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A Systematic Review on Guidelines and Recommendations for Urology Standard of Care During the COVID-19 Pandemic

      Abstract

      Context

      The first case of the new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), was identified in Wuhan, China, in late 2019. Since then, the coronavirus disease 2019 (COVID-19) outbreak was reclassified as a pandemic, and health systems around the world have faced an unprecedented challenge.

      Objective

      To summarize guidelines and recommendations on the urology standard of care during the COVID-19 pandemic.

      Evidence acquisition

      Guidelines and recommendations published between November 2019 and April 17, 2020 were retrieved using MEDLINE, EMBASE, and CINAHL. This was supplemented by searching the web pages of international urology societies. Our inclusion criteria were guidelines, recommendations, or best practice statements by international urology organizations and reference centers about urological care in different phases of the COVID-19 pandemic. Our systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Of 366 titles identified, 15 guidelines met our criteria.

      Evidence synthesis

      Of the 15 guidelines, 14 addressed emergency situations and 12 reported on assessment of elective uro-oncology procedures. There was consensus on postponing radical prostatectomy except for high-risk prostate cancer, and delaying treatment for low-grade bladder cancer, small renal masses up to T2, and stage I seminoma. According to nine guidelines that addressed endourology, obstructed or infected kidneys should be decompressed, whereas nonobstructing stones and stent removal should be rescheduled. Five guidelines/recommendations discussed laparoscopic and robotic surgery, while the remaining recommendations focused on outpatient procedures and consultations. All recommendations represented expert opinions, with three specifically endorsed by professional societies. Only the European Association of Urology guidelines provided evidence-based levels of evidence (mostly level 3 evidence).

      Conclusions

      To make informed decisions during the COVID-19 pandemic, there are multiple national and international guidelines and recommendations for urologists to prioritize the provision of care. Differences among the guidelines were minimal.

      Patient summary

      We performed a systematic review of published recommendations on urological practice during the coronavirus disease 2019 (COVID-19) pandemic, which provide guidance on prioritizing the timing for different types of urological care.

      Keywords

      1. Introduction

      During the coronavirus disease 2019 (COVID-19) pandemic, international efforts have been made to inform and prepare health care workers in order to optimize and redirect resources and personnel to manage this crisis. As of May 4, 2020, the World Health Organization (WHO) reported 239 604 deaths [

      World Health Organization. Coronavirus disease (COVID-2019) situation reports. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/.

      ]. To date, there is no approved vaccine for COVID-19, and the number of cases has continued to rise as of the date of submission.
      Several urology societies and reference centers have published recommendations to inform urology care during the COVID-19 pandemic.
      It is essential for urologists to prioritize patient safety, and to balance potential delays in diagnosis and treatment of urological conditions against risks of COVID-19 exposure and additional stress on health care resources. These issues are of particular concern in epicenters or areas with the greatest number of cases.
      The aim of this systematic review is to summarize published guidelines and recommendations on urological care during the COVID-19 pandemic from major professional urology societies and reference centers.

      2. Evidence acquisition

      2.1 Search strategy

      A comprehensive literature search was performed using a combination of keywords (MeSH terms and free text words) including (“COVID-19” OR “SARS-CoV-2” OR “Coronavirus” OR “coronavirus infections”) AND (“Urology” OR “Urogenital system”). MEDLINE, EMBASE, and CINAHL were searched (Supplementary material). The search was supplemented to include references from the pertinent articles as well as hand searches of additional relevant records on COVID-19 resource websites from the European Association of Urology (EAU), American Urological Association (AUA), and British Journal of Urology International. Our search was up-to-dated to include publications through April 17, 2020.

      2.2 Eligibility criteria

      Articles were eligible for inclusion if they contained original guidelines or recommendations on urology standards of care during the COVID-19 pandemic.

      2.3 Information sources

      Our search strategy yielded 366 articles. All the articles were combined into EndNote reference management software, and 127 duplicates were removed. Two authors (M.L.W. and F.L.H.) independently identified and reviewed the titles and abstracts. For an article to be excluded, both reviewers had to agree that the study was not relevant. The exclusion criteria were as follows: (1) not focused on urology, (2) not containing recommendations involving urology practice during COVID-19, and (3) not written in English. After reviewing the titles and abstracts, 72 papers were identified as potentially eligible for inclusion. After a full-text review, 15 were deemed eligible and were included. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram is shown in Fig. 1.
      Fig. 1
      Fig. 1PRISMA flowchart summarizing the results of the literature search. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-analyses.

