Considerations in the Triage of Urologic Surgeries During the COVID-19 Pandemic

Rise of long-distance urology transfer during the COVID-19 pandemic: Identifying factors to enhance transfers of care efficiency and clinical outcomes

OBJECTIVE

The objective of this study is to identify variables associated with clinical outcomes after urologic transfers before and during the COVID pandemic.

METHODS

After IRB approval, a retrospective chart review was performed on adult patients transferred to our institution from 01/01/2018 to 12/31/2019 ("pre-COVID") and from 01/02/2020 to 12/31/2022 ("COVID"). We identified demographics, origin hospitals, ICD-10 pre- and post-transfer diagnoses, distance of transfer, and post-transfer CPT codes.

RESULTS

During the study period, our adult urology service accepted 160 transfers with a mean patient age of 71 years. A total of 49/160 (30%) of subjects made up the "pre-COVID" cohort and 111/160 (70%) made up the "COVID" cohort. There were 11/111 (10%) transfers of >100 miles in the COVID period but 0/49 in the pre-COVID period (p = 0.02). Patients from the COVID period waited on average 1.2 days longer for a procedure after transfer compared to pre-COVID period (p = 0.03). The time until a patient's surgical procedure after transfer was a significant predictor of length of stay > 5 days (OR 1.91, CI 1.43 - 2.58, p < 0.01). Different diagnosis upon re-evaluation after transfer was associated with a decreased rate of subsequent readmission (OR 0.30, CI 0.09-0.97, p = 0.05).

CONCLUSIONS

Long-distance transfer, even >100 miles (which we termed "mega-transfers"), was a new pandemic-related phenomenon at our institution. Delays in definitive care and changes in diagnoses after transfer were associated with readmission and length of stay. Our findings illustrate the importance of inter-institutional communication, diagnostic accuracy, and post discharge planning when managing transfer patients.

Surgical Stone Trends from 2013 to 2021 in the US Medicare Population: Before and after the COVID-19 Pandemic

Introduction and Objective: In early 2020, as the SARS-Cov-2 (COVID-19) pandemic progressed, many institutions limited nonurgent surgical care. This coincided with a decade-long trend of increasing percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS) and decreasing shock wave lithotripsy (SWL) for surgical management of urolithiasis. Herein, we evaluate temporal stone surgery rates and surgeon volumes in the Medicare population and suggest how COVID-19 contributed to them. Methods: Retrospective analysis was conducted using the "Medicare Physician & Other Practitioners" database containing data from January 2013 to December 2021. Adult patients who underwent stone surgery were included. We evaluated surgeon characteristics and changes in case volumes over time adjusted for population. Results: In 2013, urologists performed 68,910 stone surgeries: SWL 42,903 (62%); URS 25,321 (37%); PCNL 686 (1%). Over the next 8 years, there was an average annual increase in URS (+13%) and PCNL (+13%) and decrease in SWL (-2%). In 2020, there was a 14% reduction in all stone cases: SWL (-25%); URS (-6%); PCNL (-8%). By 2021, case volumes recovered to pre-2020 levels, though SWL remained low: SWL 33,974 (34%); URS 64,541 (64%); PCNL 1764 (2%). From 2013 to 2021, the number of urologists performing SWL decreased (1718 to 1361) while URS and PCNL providers doubled (1,347 to 2,914 and 28 to 76, respectively). Conclusions: From 2013 to 2021, there was an increase in URS and PCNL and a decrease in SWL in the US Medicare population. The COVID-19 pandemic was associated with a decline in stone surgeries, particularly SWL. By 2021, PCNL and URS case numbers increased significantly with a smaller increase in SWL.

Is it safe to defer prostate cancer treatment? Assessing the impact of surgical delay on the risk of pathological upstaging after robot-assisted radical prostatectomy

INTRODUCTION

We sought to investigate whether surgical delay may be associated with pathological upstaging in patients treated with robot assisted radical prostatectomy (RARP) for localized and locally advanced prostate cancer (PCa).

MATERIALS AND METHODS

Consecutive firstly-diagnosed PCa patients starting from March 2020 have been enrolled. All the patients were categorized according to EAU risk categories for PCa risk. Uni- and multivariate analysis were fitted to explore clinical and surgical predictors of pathological upstaging to locally advanced disease (pT3/pT4 - pN1 disease).

RESULTS

Overall 2017 patients entered the study. Median age at surgery was 68 (IQR 63-73) years. Overall low risk, intermediate risk, localized high risk and locally advanced disease were recorded in 368 (18.2 %), 1071 (53.1 %), 388 (19.2 %) and 190 (9.4 %), respectively. Median time from to diagnosis to treatment was 51 (IQR 29-70) days. Time to surgery was 56 (IQR 32-75), 52 (IQR 30-70), 45 (IQR 24-60) and 41 (IQR 22-57) days for localized low, intermediate and high risk and locally advanced disease, respectively. Considering 1827 patients with localized PCa, at multivariate analysis ISUP grade group ≥4 on prostate biopsy (HR: 1.30; 95 % CI 1.07-1.86; p = 0.02) and surgical delay only in localized high-risk disease (HR: 1.02; 95 % CI 1.01-1.54; p = 0.02) were confirmed as independent predictors of pathological upstaging to pT3-T4/pN1 disease at final histopathological examination.

CONCLUSIONS

In localized high-risk disease surgical delay could be associated with a higher risk of adverse pathologic findings.

The Impact of SARS-CoV-2 on Patients With Lower Urinary Tract Symptoms (LUTS)

INTRODUCTION

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, the management of patients with lower urinary tract symptoms (LUTS) underwent dynamic adjustments in response to an evolving understanding of the virus's impact on different patient populations. Healthcare practitioners reevaluated therapeutic approaches for conditions like benign prostatic hyperplasia (BPH), considering the potential implications of this condition on the severity and progression of coronavirus disease 2019 (COVID-19). This study aims to investigate potential correlations between SARS-CoV-2 infection severity, exacerbation of LUTS, and BPH progression.

MATERIAL AND METHODS

This retrospective study includes patients hospitalized in our Urology Department between January 2021 and January 2023, presenting with both SARS-CoV-2 and BPH. Their ages ranged from 57 to 88 years, with a mean age of 65.4 years. The diagnosis of BPH relied on a diagnostic triad consisting of digital rectal examination, biological markers (including prostate-specific antigen (PSA) and free PSA, and ultrasound examination, with both conditions confirmed based on test results. Transurethral resection of the prostate (TURP) procedures utilized monopolar Karl Storz resection equipment, using sorbitol and bipolar Olympus devices for transurethral resection of the prostate in saline (TURPis). Haemostasia was performed using roller balls. Anticoagulation followed a prescribed scheme by cardiologists and infectious disease specialists. Statistical analysis was conducted using IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.

RESULTS

Among the 138 hospitalized patients affected by both BPH and COVID-19, 18 required emergency endoscopic procedures (specifically TURP or TURPis) to achieve hemostasis (Figures 1, 2). These individuals presented persistent hematuria despite conservative treatments. The mean duration of surgery was 57.9 minutes. Patients who underwent surgery had a longer average hospital stay compared to those who did not, with durations of 10.5 days versus 7.5 days, respectively. Additionally, urethrovesical catheter insertion was necessary in 29 cases due to acute urinary retention or worsening voiding symptoms during hospitalization. These patients are scheduled for further urological evaluation following the resolution of the COVID-19 episode. In a cohort of 53 patients for whom data were accessible, comparisons were made between the pre-COVID status and the levels of the International Prostate Symptom Score (IPSS), post-voiding residue (PVR), and quality of life (QoL). The findings revealed a mean pre-COVID IPSS value of 11.6 and a COVID-related value of 14.2, with a statistically significant difference noted (p < 0.05). The mean pre-COVID PVR was 42.3 cm2, whereas during the COVID-19 period, it measured 62.5 cm2, also exhibiting a significant difference (p < 0.05). Additionally, the QoL showed a mean pre-COVID-19 score of 2.4 and a COVID-19-associated score of 2.9, again demonstrating statistical significance (p < 0.05).

CONCLUSION

The onset of the SARS-CoV-2 pandemic posed novel challenges in the medical realm, impacting the approach to BPH management. A common practice was delaying treatment for chronic BPH until viral infection remission to reduce associated risks. Additionally, our study revealed a worse evolution in LUTS among individuals with severe COVID-19 symptoms.

Effects of first year COVID-19 pandemic on urology practice in three major Arab Countries: Sub-Analysis of a survey by Arab association of urology research group

BACKGROUND AND OBJECTIVES

The World Health Organization (WHO) declared the coronavirus disease-19 (COVID-19) pandemic on March 11, 2020. The health care system faced tremendous challenges in providing ethical and high-quality care. The impact of COVID-19 on urological practices varied widely worldwide, including in Arab countries. This study aimed to compare the influence of the COVID-19 pandemic on urology practice in Egypt, the KSA, and the UAE during the first year of the pandemic.

METHODS

This sub-analysis assessed the demographics and COVID-19's effects on urological practice in terms of adjustments to hospital policy, including outpatient consultations, the management of elective and urgent surgical cases, and the continuation of education across the three countries. The availability of personal protective equipment (PPE) and urologists' emotional, physical, and verbal intimidation during COVID-19 were also compared.

