% _21% 23% _26% 30% 28% 37% 35% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

BN BPHS Uro SM Cys RJS PB RP RPLND RPN NU RC ROP TUR

P ropor  o n of res p ondents Procedure type

Minimally invasive/alternate Tx Refer Postpone Priorize No change

1% 4% 1% 10% 6% 7% 6% 22% 24% 34% 38% 35% 38% 40%

Fig.1–ApproachtothemanagementofcommonurologicalproceduresinthetimeofCOVID-19.

BN=benignconditions;BPHS=surgeryforbenignprostatichyperplasia;COVID-19=coronavirusdisease2019;Cys=cystoscopy;NU=

nephroureterectomy;PB=prostaticbiopsy;RC=radicalcystectomy;RJS=removalofdouble-Jstent;ROP=radialorchidectomy/penectomy;RP= radicalprostatectomy;RPLND=retroperitoneallymphnodedissection;RPN=radical/partialnephrectomy;SM=stonemanagement(noinfection); TUR=transurethralresectionforbladdertumour;Tx=treatment;Uro=urodynamics.

penectomy (F5,2281 = 30.172; p < 0.001). There were no

significantdifferencesbypracticesetting.

Wheneachprocedureisplacedinrankorderofpriority

byregion(Table3),radicalcystectomywasratedaslower

priority inWest/SouthwestAsia thaninotherregions.In

Europe,NorthAmerica,andSouthAmerica,orchidectomy

wasgiventhehighestpriority,whichisinlinewithallthe

guidelines, but this was not the case in Asia or Africa.

Nephroureterectomy was ranked higher in Africa and

South/SoutheastAsiathaninotherregions.TURofbladder

tumourreceivedalowerpriorityratinginEuropeaswellas

intheacademicsetting.

Follow-uppairwisestatisticalanalysesrevealeda

signif-icantlylowermeanpriorityscoreforradicalcystectomyin

Table3–RankorderofpriorityforcommonurologicalproceduresatthetimeofCOVID-19byregiona_.

Procedure Total

(N=2494)

Region Practicesetting

Africa (n=209) E/SEAsia (n=441) Europe (n=1074) NorthAmerica (n=186) SouthAmerica (n=198) W/SWAsia (n=386) Academic (n=1161) Private (n=719) Public (n=614) Otherbenign conditionsb 1 1 1 1 1 1 1 1 1 1 BPHsurgery 2 2 2 2 2 2 2 2 2 2 Stonemanagement 3 3 3 3 3 3 3 3 3 3 Radical prostatectomy (localisedPCa) 4 5 4 4 4 4 4 4 4 4 RPLND 5 4 5 5 5 5 5 5 5 5 Radical/partial nephrectomy 6 6 6 6 6 6 7 6 6 6 Nephroureterectomy 7 9 9 8 7 7 8 8 7 7 Radicalcystectomy 8 8 8 9 8 8 6 9 8 8 TURofbladder tumour 9 10 10 7 9 9 10 7 10 9 Radical orchidectomy/ penectomy 10 7 7 10 10 10 9 10 9 10

BPH=benignprostatichyperplasia;COVID-19=coronavirus2019;E/SE=East/Southeast;PCa= prostatecancer;RPLND= retroperitoneallymphnode dissection;TUR=transurethralresection;W/SW=West/Southwest.

a

Rankorderfrom1to10:1=lowestpriority;10=highestpriority.

b _{varicocele,hydrocele,circumcision,TVTs,etc.}

1 1 5 5 6 7 8 8 8 9 1.88 2.39 4.56 5.37 5.88 6.52 7.21 7.29 7.45 7.57 0 1 2 3 4 5 6 7 8 9 10 BN BPHS SM RP RPLND RPN NU RC TUR ROP Prio rit y s c o re Procedue Median Mean (2.240) (2.739) (2.979) (2.042) (3.162) (2.858) (2.897) (3.043) (2.571) (2.889)

Fig.2–Medianandmean(SD)priorityscoresofcommonurologicalproceduresinthetimeofCOVID-19.Ratingscale:1–10;1=lowestpriority,10= highestpriority.

BN=benignconditions;BPHS=surgeryforbenignprostatichyperplasia;COVID-19=coronavirusdisease2019;NU=nephroureterectomy;RC=radical cystectomy;ROP=radialorchidectomy/penectomy;RP=radicalprostatectomy;RPLND=retroperitoneallymphnodedissection;RPN=radical/partial nephrectomy;SD=standarddeviation;SM=stonemanagement(noinfection);TUR=transurethralresectionforbladdertumour.

West/SouthwestAsiathaninallotherregions(p0.003for

all comparisons). Priority scores for orchidectomy were

significantlyhigherinEuropeandSouth America,thanin

Africaandboth Asian regions(p <0.001 forall

compar-isons).InNorthAmerica,itwasrankedsignificantlyhigher

thanEast/SoutheastAsia(p=0.001).

