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Concerns in Redirecting Uro-oncologic Patients During COVID-19 Pandemic

      To the Editor
      COVID-19 pandemic dramatically struck northern Italy during the last few weeks, causing a multiregional health system crisis for the overwhelming number of patients who required hospital admission, particularly, with regards to the occupation of intensive care units in case of acute respiratory syndrome. A survey among leading European urological centers showed a reduction in oncologic surgery of at least 40%-50% in March.

      Oderda M, Roupret M, Marra G, et al. The impact of COVID-19 outbreak on uro-oncological practice across Europe: which burden of activity are we facing ahead?Eur Urol. In press. doi.org/10.1016/j.eururo.2020.03.054

      The following weeks of April saw a drastic reduction of the remaining elective surgery. National Health Systems of Italy and England proposed to suspend nonurgent elective surgery for 3 months.
      • Iacobucci G
      Covid-19: all non-urgent elective surgery is suspended for at least three months in England.
      Unfortunately, the burden of surgery delay increases the doubling time of the waiting list to an uncertain interval, which would be very long especially for nononcologic surgical diseases. Regarding specific uro-oncologic nondeferrable procedures (ie, radical cystectomy, TURBT for high-risk diseases, nephroureterectomy, radical prostatectomy for high-risk prostate cancers, radical nephrectomy for T3-T4 renal tumors, and radical orchiectomy),

      Ficarra V, Novara G, Abrate G, et al. Urology practrice during COVID-19 pandemic. Minerva Urol Nefrol. In press. doi: 10.23736/S0393-2249.20.03846-1

      it has been suggested that they should be centralized in tertiary urological centers, which could remain COVID-19 free using a proper patient triage and being excluded from patient recruitment of the emergency department. However, in this pandemic, which has manifested as nothing that has been seen before, several tertiary centers in Italy as well as the other Western countries, such as Spain, France, UK, and US, have suffered sudden redistribution of medical resources and the conversion of hospitals into a single-disease taskforce. Moreover, the long surgical waiting lists of community hospitals, including nondeferrable oncologic cases, indicate poor compliance with similar surgical priorities of tertiary referral centers.
      • Naspro R
      • Da Pozzo LF
      Urology in the time of corona.
      Also, the reorganization of surgical activities has promoted the onset of a novel factor influencing the attempt to normalize surgical planning, namely the fear to contract COVID-19. Indeed, it has been shown that any reassembly of hospital structure, in the COVID-19 era stops the proposed operation of several patients.

      Ficarra V, Mucciardi G, Giannarini G, et al. Assessing the burden of urgent nondeferrable uro-oncologic surgery to guide prioritisation strategies during the COVID-19 pandemic: insights from three Italian high-volume referral centres. Eur Urol. In press. doi.org/ 10.1016/j.eururo.2020.03.054

      In our experience, in a community hospital of more than 430 beds in north-west Italy hit by the COVID-19 storm, the elective surgical activity was reduced to 20% on March 20 and collapsed to zero afterward, for a long 3-week interval. As on April 15, a careful observation of the institutional data showed a progressive decline of the disease curve, including no more COVID-19 patients in ICU (Fig. 1), so we were able to plan oncologically urgent interventions, such as radical cystectomy once a week. Moreover, it has been devised to enter into a contract for agreement with COVID-free private clinics, to meet, in conjunction with the National Health System, the need for other non-deferrable uro-oncologic surgeries, mainly TURBTs, radical prostatectomies for high-risk prostate cancer, and prostate biopsies. This strategy led us to regain 60% of our previous surgical activities. There are territorial differences in terms of COVID-19 penetration and health care system resources. The pandemic scenario could rapidly change due to inadequate social behaviors or in case of a sec`ond wave of infection. However, any efforts and suggestions to mitigate the secondary effect of delaying uro-oncologic treatment should be pursued.
      Figure 1
      Figure 1COVID-19 bed occupation, including ICU beds, sub-intensive care beds, and general care beds of a community hospital during the pandemic. (Color version available online.)

      References

      1. Oderda M, Roupret M, Marra G, et al. The impact of COVID-19 outbreak on uro-oncological practice across Europe: which burden of activity are we facing ahead?Eur Urol. In press. doi.org/10.1016/j.eururo.2020.03.054

        • Iacobucci G
        Covid-19: all non-urgent elective surgery is suspended for at least three months in England.
        BMJ. 2020; 368: m1106
      2. Ficarra V, Novara G, Abrate G, et al. Urology practrice during COVID-19 pandemic. Minerva Urol Nefrol. In press. doi: 10.23736/S0393-2249.20.03846-1

        • Naspro R
        • Da Pozzo LF
        Urology in the time of corona.
        Nat Rev Urol. 2020; 17: 251-253
      3. Ficarra V, Mucciardi G, Giannarini G, et al. Assessing the burden of urgent nondeferrable uro-oncologic surgery to guide prioritisation strategies during the COVID-19 pandemic: insights from three Italian high-volume referral centres. Eur Urol. In press. doi.org/ 10.1016/j.eururo.2020.03.054