RESULTS

Regarding the impact on hospital policy, consultations replaced by telemedicine were significantly higher in the KSA (36.15%), followed by the UAE (33.3%), then Egypt (10.4%) (P = 0.008). Elective cases requiring ICU admission were 65.1% in Egypt, 45.2% in the KSA, and 58.2% in the UAE and were performed only in high-risk patients. PPE was freely available in 20.8% of the Egyptian hospitals compared to 83.3% in the KSA and 81.8% in the UAE. Online courses were significantly higher in Egypt (70.8%), followed by the UAE (53%) and the KSA (41.7%) (P = 0.02). Emotional intimidation was higher than verbal intimidation, representing 80%, 75.9%, and 76% in the UAE, KSA, and Egypt, respectively.

CONCLUSION

This sub-analysis outlined significant hospital policy changes across the three Arab countries. Exposure to emotional, verbal, and physical intimidation was observed. The development of teleconsultations and online platforms for educational purposes was observed.

Perioperative outcomes of penile prosthesis implantation in Germany: results from the GRAND study

We aimed to assess the recommended annual hospital volume for inflatable penile prosthesis implantation (PPI) and to provide evidence on perioperative outcomes of semi-rigid and inflatable PPI in Germany. We used the GeRmAn Nationwide inpatient Data (GRAND) from 2005 to 2021 and report the largest study to date with 7,222 patients. 6,818 (94.4%) patients underwent inflatable and 404 (5.6%) semi-rigid PPI. Inflatable PPI was significantly associated with shorter length of hospital stay (difference of 2.2 days, 95%CI: 1.6-2.7, p < 0.001), lower odds of perioperative urinary tract infections (5.5% versus 9.2%; OR: 0.58, 95%CI: 0.41-0.84, p = 0.003) and surgical wound infections (1% versus 2.5%; OR: 0.42, 95%CI: 0.22-0.88, p = 0.012) compared to semi-rigid PPI. Overall, 4255 (62.4%) inflatable PPIs were undertaken in low- ( < 20 PPI/year) and 2563 (37.6%) in high-volume ( ≥ 20 PPI/year) centers. High-volume centers were significantly associated with shorter length of hospital stay (difference of 1.4 days, 95%CI: 1.2-1.7, p < 0.001) compared to low-volume centers. Our findings suggest that inflatable PPI leads to a shorter length of hospital stay and lower rates of perioperative urinary tract and surgical wound infections compared to semi-rigid PPI. Patients undergoing surgery in high-volume centers for inflatable PPI are discharged earlier from the hospital.

Double J Stents and Reno-Ureteral Lithiasis: Dynamic Changes in Management during the COVID-19 Pandemic

PURPOSE

To provide an evidence-based review of the use of ureteral stents in managing reno-ureteral lithiasis during the COVID-19 pandemic.

MATERIALS AND METHODS

A literature search was conducted between 2020 and 2023 using the PubMed and SCOPUS databases. As a part of the search query, we entered "ureteral stents" OR "double J stent" AND "renal colic" OR "ureteral obstruction" OR "reno-ureteral lithiasis" AND "COVID-19 Pandemic" OR "SARS-CoV-2 infection".

RESULTS

Patients with lithiasis should be categorized into low priority, intermediate priority, high priority, and emergency under the COVID-19 pandemic scenario to manage their delay and save resources, including healthcare professionals, beds, and ventilators. However, immediate interventions are necessary for individuals at risk of life-threatening septic complications. During the COVID-19 pandemic, the feasibility of conducting or resuming elective activity depended on local circumstances, the accessibility of beds and ventilators, and the execution of screening protocols. If lithiasis surgery is delayed, consequences and increased effort will be inevitable. It is possible that teleconsultation could help guide these patients and cut down on unnecessary visits and exposure.

CONCLUSIONS

COVID-19 has shifted treatment options for urinary stones, with ureteral stents being a safe, efficient, and cost-effective option for managing urolithiasis. Decompression is essential in emergency situations, while ureteral stents reduce the risk of infection and hospital visits.

Impact of the COVID-19 pandemic on bladder cancer patients: a multicenter real-world study

OBJECTIVE

Hospital management and medical treatment changed during the coronavirus disease 2019 (COVID-19) pandemic. This study investigated the impact of the COVID-19 pandemic on patients with bladder cancer.

METHODS

In this multicenter retrospective study, we collected information from the electronic medical records of outpatients who underwent cystoscopy and inpatients with confirmed bladder cancer in three hospitals in Nanjing (two province-level and one county-level hospitals) in 2019 and 2020. Patients' home addresses, treatment methods, length of stay, and pathology were compared between the periods.

RESULTS

In total, 4048 outpatients and 1242 inpatients were included. The average number of cystoscopies decreased significantly during the lockdown. In province-level hospitals, the number of cystoscopies increased gradually as the pandemic was brought under control but remained lower than that in 2019, whereas the number grew in 2020 in county-level hospitals. The rates of recurrence and radical cystectomy were higher in 2020 than in 2019. No significant difference in the pathological grade was observed. More patients who underwent radical cystectomy were diagnosed with muscle-invasive bladder cancer during the 2020 lockdown.

CONCLUSION

The pandemic severely affected patients with bladder cancer, mainly in their choice of institution and treatment.

Systematic Evaluation of Studies in the Fields of Diagnosis and Management of Prostate Cancer in Coronavirus Disease 2019 Era

Background: Prostate cancer is one of the most common cancers worldwide. The proper management of this cancer during the coronavirus disease 2019 (COVID-19) or similar outbreaks could be a serious challenge. Proper timing of surgery, radiotherapy, and other medical modalities are essential in providing the most effective treatment. Objectives: This systematic review aimed at evaluating the proper management of prostate cancer during the COVID-19 outbreak. Methods: This study was conducted from 2019 to 2022. An internet search was conducted using the keywords: Diagnosis, management, radical prostatectomy, radiotherapy, hormone ablation therapy, chemotherapy and prostate cancer, and COVID-19. The visited databases included PubMed, Scopus, Web of Sciences, Google Scholar, and Scientific Information Database. The review was performed based on the preferred reporting items for a systematic review and meta-analyses (PRISMA) guidelines. Results: Postponing the biopsy for up to three months and adopting of non-invasive diagnostic methods were likely reasonable during the COVID-19 pandemic. Patients with cancer were more prone to severe injuries and were more likely to have serious complications. Surgery, radiation therapy, brachytherapy, palliative radiation, hormone ablation therapy, and chemotherapy were among the pre-institutional treatments that had to be performed according to medical protocols as well as health and professional guidelines. Conclusions: It was recommended that the prostate cancer screening should not be performed for asymptomatic men during the COVID-19 outbreak. It was also suggested that the treatment should be performed in the shortest possible time and in the safest way.

Changes in Urologic Cancer Surgical Volume and Length of Stay During the COVID-19 Pandemic in Pennsylvania

Importance

Disruptions in cancer surgery during the COVID-19 pandemic led to widespread deferrals and cancellations, creating a surgical backlog that presents a challenge for health care institutions moving into the recovery phase of the pandemic.

Objective

To describe patterns in surgical volume and postoperative length of stay for major urologic cancer surgery during the COVID-19 pandemic.

Design, Setting, and Participants

This cohort study identified 24 001 patients 18 years or older from the Pennsylvania Health Care Cost Containment Council database with kidney cancer, prostate cancer, or bladder cancer who received a radical nephrectomy, partial nephrectomy, radical prostatectomy, or radical cystectomy between the first quarter (Q1) of 2016 and Q2 of 2021. Postoperative length of stay and adjusted surgical volumes were compared before and during the COVID-19 pandemic.

Main Outcomes and Measures

The primary outcome was adjusted surgical volume for radical and partial nephrectomy, radical prostatectomy, and radical cystectomy during the COVID-19 pandemic. The secondary outcome was postoperative length of stay.

Results

A total of 24 001 patients (mean [SD] age, 63.1 [9.4] years; 3522 women [15%], 19 845 White patients [83%], 17 896 living in urban areas [75%]) received major urologic cancer surgery between Q1 of 2016 and Q2 of 2021. Of these, 4896 radical nephrectomy, 3508 partial nephrectomy, 13 327 radical prostatectomy, and 2270 radical cystectomy surgical procedures were performed. There were no statistically significant differences in patient age, sex, race, ethnicity, insurance status, urban or rural status, or Elixhauser Comorbidity Index scores between patients who received surgery before and patients who received surgery during the pandemic. For partial nephrectomy, a baseline of 168 surgeries per quarter decreased to 137 surgeries per quarter in Q2 and Q3 of 2020. For radical prostatectomy, a baseline of 644 surgeries per quarter decreased to 527 surgeries per quarter in Q2 and Q3 of 2020. However, the likelihood of receiving radical nephrectomy (odds ratio [OR], 1.00; 95% CI, 0.78-1.28), partial nephrectomy (OR, 0.99; 95% CI, 0.77-1.27), radical prostatectomy (OR, 0.85; 95% CI, 0.22-3.22), or radical cystectomy (OR, 0.69; 95% CI, 0.31-1.53) was unchanged. Length of stay for partial nephrectomy decreased from baseline by a mean of 0.7 days (95% CI, -1.2 to -0.2 days) during the pandemic.