Amongthe10procedureslistedonthesurvey,

respon-dentsin eachregion ranked RPLND asmoderate priority

despitethefactthattheEAUcategorisesthisashighpriority

and Urological Society of Australia and New Zealand

(USANZ)as urgent.OnlyBritishAssociationof Urological

Surgeons(BAUS) guidelinesrecommend conducting

che-motherapyanddeferringtheprocedure.

4. Discussion

Theprovisionofevidence-basedcareisthecornerstoneof

health caresystems worldwide. Practice guidelines,

pre-pared by recognised experts and published by leading

professionalassociations,formthebackboneofefforts to

providethis.

The urological community became rapidly aware that

available practice guidelines lacked relevance during the

pandemiccrisis. Inresponse,many urologysocieties and

associationsdevelopedCOVID-19guidelines,outof

neces-sity,intheabsenceofobjectiveevidence.Thesenew

guide-linesaimtoprovidetoolstofacilitatedecisionmakingthat

minimise the riskfor both health careprofessionals and

patients.Theyalsoprovideablueprintforfuture

develop-ment of robust guidelines that address the present and

futurecrisissituations.

Themostimportantfindingfromthepresentsurveyis

theconfirmationofglobalvalidityoftheCOVID-19

guide-linespreparedbydifferent(inter)nationalsocietiesthrough

consensusandsupportedbythebestknowledgeavailable.

The recommendations for prioritisation by different

guideline bodieshave certain subtle nuances but, in the

vast majority of cases, offer the same recommendations

(Tables 1 and 2). These differences may be related to

resource limitations in local settings (eg, availability of

bloodproducts,intensivecareunit[ICU]beds,alternative

treatment methods, and operating room access) and

infrastructure.

Overall,responsesindicatethatcurrentpracticematches

withcurrentCOVID-19guidelines,withaggressive

malignan-ciesprioritised,lessaggressivecancersdeferredormanaged

usingalternativestrategies(whenpossible),andbenign

pro-cedurespostponed(unlessthisislikelytocauseharm)or

treated by alternativemeans (Fig.1). Notably, alternative

options are more readily available for benign conditions

(eg, double-J stent removal in operative setting can be

deferredintheoutpatientsettingunderlocalanaesthesia).

Amongalltheregions,Europeappearstobefollowingthe

guidelinesmostclosely.Thisregionreportedthehighestratesof

postponement ofprocedures categorised as low priorityby

guidelinesandthelowestrateofpostponementofprocedures

designatedashighpriorityorurgent.Forcystoscopy,bladder

tumourTUR,nephrectomy,nephroureterectomy,cystectomy,

radialorchidectomy/penectomy,andRPLND,allofwhichare

designatedashighprioritybyguidelines,Europeanswereless

likelytopostponeandmorelikelytoplacetheseonthesurgical

prioritylistthanrespondentsfrom otherregions.Referralto

dedicatedcentresforRPLNDwasalsoreportedmostoftenin

Europe. On the contrary, in East/Southeast Asia where the

pandemic isfurthestalong,participantsweremost likelyto

report that procedures are being conducted as before,suggesting

thattheirhealthcaresystemsarereturningtopre–COVID-19

states.

The second survey question,inwhichrespondentsrated how

commonurologicalproceduresshouldbeprioritised,addresses

theirlevelofknowledgeofcurrentguidelines,sinceitreflects

theirviewofhowtheseconditionsshouldbeprioritised.

Ourresultsindicateglobalunanimitythatbenign

condi-tionsareofthelowestpriority(Fig.2).Inaddition,

nephro-ureterectomy, cystectomy, and bladder tumourTUR were

scoredashighprioritybyrespondentsinallregions.These

arealltreatmentsfortransitionalcellcarcinomas,whichare

knownto havea highmalignantpotential andmay incur

suboptimal outcomes if treatments are delayed. This is

reflectedinallguidelinesthatrecognisetheseprocedures

asurgent/highpriority,particularlyforhigh-riskpatients.In

contrast,proceduresforprostatecancerandrenalcell

carci-nomawereratedasmoderatepriority,asgoodoutcomescan

stillbeachievedwithmanagementotherthansurgical

resec-tion(eg,active surveillance,medicaltherapy,radiation)in

appropriatelyselectedpatients.Respondents’prioritisation

scoresareinlinewithavailableCOVID-19guidelines.

ItisstrikingthattheAsianregionsandAfricadidnotrank

orchidectomyasthehighest-priorityprocedure,despitethe

factthatthisiswhatallguidelinesrecommendandthefact

thatthisprocedurecanbeperformedwithouttheneedfor

bloodtransfusion,prolongedhospitalisation,orICUstay.