      2.4 Data extraction

      Two independent reviewers (F.S.L. and F.L.H.) extracted all relevant recommendations from each guideline. Disagreements concerning data extraction were resolved by discussion and consensus. Thereafter, a recommendation matrix was constructed considering distinct conditions, such as urological oncology, endourology, outpatient procedures, other benign procedures, emergencies, and transplantation. The following variables were extracted from the articles: list of authors, title of the article, publication date, country, search strategy, purpose of the guideline, guideline type, subareas covered, and conclusions.

      3. Evidence synthesis

      For quality assessment, the team checked for the level of evidence and grade of recommendations.
      The authors summarized the recommendations using a triage grading system based on two factors: (1) possible impairment in patient condition or survivorship if surgery is not performed and (2) different regional health care resource settings (Fig. 2).
      Fig. 2
      Fig. 2Proposed emergency and elective procedures triage color codes to summarize collated evidence, integrating survival and healthcare resources.
      Published data were used for this systematic review; hence, no ethical approval was sought.

      4. Results

      4.1 Study selection and characteristics of the included guidelines

      All 15 included articles were accepted for publication between March 15 and April 17, 2020. The articles came from various institutions in Europe (Italy, UK, Belgium, and Switzerland), the Americas (USA, Canada, and Brazil), and Australia/New Zealand. All the 15 guidelines were based on expert opinion (Table 1).
      Table 1List of included articles.
      Author(s)/title/journalDate

      Month, day (2020)
      Situation reportedObjectiveSubareasMethodsTopics
      Global

      Total confirmed cases/total deaths
      Country

      Total confirmed cases

      Total deaths (new deaths in 24 h)
      Ficarra et al

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

      /Urology practice during COVID-19 pandemic/Minerva Urol Nefrol
      March 23332 930/14 50959 138 cases

      5476 (649) deaths

      Italy
      To summarize the procedures that should be performed in urgent, nonurgent, postponed conditions for the corresponding urological disorderUro-oncology, endourology, outpatients, benign conditions, emergenciesExpert opinionUrgencies, bladder, prostate, testicular, penile, cystoscopy
      Stensland et al
      • Stensland K.D.
      • Morgan T.M.
      • Moinzadeh A.
      • et al.
      Considerations in the triage of urologic surgeries during the COVID-19 pandemic.
      /Considerations in the triage of urologic surgeries during the COVID-19 pandemic/Eur Urol
      March 25413 467/18 43369 176 cases

      6820 (743) deaths

      Italy

      8081 cases

      422 (87) deaths

      UK
      To recommend surgeries and rationality to delay or treatUro-oncology, endourology, outpatients, benign conditions, emergenciesExpert opinionGeneral
      Mottrie et al

      Mottrie A. ERUS (EAU Robotic Urology Section) guidelines during COVID-19 emergency. https://uroweb.org/wp-content/uploads/ERUS-guidelines-for-COVID-def.pdf.

      /ERUS (EAU Robotic Urology Section) guidelines during COVID-19 emergency/Eur Urol
      March 25413 467/18 433220 516 cases

      11 986 (1797) deaths

      Europe
      Recommendations, based on the most recent scientific pieces of evidence, to safeguard the health of health care workers and their patients, in the context of robotic surgeryUro-oncology (robotics)GuidelinesUrothelial cancer, prostate, renal mass, testicular, functional, reconstructive
      USANZ

      USANZ. Guidelines for urological prioritisation during COVID-19. https://www.usanz.org.au/news-updates/our-announcements/usanz-announces-guidelines-urological-prioritisation-covid-19.

      /Guidelines for urological prioritisation during COVID-19
      March 25413 467/18 4332252 Cases

      8 (1) deaths

      Australia

      189 cases

      0 (0) death

      New Zealand
      Guidelines for surgical prioritizationUro-oncology, endourology, outpatients, benign conditions, emergenciesSociety guidelinesUro-oncology, urgencies, endourology, outpatients
      Katz et al

      Katz E.G., Stensland K.S., Mandeville J.A., et al. Triaging office-based urology procedures during the COVID-19 pandemic. J Urol. In press. https://doi.org/10.1097/JU.0000000000001034.