Conclusions and Relevance

This cohort study suggests that partial nephrectomy and radical prostatectomy surgical volume decreased during the peak waves of COVID-19, as did postoperative length of stay for partial nephrectomy.

Comparative assessment of patients' admission to urology departments during and before the COVID-19 pandemic: a retrospective cohort study

Aim: To determine the diseases that presented to the urology department during the COVID-19 pandemic and for hospital-based comparison with the diseases that presented in the same period of the previous year. Material and Method: In this retrospective follow-up study, patients who were admitted to the tertiary university hospital and secondary state hospital urology departments between April-July 2019 and April-July 2020 were included in the study. We searched the health administrative data using the International Classification of Diseases-10 codes. The number and variety of patients who were admitted to the urology departments in the same months of 2019 and 2020 were compared. Results: In both hospitals, the total number of admissions decreased during the pandemic in 2020 compared to the pre-pandemic year. Also, elective admissions decreased in 2020 compared to the pre-pandemic year (p

Clinical impact of the suspension of the ERAS protocol on patients undergoing radical cystectomy during the COVID-19 pandemic

INTRODUCTION

During the beginning of the COVID-19 pandemic in our center, neither prehabilitation nor multimodal rehabilitation could be applied due to the excessive patient load on the health system and to reduce SARS-CoV-2 transmission. The objective of our study was to analyze the evolution, complications, and survival up to one year of patients who underwent radical cystectomy in our hospital from March 1st to May 31st, 2020 (period of the first wave COVID-19 pandemic in Spain). We also compared the results with cystectomized patients outside the pandemic period and with application of the ERAS (Enhanced Recovery After Surgery) protocol.

MATERIAL AND METHODS

Single-center, retrospective cohort study of patients scheduled for radical cystectomy from March 1st, 2020 to May 31st, 2020. They were matched with previously operated patients using a 1:2 propensity matching score. The matching variables were demographic data, preoperative and intraoperative clinical conditions.

RESULTS

A total of 23 radical cystectomies with urinary diversion were performed in the period described. In none of the cases the prehabilitation or the follow-up of our ERAS protocol could be applied, and this was the only difference we found between the 2 groups. Although the minimally invasive approach was more frequent in the pandemic group, the difference was not statistically significant. Three patients were diagnosed with COVID-19 during their admission, presenting severe respiratory complications and high in-hospital mortality. Apart from respiratory complications secondary to SARS-CoV-2, we also found statistically significant differences in other postoperative complications. The hospital stay increased by 3 days in the pandemic group.

CONCLUSIONS

Patients who underwent radical cystectomy at our center during the first wave of the COVID-19 pandemic had a higher number and severity of respiratory and non-respiratory complications. Discontinuation of the ERAS protocol was the main difference in treatment between groups.

Impact of the SARS-CoV-2 pandemic on the survival of patients with high-grade glioma and best practice recommendations

The severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) has changed the clinical day-to-day practice. The aim of this study was to evaluate the impact of the pandemic on patients with high-grade glioma (HGG) as well as to derive best practice recommendations. We compared a multi-institutional cohort with HGG (n = 251) from 03/2020 to 05/2020 (n = 119) to a historical cohort from 03/2019 to 05/2019 (n = 132). The endpoints were outcome (progression-free survival (PFS) and overall survival (OS)) as well as patterns of care and time intervals between treatment steps. The median OS for WHO grade 4 gliomas was 12 months in 2019 (95% Confidence Interval 9.7-14.3 months), and not reached in 2020 (p = .026). There were no other significant differences in the Kaplan-Meier estimates for OS and PFS between cohorts of 2019 and 2020, neither did stratification by WHO grade reveal any significant differences for OS, PFS or for patterns of care. The time interval between cranial magnetic resonance imaging (cMRI) and biopsy was significantly longer in 2020 cohort (11 versus 21 days, p = .031). Median follow-up was 10 months (range 0-30 months). Despite necessary disease containment policies, it is crucial to ensure that patients with HGG are treated in line with the recent guidelines and standard of care (SOC) algorithms. Therefore, we strongly suggest pursuing no changes to SOC treatment, a timely diagnosis and treatment with short time intervals between first symptoms, initial diagnosis, and treatment, as well as a guideline-based cMRI follow-up.

[CLINICAL IMPACT OF THE SUSPENSION OF THE ERAS PROTOCOL ON PATIENTS UNDERGOING RADICAL CYSTECTOMY DURING THE COVID-19 PANDEMIC.]

INTRODUCTION

During the beginning of the COVID-19 pandemic in our center, neither prehabilitation nor multimodal rehabilitation could be applied due to the excessive patient load on the health system and to reduce SARS-CoV-2 transmission. The objective of our study was to analyze the evolution, complications, and survival up to one year of patients who underwent radical cystectomy in our hospital from March 1st to May 31st, 2020 (period of the first wave COVID-19 pandemic in Spain). We also compared the results with cystectomized patients outside the pandemic period and with application of the ERAS (Enhanced Recovery After Surgery) protocol.

MATERIAL AND METHODS

Single-center, retrospective cohort study of patients scheduled for radical cystectomy from March 1st,2020 to May 31st, 2020. They were matched with previously operated patients using a 1:2 propensity matching score. The matching variables were demographic data, preoperative and intraoperative clinical conditions.

RESULTS

A total of 23 radical cystectomies with urinary diversion were performed in the period described. In none of the cases the prehabilitation or the follow-up of our ERAS protocol could be applied, and this was the only difference we found between the 2 groups. Although the minimally invasive approach was more frequent in the pandemic group, the difference was not statistically significant. Three patients were diagnosed with COVID-19 during their admission, presenting severe respiratory complications and high in-hospital mortality. Apart from respiratory complications secondary to SARS-CoV-2, we also found statistically significant differences in other postoperative complications. The hospital stay increased by 3 days in the pandemic group.

CONCLUSIONS

Patients who underwent radical cystectomy at our center during the first wave of the COVID-19 pandemic had a higher number and severity of respiratory and non-respiratory complications. Discontinuation of the ERAS protocol was the main difference in treatment between groups.

Impact of the coronavirus disease 2019 pandemic on the number of undergoing radical nephroureterectomy and postoperative adjuvant systematic therapy for upper tract urothelial carcinomas in Japan: A multicenter retrospective study

OBJECTIVES

The coronavirus disease 2019 pandemic has affected cancer management worldwide. For upper tract urothelial carcinomas, delays in treatments are not recommended even during the pandemic. We investigated the impact of the pandemic on patients with these carcinomas who underwent radical nephroureterectomy (RNU) and adjuvant systematic therapy before and after COVID-19 spread in Japan.

METHODS

This multicenter retrospective study included 304 patients who underwent RNU for upper tract urothelial carcinomas between May 1, 2019, and December 31, 2021, in Aichi, Japan. The patients were categorized into three groups based on whether they underwent surgery in the prepandemic (before infection spread in Japan), early pandemic (between confirmation of the first case and vaccination initiation), and late pandemic (after the start of vaccination in Japan) phases. The patient characteristics, diagnostic methods, pathological findings, and postoperative therapy were compared among the three phases.

RESULTS

Overall, 74, 152, and 78 patients underwent RNU in the prepandemic, early pandemic, and late pandemic phases, respectively. The number of patients who underwent preoperative ureteroscopy decreased significantly from the prepandemic phase to the late pandemic phase due to pandemic-related restrictions (p = 0.016). There was no difference in the time to the first visit or pathological findings. Among patients classified as high-risk according to existing clinical trials, the proportion receiving adjuvant systematic therapy after RNU decreased significantly from 52.3% to 19% (p = 0.003).

CONCLUSIONS

There was no difference in the pathological findings. The number of patients receiving appropriate adjuvant systematic therapy decreased during the pandemic.

Effect of porosity on mechanical and biological properties of bioprinted scaffolds

Treatment of tissue defects commonly represents a major problem in clinics due to difficulties involving a shortage of donors, inappropriate sizes, abnormal shapes, and immunological rejection. While many scaffold parameters such as pore shape, porosity percentage, and pore connectivity could be adjusted to achieve desired mechanical and biological properties. These parameters are crucial scaffold parameters that can be accurately produced by 3D bioprinting technology based on the damaged tissue. In the present research, the effect of porosity percentage (40%, 50%, and 60%) and different pore shapes (square, star, and gyroid) on the mechanical (e.g., stiffness, compressive and tensile behavior) and biological (e.g., biodegradation, and cell viability) properties of porous polycaprolactone (PCL) scaffolds coated with gelatin have been investigated. Moreover, human foreskin fibroblast cells were cultured on the scaffolds in the in-vitro procedures. MTT assay (4, 7, and 14 days) was utilized to determine the cytotoxicity of the porous scaffolds. It is revealed that the porous scaffolds produced by the bioprinter did not produce a cytotoxic effect. Among all the porous scaffolds, scaffolds with a pore size of about 500 μm and porosity of 50% showed the best cell proliferation compared to the controls after 14 days. The results demonstrated that the pore shape, porosity percentage, and pore connectivity have an important role in improving the mechanical and biological properties of porous scaffolds. These 3D bioprinted biodegradable scaffolds exhibit potential for future application as polymeric scaffolds in hard tissue engineering applications.