In all regions, RPLND was rated as moderate priority

despite beinggivenhigh prioritybyallguidelinesexcept

thoseofBAUS(Table2).Thepotentialreasonsfortheneed

fortransfusionorICUstaycancontributetothisfinding,as

bothareresourcesthatmaybelimitedduringapandemic.

EAU and ACS guidelines recommend that hospitals and

surgical centres consider their logisticcapabilityto meet

patients’needswhenprioritisingsurgeries.

Asforthebenignconditions,stonetreatmentis

priori-tisedoverBPHmanagement.Thisisinlinewiththenew

COVID-19 guidelines and underscores a higher potential

threat fromstonedisease, thanfromvoiding complaints,

tothesafetyofpatients.

Guidelines cannot address differences in practice

betweenurologistsworkinginacademic,public,orprivate

settings. It is reassuring that there is no difference by

practice settingwhenprioritisingforthedifferentbenign

and malignantconditions (Table3). The sameis true for

regional differences. Overall, there is a striking level of

agreement in prioritising different surgical procedures,

eitherbenignormalignant.

The questionremains“whenorwill everpractice

nor-malise?” Oncethey do, an enormous backlogof patients

deferredduringthecurrenttriagemustbeaddressed.Can

thesenovelCOVID-19guidelinescontinuetobeuseduntil

conditionsnormaliseorwilltransitionguidelinesbemade?

This study has several limitations. It includedself-selected,

nonrepresentative, and nonrandom participants from all

aroundtheworld.Atthetimeofsurvey,regions/countries

wereatvaryingphasesofthepandemicthatmightresultin

differencesintermsofspeedofactionofadoptedmeasures

andstrategies.Thestrengthofthissurveyisthatitrepresents

aglobalandtimelysnapshotofthecurrentsituationinline

withtheproposedCOVID-19guidelines.Uponnormalisation

ofconditions,therewillbenoopportunityto confirmthe

validityoftheguidelinesinanotherformat.

5. Conclusions

Urologists’priorityrankingsforcommonurologicalprocedures

areinlinewiththemostcommonlyusedguidelinesforthe

managementofurologicalpatientsduringthepandemic.Actual

practicealsoseemstobeinagreementwithguideline

recom-mendations. Deviations from the guidelines likely reflect

regionaldifferencesinresources.EAUandACSguidelines

rec-ommendprioritisingsurgeriesbasedonlocalresource

availabil-ity, sothesepractices can beinterpreted notas afailure to

implementguidelinesbutas areflectionoflocal adaptation

toindividualcircumstances.RespondentsfromEuropereported

thehighestagreementwithguidelinerecommendations.

Authorcontributions:StavrosGravashadfullaccesstoallthedatainthe studyandtakes responsibilityfor the integrityof the dataandthe accuracyofthedataanalysis.

Studyconceptanddesign:Gravas,Bolton,Gomez,Klotz,Kulkarni, Tan-guay,delaRosette.

Acquisitionofdata:Gravas,Fournier,Oya,Summerton,Scarpa,Chlosta, Gkialas, Xie, Rasyid, Bolton, Gomez, Klotz,Kulkarni, Tanguay,de la Rosette.

Analysisandinterpretationofdata:Gravas,delaRosette. Draftingofthemanuscript:Gravas,delaRosette.

Criticalrevisionofthemanuscriptforimportantintellectualcontent: Four-nier, Oya, Summerton, Scarpa, Chlosta, Gkialas, Xie, Rasyid, Bolton, Gomez,Klotz,Kulkarni,Tanguay.

Statisticalanalysis:None. Obtainingfunding:None.

Administrative,technical,ormaterialsupport:None. Supervision:Gravas,delaRosette.

Other:None.

Financialdisclosures:StavrosGravascerti_fiesthatallcon_flictsof inter-est,includingspecificfinancialinterestsandrelationshipsandaf filia-tionsrelevanttothesubjectmatterormaterialsdiscussedinthe manu-script (eg, employment/affiliation, grants or funding, consultancies, honoraria,stockownershiporoptions,experttestimony,royalties,or patentsfiled,received,orpending),arethefollowing:None.

Funding/Support androle of the sponsor: The SIUdid not receive externalfundingforthisstudy.

Acknowledgements:The authorswouldlike toacknowledgesupport fromSIUCentralOffice,includingMerveilledeSouza,CarrieThompson,

MelissaSt-Onge,SusiePetrusa,ChristineAlbino,aswellasthe contri-butionsofAlisonPalkhivalaformedicalwritingandeditorialsupport, andMichaelBarlevforstatisticalsupport.

AppendixA. Supplementarydata

Supplementary material related to this article can be

found, in the online version, at doi:https://doi.org/10.

1016/j.euf.2020.06.006.

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