      /Triaging office-based urology procedures during the COVID-19 pandemic/J Urol
      March 25413 467/18 43351 914 cases

      673 (202) deaths

      USA
      Representing a collection of urologists from several institutions across 45 countries, with expertise in different subspecialty fields of urology—seek to provide 46 frameworks to help triage office-based proceduresUro-oncology, endourology, outpatients, benign conditions, emergenciesExpert opinionCystoscopy, prostate biopsies, ureteral stent removal, urodynamics, female urology
      Kutikov et al

      Kutikov A., Weinberg D.S., Edelman M.J., Horwitz E.M., Uzzo R.G., Fisher R.I. A war on two fronts: cancer care in the time of COVID-19. Ann Intern Med. In press. https://doi.org/10.7326/M20-1133.



      /A war on two fronts: cancer care in the time of COVID-19/Ann Intern Med
      March 27509 164/23 33568 334 cases

      991 (107) deaths

      USA
      Guidance on decisions about immediate cancer treatmentUro-oncologyExpert opinionUrothelial cancer, prostate, renal mass, testicular
      Goldman and Haber

      Goldman HB, Haber GP. Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 era. J Urol. In press. https://doi.org/10.1097/JU.0000000000001067.

      /Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 era/J Urol
      March 30693 282/33 106122 653 cases

      2112 (444) deaths

      USA
      Recommended surgical priority tiersUro-oncology, endourology, outpatients, benign conditions, emergenciesExpert opinionDiagnostic cystoscopy, surveillance cystoscopy, intravesical instillations for bladder cancer, prostate biopsies and administration of androgen deprivation, cystoscopy with ureteral stent removal, Foley and suprapubic catheter exchanges, urodynamics
      Ahmed et al

      Ahmed K., Hayat S., Dasgupta P. Global challenges to urology practice during COVID-19 pandemic. BJU Int. In press. https://doi.org/10.1111/bju.15082.

      /Global challenges to urology practice during COVID-19 pandemic/BJU Int
      April 3972 303/50 32138 700 cases

      2910 (389) deaths

      UK
      Putting together a collection of the latest BJUI-published articles on the topic.

      Adapted from RCS Intercollegiate General Surgery Guidance
      Uro-oncology, endourology, outpatients, benign conditions, emergenciesExpert opinionOutpatients, general safety
      Lalani et al
      • Lalani A.A.
      • Chi K.N.
      • Heng D.Y.C.
      • et al.
      Prioritizing systemic therapies for genitourinary malignancies: canadian recommendations during the COVID-19 pandemic.
      /Prioritizing systemic therapies for genitourinary malignancies: Canadian recommendations during the COVID-19 pandemic/Can Urol Assoc J
      April 51 133 758/62 78412 938 Cases

      214 (62) deaths

      Canada
      18 academic genitourinary medical oncologists from 11 cancer centers across Canada participated in preparing this guidance document for managing patients during the current pandemicUro-oncologyExpert opinionUrothelial cancer, prostate, renal mass, testicular
      Carneiro et al
      • Carneiro A.
      • Wroclawski M.L.
      • Nahar B.
      • et al.
      Impact of the COVID-19 pandemic on the urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period.
      /Impact of the COVID-19 pandemic on the urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period/Int Braz J Urol
      April 91 436 198/85 52113 717 cases

      667 (114) deaths

      Brazil
      Providing suggestions and recommendations for the management of urological conditions in times of COVID-19 crisis in Brazil and other low- and middle-income countriesUro-oncology, endourology, outpatients, benign conditions, emergenciesExpert opinionUrolithiasis, BPH, hematuria, urgencies, urodynamic, prostate biopsy, intravesical instillations, urothelial cancer, prostate, renal mass, testicular
      Quaedackers et al

      Quaedackers JSLT, Stein R, Bhatt N., et al. Clinical and surgical consequences of the COVID-19 pandemic for patients with pediatric urological problems: statement of the EAU Guidelines Panel for Paediatric Urology, March 30 2020. J Pediatr Urol. In press. https://doi.org/10.1016/j.jpurol.2020.04.007.