Impact of COVID-19 on Uro-Oncological Patients: A Comprehensive Review of the Literature

Background: The aim of this paper is to discuss the impact of COVID-19 on patients with urological malignancies (prostate cancer, bladder and upper tract urothelial cancer, kidney cancer, penile and testicular cancer) and to review the available recommendations reported in the literature. Methods: A review was performed, through the PubMed database, regarding available recommendations reported in the literature, to identify studies examining the impact of COVID-19 on treatment and clinical outcomes (including upstaging, recurrence, and mortality) for uro-oncological patients. Results: The COVID-19 pandemic dramatically changed the urological guidelines and patients' access to screening programs and follow-up visits. Great efforts were undertaken to guarantee treatments to high-risk patients although follow up was not always possible due to recurrent surges, and patients with lower risk cancers had to wait for therapies. Conclusions: Physically and mentally, uro-oncological patients paid a heavy price during the COVID-19 pandemic. Long term data on the "costs" of clinical decisions made during the COVID-19 pandemic are still to be revealed and analyzed.

Can We Identify Patients in Danger of Delayed Treatment? Management of COVID-19 Pandemic Backlog in Urology Care in Poland

The COVID-19 pandemic had a tremendous impact on healthcare systems around the world. This study aims to research the course of surgical treatment in urology during the pandemic in 2020, evaluate the volume of deferred treatment in urology in Poland, and indicate groups of patients that are especially vulnerable to a delay in the delivery of healthcare services. The National Health Found statistics (NHF) database was searched for information on procedures completed in urology departments from 2015 to 2020. Changes in hospital discharges of adults from 2019 to 2021 were investigated using monthly reports of NHF on patient billing groups. Statistics of PSA, testosterone, and creatinine testing were extracted from NHF reports. Annual changes in the number of surgeries were calculated. Then, the estimation of the expected quantity of procedures without the occurrence of the pandemic was performed using linear regression based on data from 2015 to 2020. The estimation was assumed reliable at R² > 0.8. The difference between collected and estimated data was analysed. In 2020, the volume of radical prostatectomies, cystectomies, and kidney surgeries noted downturns following lockdowns in March and November. All analysed procedures, except radical cystectomy, noted a reduction in the entire year. The declines reached -34% in shockwave lithotripsy, -13% in ureterorenoscopic lithotripsy, -22% in cystolithotripsy, -28% in percutaneous lithotripsy, -12% in transurethral resection of a bladder tumour (TURBT), -31% in transurethral resection of the prostate, -15% in nephrectomy and kidney tumorectomy, and -10% in radical prostatectomy. Among the analysed procedures, only radical cystectomy rates increased 5%. Prostate-specific antigen and creatinine tests fell -17%, and testosterone testing was down -18%. In conclusion, the patients most vulnerable to delayed treatment due to the post-pandemic backlog are those requiring TURBT, kidney cancer operations, and radical prostatectomies. Solving backlogs in urology should prioritise cancer patients and thus requires improved access to cystoscopy, TURBT, diagnoses and surgery of prostate and kidney tumours. Addressing the needs of patients suffering from benign diseases demands appropriate measures to increase the surgical productivity of urology departments.

Predicting the probability of pT3 or higher pathological stage at radical prostatectomy: COVID19-specific considerations

Background

We tested whether a model identifying prostate cancer (PCa) patients at risk of pT3-4/pN1 can be developed for use during COVID19 pandemic, in order to guarantee appropriate treatment to patients harboring advanced disease patients without compromising sustainability of care delivery.

Methods

Within the Surveillance, Epidemiology and End Results database 2010-2016, we identified 27,529 patients with localized PCa and treated with radical prostatectomy. A multivariable logistic regression model predicting presence of pT3-4/pN1 disease was fitted within a development cohort (n=13,977, 50.8%). Subsequently, external validation (n=13,552, 49.2%) and head-to-head comparison with NCCN risk group stratification was performed.

Results

In model development, age, PSA, biopsy Gleason Grade Group (GGG) and percentage of positive biopsy cores were independent predictors of pT3-4/pN1 stage. In external validation, prediction of pT3-4/pN1 with novel nomogram was 74% accurate versus 68% for NCCN risk group stratification. Nomogram achieved better calibration and showed net-benefit over NCCN risk group stratification in decision curve analyses. The use of nomogram cut-off of 49% resulted in pT3-4/pN1 rate of 65%, instead of the average 35%.

Conclusion

The newly developed, externally validated nomogram predicts presence of pT3-4/pN1 better than NCCN risk group stratification and allows to focus radical prostatectomy treatment on individuals at highest risk of pT3-4/pN1.

The impact of COVID-19 pandemic on reconstructive urologic surgery and andrology Spanish units' practice during the state of alarm in 2020: National survey

INTRODUCTION

In Spain the state of alarm secondary to COVID-19 dramatically changed the medical and surgical assistance activity of other pathologies. Regarding urological pathologies, those considered as "non-urgent" (andrology and reconstructive surgery) were postponed or even unattended.

MATERIAL AND METHODS

In May 2020, once the first COVID-19 wave was almost over and still in the state of alarm, a 24-item survey was sent to 120 urologists from the Andrology Group and the Urologic Reconstructive Surgery Group of the Spanish Urological Association (AEU). Its aim was to determine the impact on clinical and surgical practice in both subspecialties.

RESULTS

We observed a response rate of 75.8% with 91 answered surveys. Before the state of alarm, 49.5% of urologists had 1-2 weekly surgical sessions available, surgical waiting list was 3-12 months for the 71.4%, and 39.6% attended between 20-40 patients weekly in office. During the state of alarm, 95.6% were given any kind of surgical guidelines, prioritizing emergency and oncologic pathologies. In the 85.7% of the hospitals neither andrology nor reconstructive surgeries were performed. In office, around 50% of patients were attended not on-site, most of them through telemedicine (phone calls and e-mails).

CONCLUSIONS

The negative pandemic implications in relation to the andrology and reconstructive surgery pathologies were truly important. After almost 2 years from the start of the pandemic, the true final impact on our health system has yet to be determined.

The Influence of SARS-CoV-2 on Minimally Invasive Therapeutic Approach for Benign Prostatic Hyperplasia

Introduction: The COVID-19 pandemic definitely changed the management of patients with benign prostatic hyperplasia (BPH). This study followed the modalities of treatments in patients with BPH associated with SARS-CoV-2 attending the Urology Clinic of "Sf. Ioan" Emergency Clinical Hospital, Bucharest, Romania. Material and methods:The present study included 81 patients (mean age 63.2 years, age range 55-87 years) with SARS-CoV-2 and BPH who were admitted to our Urology Department between January 2021 and January 2022. The diagnosis of SARS-CoV-2 was based on the PCR test and that of BPH by using the diagnostic triad consisting of digital rectal examination, PSA, free PSA and ultrasound examination. It should be noted that some of the hospitalized patients were following treatment with alpha blockers and/or 5-alpha-reductase inhibitors at the time of admission. Results:Out of the 81 hospitalized cases, 13 required emergency endoscopic intervention under spinal anaesthesia (TURP or TURisP) for haemostasis because those patients presented with persistent haematuria which did not respond to conservative treatment. A number of 17 cases showed acute urinary retention during hospitalization and a urethrovesical catheter was fitted and will be re-evaluated urologically after the COVID episode. Of the remaining 51 subjects with BPH, 17 already had chronic urinary retention on admission, with urethrovesical probe present, 13 cases began during hospitalization with alpha-blocker treatment associated with 5-alpha-reductase inhibitors; meanwhile, there were no urological interventions to modify the treatment regimen in the remaining 21 patients, who were strictly managed on the side of COVID-19 infection. Conclusion:There was no clear influence of the evolution of patients with BPH due to SARS-CoV-2 pathology, and the general management trend was to delay chronic cases until the time of viral infection remission.

How has the COVID-19 pandemic influenced prostate cancer?-a tertiary single-centre analysis of oncological results, diagnosis and treatment times

Background

The coronavirus disease 2019 (COVID-19) pandemic has affected care for diseases like cancer. The aim was to evaluate the impact of COVID-19 on waiting times for diagnosis and treatment of prostate cancer (PC), as well as the possible effect on the treatment results in PC patients undergoing radical prostatectomy.

Methods

We compared the results of 497 patients who underwent biopsy prior to the COVID-19 pandemic (1 January-31 December 2019) with those of 290 patients biopsied during the COVID-19 pandemic (1 January-31 December 2020). Demographic data, tumour characteristics, type of treatment and diagnosis times were comparable. Prostate specific antigen (PSA) levels were recorded at consultation prior to biopsy and after treatment. Mann-Whitney and chi-square tests were used to compare continuous variables and percentages, respectively.

