Management of patients who opt for radical prostatectomy during the coronavirus disease 2019 (COVID-19) pandemic: an international accelerated consensus statement

OBJECTIVE

Coronavirus disease-19 (COVID-19) pandemic caused delays in definitive treatment of patients with prostate cancer. Beyond the immediate delay a backlog for future patients is expected. The objective of this work is to develop guidance on criteria for prioritisation of surgery and reconfiguring management pathways for patients with non-metastatic prostate cancer who opt for surgical treatment. A second aim was to identify the infection prevention and control (IPC) measures to achieve a low likelihood of coronavirus disease 2019 (COVID-19) hazard if radical prostatectomy (RP) was to be carried out during the outbreak and whilst the disease is endemic.

METHODS

We conducted an accelerated consensus process and systematic review of the evidence on COVID-19 and reviewed international guidance on prostate cancer. These were presented to an international prostate cancer expert panel (n = 34) through an online meeting. The consensus process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. The Consensus opinion was defined as ≥80% agreement and this was used to reconfigure the prostate cancer pathways.

RESULTS

Evidence on the delayed management of patients with prostate cancer is scarce. There was 100% agreement that prostate cancer pathways should be reconfigured and measures developed to prevent nosocomial COVID-19 for patients treated surgically. Consensus was reached on prioritisation criteria of patients for surgery and management pathways for those who have delayed treatment. IPC measures to achieve a low likelihood of nosocomial COVID-19 were coined as 'COVID-19 cold' sites.

CONCLUSION

Reconfiguring management pathways for patients with prostate cancer is recommended if significant delay (>3-6 months) in surgical management is unavoidable. The mapped pathways provide guidance for such patients. The IPC processes proposed provide a framework for providing RP within an environment with low COVID-19 risk during the outbreak or when the disease remains endemic. The broader concepts could be adapted to other indications beyond prostate cancer surgery.

Intraoperative aerosol viral transmission in minimally invasive surgery: a scoping review and impact on clinical guidelines and practice during the onset of the coronavirus disease 2019 (COVID-19) pandemic

OBJECTIVE

To identify the available evidence on aerosol viral transmission risk during minimally invasive surgery (MIS) and evaluate its impact on guidelines development and clinical activity worldwide during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

We performed a scoping review on PubMed, Cochrane, the Excerpta Medica dataBASE (EMBASE), Clinical Trial Register, and the Grey Literature Repository databases, to identify reports on viral transmission via surgical smoke or aerosolisation. A systematic review of all available national and international guidelines was also performed to report their recommendations. Additionally, a worldwide transdisciplinary survey was performed to capture the actual compliance to dedicated guidelines and their impact on MIS activity.

RESULTS

Based on a selection of 17 studies, there was no evidence to support the concerns of an intraoperative viral transmission via pneumoperitoneum aerosolisation. Most national surgical and urological societies either did address this topic or referred to international guidelines. The guidelines of the American College of Surgery, the Royal College of Surgeons, and the European Association of Urology Robotic Urology Section, recommended an avoidance of MIS due to an increased risk of intraoperative aerosol-enhanced transmission. The results of the survey completed by 334 respondents, from different surgical abdominal specialties, suggested a lack of compliance with the guidelines.

CONCLUSION

There seems to be a dissonance between contemporary guidelines and ongoing surgical activity, possibly due to the perceived lack of evidence. Recommendations regarding changes in clinical practice should be based on the best available research evidence and experience. A scoping review of the evidence and an assessment of the benefits and harms together with a survey showed that laparoscopic procedures do not seem to increase the risk of viral transmission. Nevertheless, the few publications and low quality of existing evidence limits the validity of the review.