Results

In 2020, there were fewer urology consultations (35,160 vs. 40,225 in 2019). The median PSA in 2020 was significantly higher (14.3 vs. 9.9 ng/dL in 2019). In 2019, 53.1% (N=264) of the biopsies were positive for cancer vs. 47.2% (N=137) in 2020 (P=0.104). In 2020, more patients presented with metastatic disease (7.3% vs. 1.9%, P=0.009). Also, in 2020 there was a longer waiting time for prostate biopsy (42.1 vs. 35.3 days in 2019, P=0.019). A total of 132 patients underwent laparoscopic radical prostatectomy (LARP). The median time until surgery was similar in both years (71.9 vs. 58.29 days). During 2020, a higher percentage of patients had ISUP grade 4 in the surgical specimen (34.3% vs. 17.5%, P=0.07). Furthermore, a higher percentage of aggressive (pT3) tumours were diagnosed (37.2% vs. 27.2%, P=0.08), and the percentage of patients with involvement of surgical margins was also higher (48.6% vs. 29.3%, P=0.027). There were no differences between the groups in terms of biochemical recurrence or persistent PSA at one year (P=0.711).

Conclusions

Delayed biopsy during the COVID-19 period did not appear to adversely impact biopsy results. Patients biopsied in 2020 had higher PSA, possibly due to proper triaging. A higher rate of adverse pathology outcomes was observed in patients undergoing radical prostatectomy during the pandemic, probably due to understaging of the biopsy. This study serves to raise awareness of the risk of deterioration of care of PC patients due to possible underdiagnosis.

Association between COVID-19 Burden, Population Vaccination Status, and Urologic Oncology Surgery Volume: A National Multicenter Cross-Sectional Study

Initial deleterious effects of the COVID-19 pandemic on urologic oncology surgeries are well described, but the possible influence of vaccination efforts and those of pandemic conditions on surgical volumes is unclear. Our aim was to examine the association between changing vaccination status and COVID-19 burden throughout the pandemic and the volume of urologic oncology surgeries in Israel. This multi-center cross-sectional study included data collected from five tertiary centers between January 2019 and December 2021. All 7327 urologic oncology surgeries were included. Epidemiological data were obtained from the Israeli Ministry of Health database. A rising trend in total urologic oncology surgery volumes was observed with ensuing COVID-19 wave peaks over time (X2 = 13.184, df = 3, p = 0.004). Total monthly surgical volumes correlated with total monthly hospitalizations due to COVID-19 (R = -0.36, p = 0.015), as well as with the monthly average Oxford Stringency Index (R = -0.31, p = 0.035). The cumulative percent of vaccinations and of new COVID-19 cases per month did not correlate with total monthly urologic surgery volumes. Our study demonstrates the gradual acclimation of the Israeli healthcare system to the COVID-19 pandemic. However, hospitalizations due to COVID-19, as well as restriction stringency, correlate with lower volumes of urologic oncological surgeries, regardless of the population's vaccination status.

An Analysis of Google Trends During COVID-19: Determining Public Urological Cancer Concerns

Background The COVID-19 pandemic put a massive strain on the healthcare system as patients avoided the hospital, elective cases were postponed, and general medical anxiety was increased. We aimed to capture public interest in urological cancers during this massive shock to the medical field. Methodology A total of 12 keywords related to the three most prevalent urological cancers (prostate, bladder, and kidney) were searched using Google Trends from 2018 to 2022. The search volume index of these 12 keywords was extracted to assess public interest before and after the pandemic. Results There was a reduction in search volume for "prostate, bladder, and kidney cancer" and "kidney cancer treatment" after the postponement of elective surgeries. However, there was an increase in search volume for "prostate, bladder, and kidney cancer survival rates" and "prostate cancer symptoms" after this period. There was no change in search volume for bladder cancer symptoms, bladder cancer treatment, or kidney cancer symptoms. Conclusions Public interest in urological cancers decreased after COVID, while interest in survival rates across all three cancers increased. Future research is needed to investigate the effects of changing priorities and delays in medical care on patients' experiences with urological cancers.

Effect of One Year COVID-19 on Trauma of Lower Extremity at Orthopaedic Service in Prof Soeharso Orthopaedic Hospital, Indonesia: A Cross-sectional Study

Introduction

The World Health Organization announced the COVID-19 outbreak as a global pandemic on March 11, 2020. Despite the fact that orthopaedic departments are not considered first-line department in the war against pandemic, the pandemic has had a big effect on orthopaedic services. A few studies have found the pandemic effect on the orthopaedics field, but none have found the effect of a one-year pandemic, especially in Indonesia. This study aimed to know the effect of one-year COVID-19 on trauma of lower extremity at Orthopaedic Service in Prof Soeharso Top Referral Orthopaedic Hospital, Indonesia.

Materials and methods

It is a cross-sectional study. The study compared the population group during one year of the COVID-19 pandemic in Indonesia to the same period one year before. This study was conducted in Prof. Dr. R. Soeharso Orthopaedic Hospital, Surakarta, Indonesia from March 2019-February 2021. The subjects were patients of lower extremity trauma both surgical procedure and outpatient visit. Patients recorded on other orthopaedic service support installations like radiology, laboratory, or physiotherapy were excluded.

Results

There was a significant reduction (54.9%) in total trauma of lower extremities patients in Prof Dr R Soeharso Orthopaedic Hospital, Surakarta, from 2146 (pre-COVID-19) to 968 (during COVID-19) in the March 2019-February 2021 period. There was also a significant reduction (90.9%) in total cases outpatient visit in pre-COVID-19 compared to during COVID-19 (p<0.05) and surgical procedures (39%) in pre-COVID-19 compare to the COVID-19 period (p<0.05).

Conclusion

There was a significant reduction on trauma of lower extremities patients both outpatient visits and surgical procedures during pandemic COVID-19 than before the COVID-19 occurred.

Impact of COVID-19 on the management and outcomes of ureteric stones in the UK: a multicentre retrospective study

OBJECTIVES

To determine if management of ureteric stones in the UK changed during the coronavirus disease 2019 (COVID-19) pandemic and whether this affected patient outcomes.

PATIENTS AND METHODS

We conducted a multicentre retrospective study of adults with computed tomography-confirmed ureteric stone disease at 39 UK hospitals during a pre-pandemic period (23/3/2019-22/6/2019) and a period during the pandemic (the 3-month period after the first severe acute respiratory syndrome coronavirus-2 case at individual sites). The primary outcome was success of primary treatment modality, defined as no further treatment required for the index ureteric stone. Our study protocol was published prior to data collection.

RESULTS

A total of 3735 patients were included (pre-pandemic 1956 patients; pandemic 1779 patients). Stone size was similar between groups (P > 0.05). During the pandemic, patients had lower hospital admission rates (pre-pandemic 54.0% vs pandemic 46.5%, P < 0.001), shorter mean length of stay (4.1 vs 3.3 days, P = 0.02), and higher rates of use of medical expulsive therapy (17.4% vs 25.4%, P < 0.001). In patients who received interventional management (pre-pandemic 787 vs pandemic 685), rates of extracorporeal shockwave lithotripsy (22.7% vs 34.1%, P < 0.001) and nephrostomy were higher (7.1% vs 10.5%, P = 0.03); and rates of ureteroscopy (57.2% vs 47.5%, P < 0.001), stent insertion (68.4% vs 54.6%, P < 0.001), and general anaesthetic (92.2% vs 76.2%, P < 0.001) were lower. There was no difference in success of primary treatment modality between patient cohorts (pre-pandemic 73.8% vs pandemic 76.1%, P = 0.11), nor when patients were stratified by treatment modality or stone size. Rates of operative complications, 30-day mortality, and re-admission and renal function at 6 months did not differ between the data collection periods.

CONCLUSIONS

During the COVID-19 pandemic, there were lower admission rates and fewer invasive procedures performed. Despite this, there were no differences in treatment success or outcomes. Our findings indicate that clinicians can safely adopt management strategies developed during the pandemic to treat more patients conservatively and in the community.

Current trends and outcomes of non-elective neurosurgical care in Central Europe during the second year of the COVID-19 pandemic

Reflecting the first wave COVID-19 pandemic in Central Europe (i.e. March 16th–April 15th, 2020) the neurosurgical community witnessed a general diminution in the incidence of emergency neurosurgical cases, which was impelled by a reduced number of traumatic brain injuries (TBI), spine conditions, and chronic subdural hematomas (CSDH). This appeared to be associated with restrictions imposed on mobility within countries but also to possible delayed patient introduction and interdisciplinary medical counseling. In response to one year of COVID-19 experience, also mapping the third wave of COVID-19 in 2021 (i.e. March 16 to April 15, 2021), we aimed to reevaluate the current prevalence and outcomes for emergency non-elective neurosurgical cases in COVID-19-negative patients across Austria and the Czech Republic. The primary analysis was focused on incidence and 30-day mortality in emergency neurosurgical cases compared to four preceding years (2017–2020). A total of 5077 neurosurgical emergency cases were reviewed. The year 2021 compared to the years 2017–2019 was not significantly related to any increased odds of 30 day mortality in Austria or in the Czech Republic. Recently, there was a significant propensity toward increased incidence rates of emergency non-elective neurosurgical cases during the third COVID-19 pandemic wave in Austria, driven by their lower incidence during the first COVID-19 wave in 2020. Selected neurosurgical conditions commonly associated with traumatic etiologies including TBI, and CSDH roughly reverted to similar incidence rates from the previous non-COVID-19 years. Further resisting the major deleterious effects of the continuing COVID-19 pandemic, it is edifying to notice that the neurosurgical community´s demeanor to the recent third pandemic culmination keeps the very high standards of non-elective neurosurgical care alongside with low periprocedural morbidity. This also reflects the current state of health care quality in the Czech Republic and Austria.

The Impact of Surgical Waiting Time on Oncological Outcomes in Patients with Upper Tract Urothelial Carcinoma Undergoing Radical Nephroureterectomy: A Systematic Review

Radical nephroureterectomy (RNU) with bladder cuff excision is a standard of care in patients with high-risk upper tract urothelial carcinoma (UTUC). Although several recommendations and guidelines on the delayed treatment of urologic cancers exist, the evidence on UTUC is scarce and ambiguous. The present systematic review aimed to summarize the available evidence on the survival outcomes after deferred RNU in patients with UTUC. A systematic literature search of the three electronic databases (PubMed, Embase, and Cochrane Library) was conducted until 30 April 2022. Studies were found eligible if they reported the oncological outcomes of patients treated with deferred RNU compared to the control group, including those patients treated with RNU without delay. Primary endpoints were cancer-specific survival (CSS), overall survival (OS), and recurrence-free survival (RFS). In total, we identified seven eligible studies enrolling 5639 patients. Significant heterogeneity in the definition of “deferred RNU” was found across the included studies. Three out of five studies reporting CSS showed that deferring RNU was associated with worse CSS. Furthermore, three out of four studies reporting OS found a negative impact of delay in RNU on OS. One out of three studies reporting RFS found a negative influence of delayed RNU on RFS. While most studies reported a 3 month interval as a significant threshold for RNU delay, some subgroup analyses showed that a safe delay for RNU was less than 1 month in patients with ureteral tumors (UT) or less than 2 months in patients with hydronephrosis. In conclusion, long surgical waiting time for RNU (especially more than 3 months after UTUC diagnosis) could be considered as an important risk factor having a negative impact on oncological outcomes in patients with UTUC; however, the results of the particular studies are still inconsistent. The safe delay for RNU might be shorter in specific subsets of high-risk patients, such as those with UT and/or hydronephrosis at the time of diagnosis. High-quality additional studies are required to establish evidence for valid recommendations.

Impact of COVID-19 pandemic on patients with obstructing urinary stones complicated by infection

Objective

To assess the influence of COVID-19-imposed life changes on presentation and outcomes of patients with obstructing urinary stones complicated by infection.

Patients and methods

All patients presenting with obstructing urinary stones and infection 1 year before the pandemic (March 2019 to February 2020; n = 66) and 1 year since its onset (March 2020 to February 2021; n = 45) were enrolled. Demographics, clinical presentation, laboratory panel, stone characteristics and outcomes were compared between groups. Univariate and multivariate logistic regression models were performed for analysis.

Results

The COVID-19 period was characterised by younger patients, female predominance, higher temperature at presentation and more bilateral obstructing stones (p < 0.05). The admission rate to intensive care units was double that of the pre-pandemic period, whereas time between diagnosis and treatment was similar. The univariate analysis revealed higher rates of severe sepsis (odds ratio [OR] = 3, p = 0.01), systemic inflammatory response syndrome (SIRS) ≥ 2 (OR = 2.9, p = 0.01) and risk, injury, failure, loss of kidney function and end-stage kidney (RIFLE) criteria ≥ 1 (OR = 2.2, p = 0.04) in the pandemic period group. The multivariate analyses revealed the COVID-19 period as being the sole variable associated with severe sepsis (OR = 3.1, p = 0.02), SIRS ≥ 2 (OR = 3.8, p = 0.005) and RIFLE ≥ 1 (OR = 2.6, p = 0.05).

Conclusions

The pandemic period was characterised by a worse clinical state at presentation of patients with obstructing urinary stones complicated by infection, probably reflecting delay in arrival to emergency services.

Stage migration of testicular germ cell tumours in Alberta, Canada, during the COVID-19 pandemic: a retrospective cohort study

BACKGROUND

An absence of screening recommendations and the rapid progression of testicular germ cell tumours (TGCTs) offer a perspective on the potential impact of the COVID-19 pandemic on cancer presentations. We evaluated the presenting cancer stages of TGCTs in a real-world population before and during the pandemic to assess stage migration.

METHODS

We performed a retrospective review of all new patients with TGCT diagnoses in Alberta, Canada, from Dec. 31, 2018, to Apr. 30, 2021, using the Alberta Cancer Registry. Because potential changes in staging should not occur instantaneously, we used a 6-month lag time from Apr. 1, 2020, for seminomas, and a 3-month lag time for nonseminomas, to compare initial cancer stages at presentation before and during the pandemic. We evaluated monthly rates of presentation by stage and histology. Exploratory outcomes included the largest tumour dimension, tumour markers and, for advanced disease, risk category and treatment setting.

RESULTS

Of 335 patients with TGCTs, 231 were diagnosed before the pandemic and 104 during the pandemic (using a lag time). In total, 18 (7.8%) patients diagnosed before the pandemic presented with stage III disease, compared to 16 (15.4%) diagnosed during the pandemic (relative risk 1.97, 95% confidence interval [CI] 1.05-3.72). We observed no significant differences for secondary outcomes. Without a lag time, the rate ratio for a stage II presentation decreased significantly during the pandemic (0.40, 95% CI 0.21-0.72).

INTERPRETATION

We observed signs of TGCT stage migration during the COVID-19 pandemic, driven by a decline in stage II disease and a potential rise in stage III disease. Management of TGCTs should remain a priority, even during a global pandemic.

How Does the COVID-19 Pandemic Influence Histopathological Outcomes for Urologic Cancers?

Objective: The coronavirus disease 2019 (COVID-19) pandemic disrupted all routine health care services and resulted in a significant reconfiguration of urologic cancer services and care pathways across the globe. This study aimed to retrospectively determine the pandemic’s impact on the urologic oncological surgery outcomes at a high-volume referral center.

Materials and methods: We compared the number and histopathological outcomes of urologic oncological procedures in a referral center coded during the pandemic and data of the period before the pandemic as control. Data were extracted from patient files and hospital records. The pathological examination included a complete histopathological staging according to TNM stage.

Results: A total of 683 patients were included in the study, 424 (62%) of which were operated in the pre-pandemic period. There was a 39% decline in urologic oncological surgical activity in the pandemic, mostly in renal and prostate cancer. The mean tumor size was larger in renal cancer patients who underwent surgery during the pandemic (5.6 cm vs 4.5 cm, p=0.002). During the pandemic, more lymph node involvement was seen after radical cystectomy and prostatectomy (50% vs 27.8%, p=0.024 and 12.5% vs 4.5%, p=0.026, respectively). No differences in terms of main pathologic features were observed in patients undergoing radical orchiectomy.

Conclusion: COVID-19 appeared to adversely effect oncologic outcomes in patiens undergone surgery for prostate and bladder cancer. Tumor development induced by a delay in diagnosis may cause severe consequences for patients. Reprioritizion of non-deferrable urologic oncological seems crucial.

The effect of COVID-19 on prostate cancer testing in Australia

Aim

The effects of the COVID-19 pandemic on healthcare in Australia have yet to be fully determined. There are well documented decreases in the rates of screening and diagnostic testing for many cancers in 2020, with commensurate stage migration of cancers when they are eventually detected. We aimed to determine whether there was a decrease in the rate of prostate cancer (PC) screening and testing in Australia in 2020.

Method

Data was extracted from the Department of Human Services (DHS) website for Medicare Benefits Schedule (MBS) item numbers for tests pertinent to detection of Prostate Cancer. This data is de-identified and publicly available. Data was analysed at both a national, and a state level.

Results

For 2020 nationwide the percentage change for prostate cancer testing was minor with 97% as many PSA tests, 99% as many prostate MRIs, and 105% as many prostate biopsies as the average for the preceding years. The differences were not significant (PSA tests p = 0.059 and prostate biopsies p = 0.109). The predicted values are fairly similar to both the average values for the preceding 5 years and the actual number of tests done in 2020. With exception of PSA tests in Victoria the actual number of tests performed was within the 95% Prediction Interval (performed: 167,426; predicted 171,194–196,699; p = 0.015).

Conclusion

The current pandemic has had a widespread reach across Australia, with varying impact across each state and territory. Contrary to the trends across the world, our data suggest that during 2020 in Australia most areas remained unaffected in terms of prostate cancer testing excluding Victoria, which had statistically significant decrease in the number of PSA tests correlating with the extended lockdown that occurred in the state.

Telemedicine and Telehealth in Urology-What Do the 'Patients' Think About It?

Telemedicine is the delivery of healthcare to patients who are not in the same location as the physician. The practice of telemedicine has a large number of advantages, including cost savings, low chances of nosocomial infection, and fewer hospital visits. Teleclinics have been reported to be successful in the post-surgery and post-cancer therapy follow-up, and in offering consulting services for urolithiasis patients. This review focuses on identifying the outcomes of the recent studies related to the usage of video consulting in urology centers for hematuria referrals and follow-up appointments for a variety of illnesses, including benign prostatic hyperplasia (BPH), kidney stone disease (KSD), and urinary tract infections (UTIs) and found that they are highly acceptable and satisfied. Certain medical disorders can cause embarrassment, social exclusion, and also poor self-esteem, all of which can negatively impair health-related quality-of-life. Telemedicine has proven beneficial in such patients and is a reliable, cost-effective patient-care tool, and it has been successfully implemented in various healthcare settings and specialties.

Impacto De La Pandemia En La Actividad De Las Unidades De Cirugía Reconstructiva Urológica Y De Andrología En España Durante El Estado De Alarma (Covid-19) En 2020: Resultados De Una Encuesta Nacional

Introducción

El estado de alarma debido a la COVID-19 revolucionó la actividad asistencial y quirúrgica. Dentro de la enfermedad urológica, aquellas consideradas «demorables» como la andrológica y la reconstructiva sufrieron un retraso considerable en su atención.

Material y métodos

En mayo de 2020, tras haber superado casi la primera ola de la pandemia y en pleno estado de alarma, se envió una encuesta con 24 ítems a 120 urólogos integrados en los Grupos de Cirugía Reconstructiva Urológica y Andrología de la Asociación Española de Urología (AEU) para conocer la repercusión asistencial sobre la actividad clínica y quirúrgica en ambas subespecialidades.

Resultados

Se alcanzó una tasa de respuesta del 75,8% con 91 encuestas recibidas. Previo al estado de alarma, el 49,5% disponía de uno a 2 quirófanos semanales, el 71,4% afrontaba una lista de espera quirúrgica de entre 3 y 12 meses, y el 39,6% atendía entre 20 y 40 pacientes semanales en consulta. Durante el estado de alarma, el 95,6% recibió directrices sobre cirugías a realizar, priorizando la cirugía urgente y la oncológica. En el 85,7% de los centros no se realizó ninguna cirugía andrológica ni reconstructiva. Alrededor del 50% de las consultas no fueron presenciales, recurriendo a la telemedicina (teléfono o e-mail) en la mayoría de los casos.

Conclusiones

Las repercusiones de la pandemia sobre las enfermedades andrológicas y las candidatas a cirugía reconstructiva fueron muy importantes. Tras casi 2 años del inicio de la pandemia, aún queda por determinar el verdadero impacto final en nuestro sistema sanitario.

Development and use of the PodEssential and Paeds-PodEssential triage tools to define "essential" podiatry services. A Delphi survey, scoping review, and face validity testing study

BACKGROUND

The coronavirus pandemic resulted in unique challenges for podiatrists in Australia. Podiatrists were tasked with having to make triage decisions about face-to-face care without clear guidelines. This research aimed to develop podiatry triage tools to understand individual risk for adults and children, and explore the face validity of both tools.

METHODS

An online three-round modified Delphi technique was used to elicit podiatrists' opinions on conditions, assessments and social factors that elevate risk. Additional elements of known foot and/or leg risk were informed by a synchronous scoping review. Australian podiatrists who held a clinical role treating patients or directly managing podiatrists treating patients within the past six months were recruited. Where 70% of participants reported the same or similar theme in Round 1, statements were accepted with consensus. Where 50-69% of participants reported a similar theme, these were returned to participants to rate agreement using a four-point Likert agreement scale. Statements identified in the scoping review were added at Round 2, if not already identified by participants. The final round presented participants with triage tools, and a series of mock patient scenarios.. Participants were asked to indicate if they would or would not provide face to face podiatry service based on these scenarios.

RESULTS

There were 40 participants who responded to Round 1 (Adult presentations), of these, 23 participants also provided paediatric presentation responses. Participants developed and agreed upon 20 statements about risk in podiatry service delivery for both adults and children across Rounds 1 and 2. The PodEssential and Paed-PodEssential were developed based on these statements indicating stand-alone condition risk (tier 1), elements that should elevate risk (in the absence of a stand-alone condition) (tier 2), and assessments results identifiying a limb at risk (tier 3) in adults and children respectively. Participants utilising these tools in Round 3 more frequently indicated face-to-face service when mock patient scenarios included a greater number elements, suggesting the tool can be useful in making triage decisions.

CONCLUSION

The PodEssential and Paeds-PodEssential tools direct conditions requiring urgent attention as well as providing considered elements to a person's health status to assist in making triage decisions.

COVID‑19‑related postponement of elective sexual or reproductive health operations deteriorates private and sexual life: an ongoing nightmare study

We aimed to assess the impact of postponing sexual or reproductive health surgeries on patients' psychosocial distress and personal or occupational life during the COVID-19 pandemic. A total of 77 elective sexual or reproductive health surgeries were postponed. Of them, 38 patients are still on the waiting list for an appointment and, despite our efforts, we managed to operate only 39 patients when operation capacity returned to a normal level. At the time of surgery, all patients were requested to complete a 14-item questionnaire, assessing patients' perception of the COVID-19 pandemic. Patients marked the necessity of operation at the time of initial postponement as urgent and as highly urgent at the time of surgery. Due to the postponement of surgery, they reported experiencing severe restrictions in private life and more concerns and worries for their disease. Interestingly, patients who could not perform sexual intercourse due to the underlying disease wanted to receive surgery more urgently (p = 0.001) and displayed more restrictions in private life (p = 0.007). On the contrary, the duration of surgery postponement was not associated with worse outcomes. Overall, postponement of surgery poses a huge psychological burden that leads to further personal restrictions. Patients that cannot perform sexual intercourse should be prioritized for treatment.

Changes in practice patterns of nephrolithiasis in the era of the coronavirus disease 2019 pandemic: a review

PURPOSE OF REVIEW

The coronavirus disease 2019 (COVID-19) pandemic led to a drastic change in healthcare priorities, availability of resources and accommodation of different needs and scenarios. We sought to review the effect of the pandemic on different aspects of nephrolithiasis.

RECENT FINDINGS

The pandemic resulted in a significant impact on management of patients with nephrolithiasis around the world. A significant decrease in patient presentation and differences in strategies of management to truncate exposure and surgery time and expedite patient discharge deferring definitive management has been noted. Moreover, new safety measures such as COVID-19 PCR testing prior to surgery and limiting any intervention for COVID-19 positive patients to only life-saving scenarios has been implemented. Different emergency triaging proposals are being used, mainly including high risk patients with septic shock or complete obstruction/renal injury. Moreover, the emergence of telehealth has changed outpatient practice dramatically with a significant adoption to minimize exposure. Lastly, the effect of COVID-19 on renal physiology has been described with significant potential to cause morbidity from immediate or delayed acute kidney. No physiological effect on stone formation has yet been described, and transmission through urine is rare.

SUMMARY

The COVID-19 pandemic has markedly shifted the treatment of nephrolithiasis in many ways, including emergency triage, outpatient care, and definitive management. Although various approaches and algorithms proposed are meant to optimize management in the time of the pandemic, further studies are required for validation.

Triaging urological surgeries to cope with the coronavirus-19 pandemic

PURPOSE OF REVIEW

The coronavirus-19 (COVID-19) pandemic has led to strains on hospital resources and difficulties in safely and effectively triaging surgical procedures. In this article, we discuss the important considerations for triaging urologic surgeries during a global pandemic, mitigating factors on how to perform surgeries safely, and general guidelines for specific surgeries.

RECENT FINDINGS

Many urological procedures have been cut back due to the pandemic, with benign disease states being most affected whereas oncology cases affected least. Current recommendations in urology triage life-threatening conditions, or conditions that may lead to life-threatening ailments as a priority for treatment during the pandemic. Additionally, published recommendations have been put forth recommending all surgical patients be screened for COVID-19 to protect staff, prevent disease dissemination, and to educate patients on worse outcomes that can occur if infected with COVID-19 in the postoperative period.

SUMMARY

COVID-19 has caused worldwide shortages of healthcare resources and increased the need to ethically triage resources to adequately treat the urologic community. These resource limitations have led to increased wait times and cancellations of many urology surgeries that are considered 'elective'.

How did the first year of the COVID-19 pandemic affect urology practice in Arab countries? A cross-sectional study by the Arab Association of Urology research group

Objective:

The aim of this study was to assess of the effect of coronavirus disease 2019 (COVID-19) pandemic on urology practice in the Arab world during the first year of the crisis.

Methods:

An Internet-based questionnaire was created and sent out via email to members of the Arab Association of Urology (AAU) using ‘Google Forms’. The survey assessed participants’ demographics in terms of age, gender, country of origin, type of practice and position. Impacts of COVID-19 on urological practice were assessed in terms of the changes in hospital policies regarding consultations, and elective and emergency surgical cases. Moreover, impacts of COVID-19 on urologists were assessed.

Results:

A total of 255 AAU members across 14 Arab countries (Emirates, Egypt, Saudi Arabia, Iraq, Jordan, Algeria, Kuwait, Yemen, Qatar, Lebanon, Libya, Oman, Sudan and Syria) completed the survey; 4% were female urologists. Consultations at outpatient clinics were closed or restricted to emergency cases or replaced by telemedicine in almost 15%, 40% and 25% of hospitals, respectively. Elective surgeries were stopped or reduced to under 25% of surgical capacity in >10% and about 25% of hospitals, respectively. Almost 90% (228) reported changes in the policy for emergency theatres. Nearly 65% of hospitals offered preoperative COVID-19 testing to patients and 50% of hospitals provided personal protective equipment (PPE) to their urologists. Of 99% (253) who reported a change in urological education, 95% relied on online webinars. About 56% of respondents had their own private practice, of whom 91% continued private practice during the crisis. About 38% of participants reported exposure to intimidation (75% emotional, 20% verbal and 5% physical).

Conclusion:

The COVID-19 pandemic resulted in major changes in hospitals’ policies regarding outpatient consultations, elective and emergency operative cases, and the shift to telemedicine. Arab urologists have been facing major challenges either in both the governmental or the private sectors, and some of them were exposed to emotional, verbal and even physical intimidation.

A prioritization score for elective urological surgery during the COVID-19 pandemic: The Medically Necessary Time-Sensitive (MeNTS) score system

Purpose:

The COVID19 pandemic has caused a redistribution of hospital resources. Prioritization strategies are needed in order to organize elective surgeries. We compared the new Medically Necessary Time-Sensitive score (MeNTS) and its factors (disease, procedure, and patient factors) between operated and deferred cases, and also to a subjective priority scale in the Urology department.

Methods:

The MeNTS score and a subjective prioritization scale were prospective applied to all patients included on the surgical waiting list from March 10 to September 9, 2020. Mann-Whitney U test was used to compare MeNTS scores between operated and non-operated groups. Kruskal-Wallis test was used to compare MeNTS scores between three subjective priority groups.

Results:

A total of 150 cases were operated while 100 were deferred. Median total MeNTS score in the operated group was 39.5 whereas in the non-operated group it was 38 ( p = 0.135). Median disease factors score was 9.5 in the operated group and 11 in the non-operated group( p = 0.033). Median procedure factors score was 10 in both groups ( p = 0.02). Median patient factors score was 17 in the operated group and 18 in the non-operated group ( p = 0.210). Disease factors displayed a significant difference between the three subjective priority groups

Conclusions:

Total MeNTS score does not show significant differences between operated and non-operated patients. However, we demonstrate a relationship between MeNTS disease factors and the operated group as well as with the subjective priority scale.

Safety and economics of an enhanced recovery after surgery protocol in pelvic reconstructive surgery

Introduction and hypothesis

We hypothesized that an enhanced recovery after surgery (ERAS) protocol for patients undergoing female pelvic reconstructive surgery would conserve hospital resources without compromising patient safety.

Methods

In June 2020, an ERAS protocol designed to promote same-day discharge was initiated that included pre-operative hydration, a urinary anesthetic, non-narcotic analgesia, perineal ice, a bowel regimen, enrollment of the family to assist with care, and communication regarding planned same-day discharge. We compared demographic, operative, hospital stay, complications, and cost data in patients undergoing pelvic organ prolapse or incontinence surgery over 4 sequential months pre (PRE; N = 82) and post (POST; N = 91) ERAS implementation using univariate statistics.

Results

There were no differences in demographics, operative details, or complications (p > 0.05). There were no significant differences in overall revenues or expenses (p > 0.05), but bed unit cost was significantly lower in the POST group ($210 vs $533, p < 0.0001). There was a trend toward an increased operating margin in POST patients ($4,554 vs $2,151, p = 0.1163). Significantly more POST surgeries were performed in an ambulatory setting (73.6% vs 48.8%, p = 0.0008) and resulted in same-day discharge (80.2% vs 50.0%, p = 0.0003). There were no differences in the rates of emergency room or unexpected clinic visits (p > 0.05). Prescribed post-operative opiate dose was significantly reduced in POST patients (p < 0.0001).

Conclusions

In patients undergoing female pelvic reconstructive surgery, an ERAS protocol facilitated transfer of procedures to an ambulatory surgical site and permitted same-day discharge without increasing complications, clinic visits, or emergency room visits. It also reduced bed unit cost and may improve operating margins.

Impact of the COVID-19 Pandemic on Urologic Oncology Surgery: Implications for Moving Forward

The COVID-19 pandemic has caused the destruction of routine hospital services globally, leading to an increase in the backlog of elective surgery cases. The aim of the study was to retrospectively investigate the pandemic's impact on the urologic oncology surgical activity of a high-volume center located in Milan, Italy. The number and type of procedures performed in 2020 during the COVID-19 pandemic was evaluated using 2019 data as control. Waiting times for each surgical procedure were compared, on a bimonthly basis, between the two different years. Overall, a 26.7% reduction in the number of urologic oncology surgeries between 2019 and 2020 was observed (2019: 720, 2020: 528). Both the main indication for surgery and the type of procedure performed significantly differed between 2019 and 2020 (all p < 0.0001), with a decrease in the number of radical prostatectomies and an increase in the number of radical cystectomies and radical nephrectomies/nephroureterectomies performed in 2020. Waiting time decreased by 20% between 2019 and 2020, with the most significant reduction seen after the first wave of the COVID-19 pandemic (July-October 2020), in particular for partial nephrectomy and radical prostatectomy, possibly due to the underdiagnosis of cases. In conclusion, in accordance with recommendations by international urological societies on prioritization strategies for oncological procedures, a higher proportion of surgeries for high-risk tumors was performed in 2020 at our center at the expense of procedures for lower risk diseases; however, future implications for patients' prognosis still need to be determined.

Pediatric urology surgical practice in the time of COVID-19: Results from tertiary Saudi Arabia hospitals

Purpose:

Our study aimed to evaluate the effect of COVID-19 on pediatric urology practice in the Kingdom of Saudi Arabia (KSA).

Methods:

Data of 10 tertiary hospitals in KSA were retrospectively analyzed. Data of outpatient department (OPD) visits and pediatric urology surgical procedures from January 1, 2019, to April 30, 2019, and from January 1, 2020, to April 30, 2020, were extracted. The primary outcome was to compare OPD visits and pediatric urology workload in the first third of 2020 versus 2019, where there was no curfew. The secondary outcome was to compare the same variables during the full curfew time, i.e., April 2020 versus April 2019.

Results:

The number of OPD visits was lower in the first third of 2020 (7390 vs. 10,379 in 2019 P < 0.001). OPD visits in April 2020 were 78.6% lower than in April 2019, and teleclinics represented 850 (94.3%). Elective procedures in the first third of 2020 were 688, with a reduction rate of 34.3% compared to the same period of 2019 (P < 0.001). In April 2020, there were 18 elective surgeries, with a 91.4% decrease than in April 2019. Ureteric reimplantation, hypospadias, cryptorchidism, and circumcision stopped, while pyeloplasty (n = 14) and urolithiasis (n = 4) procedures had declined by 50% and 76.5%, respectively. Most of the procedures (71.8%) were day surgery. Emergency procedures were similar in the first third of 2020 (65 vs. 64 in 2019, P = 0.994) and declined in April 2020 by 6.7% versus April 2019. During the full curfew, the most common emergency intervention were cases with obstructive uropathy (42.8%), followed by torsion testis (28.6%), posterior urethral valve (14.3%), and urological trauma (14.3%).

Conclusions:

In KSA, the number of elective pediatric surgical procedures were reduced by >90%, while the number of emergency pediatric surgical procdures were similar during COVID-19 pandemic compared with non-COVID-19 time. Ureteric reimplantation, hypospadias repair, cryptorchidism, and circumcision procedures were postponed. Pyeloplasty and urolithiasis-related procedures were performed to prevent irreversible disease progression or organ damage. There was an increase in rate of teleclinic and day surgery to reduce the risk of COVID-19 infection.

COVID-19: The impact on urolithiasis treatment in Brazil

Introduction:

It has been more than a year since the first case of Covid-19 was diagnosed in Brazil, and its most problematic feature is the oversaturation of the healthcare system capacity. Urolithiasis is a disease that requires timely and appropriate management. The present study aimed to evaluate the impact of the pandemic in hospital admissions for urolithiasis in the Brazilian public healthcare system.

Materials and Methods:

In this cross-sectional study, hospital admissions were obtained from the Brazilian Public Health Information system. All hospital admissions associated with urolithiasis diagnosis (ICD-10 N20) between March 2017 and February 2021 were analyzed.

Results:

During the COVID-19 outbreak, there was a significant decrease in hospital admissions (p<0.0001). More than 20.000 patients probably did not have the opportunity to undergo their surgeries. The impact of the COVID-19 outbreak on women's admissions was significantly more intense than for men, reducing from 48.91% to 48.36% of the total (p=0.0281). The extremes of age seemed to be more affected, with patients younger than 20 years and older than 60 years having a significant reduction in access to hospital services (p=0.033).

Conclusions:

In conclusion, we have noticed a considerable reduction in overall admissions for the treatment of urolithiasis in the Brazilian public healthcare system during the first year of the Covid-19 pandemic. Women and individuals older than 60 years were especially affected. In contrast, we noted a rise in urgent procedures, comparing with the average of the corresponding period of the three previous years. Recovery plans will be needed while returning to activities to handle the impounded surgical volume.