      /Clinical and surgical consequences of the COVID-19 pandemic for patients with pediatric urological problems: statement of the EAU Guidelines Panel for Paediatric Urology/J Pediatr Urol
      April 91 436 198/85 521759 661 cases

      61 516 (3877) deaths

      Europe
      Statement with recommendations for pediatric urological cases based on published studies as well as expert opinion of the pediatric urology guidelines panel of the EAUPediatric urologySociety guidelinesPediatric urology
      Proietti et al

      Proietti S., Gaboardi F., Giusti G. Endourological stone management in the era of the COVID-19. Eur Urol. In press. https://doi.org/10.1016/j.eururo.2020.03.042.

      /Endourological stone management in the era of the COVID-19/Eur Urol
      April 141 844 863/117 021159 516 Cases

      20 465 (564) deaths

      Italy
      Prioritization scheme for stone patients scheduled for surgery during the COVID-19 pandemicEndourologyExpert opinionUrolithiasis
      Gillessen et al
      • Gillessen S.
      • Powles T.
      Advice regarding systemic therapy in patients with urological cancers during the COVID-19 pandemic.
      /Advice regarding systemic therapy in patients with urological cancers during the COVID-19 pandemic/Eur Urol
      April 172 074 529/139 37826 651 cases

      1016 (43) deaths

      Switzerland

      103 097 cases

      13 729 (861)

      UK
      Providing treatment guidelines as a pragmatic perspective on the risk/benefit ratioUro-oncologyExpert opinionUrothelial cancer, prostate, renal mass, testicular
      Ribal et al
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      /EAU Guidelines Office-Rapid-Reaction-Group. An organization wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era
      April 172 074 529/139 3781 050 871 cases

      93 480 (4163) deaths

      Europe
      Treatment guidelines with most levels of evidence using a 4-level priorityUro-oncology, endourology, outpatients, benign conditions, emergenciesSociety guidelinesUrothelial cancer, prostate, renal mass, testicular
      Metzler et al
      • Metzler I.S.
      • Sorensen M.D.
      • Sweet R.M.
      • Harper J.D.
      Stone care triage during COVID-19 at the University of Washington.
      /Stone care triage during COVID-19 at the University of Washington/J Endourol
      April 172 074 529/139 378632 781 Cases

      28 221 (2350) deaths

      USA
      Categorizing patients into five groups of priorityEndourologyExpert opinionUrolithiasis
      BPH = benign prostatic hyperplasia; COVID-19 = coronavirus disease 2019; EAU = European Association of Urology; USANZ = Urological Society of Australia and New Zealand.

      4.2 Uro-oncology

      Postponing treatments for low- and intermediary-risk prostate cancer (PCa) was widely proposed as it is unlikely to result in clinical harm. Concerning high-risk PCa, some authors disagree upon postponement of surgery, while the others recommended proceeding with radical prostatectomy [

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

      ,

      USANZ. Guidelines for urological prioritisation during COVID-19. https://www.usanz.org.au/news-updates/our-announcements/usanz-announces-guidelines-urological-prioritisation-covid-19.

      ]. Goldman and Haber [

      Goldman HB, Haber GP. Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 era. J Urol. In press. https://doi.org/10.1097/JU.0000000000001067.

      ] stated that surgery can be delayed beyond 3 mo, and Ribal et al [
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      ] and Kutikov et al [

      Kutikov A., Weinberg D.S., Edelman M.J., Horwitz E.M., Uzzo R.G., Fisher R.I. A war on two fronts: cancer care in the time of COVID-19. Ann Intern Med. In press. https://doi.org/10.7326/M20-1133.

      ] recommended treatment before the end of 3 mo. Indeed, considering the EAU guideline, depending on the local situation of the pandemic, surgery for high-risk PCa can be postponed until after the pandemic [
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      ]. Prescribing neoadjuvant androgen deprivation therapy in this situation is an option [
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      ,

      Kutikov A., Weinberg D.S., Edelman M.J., Horwitz E.M., Uzzo R.G., Fisher R.I. A war on two fronts: cancer care in the time of COVID-19. Ann Intern Med. In press. https://doi.org/10.7326/M20-1133.

      ,
      • Carneiro A.
      • Wroclawski M.L.
      • Nahar B.
      • et al.
      Impact of the COVID-19 pandemic on the urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period.
      ]. In the case of muscle-invasive bladder cancer, several authors stated that radical cystectomy is nondeferrable and neoadjuvant chemotherapy can be omitted [5,6,8,]. Carneiro et al [7] suggested that neoadjuvant chemotherapy can be delayed for up to 6–8 wk and cystectomy can be delayed for up to 10 wk. The authors agreed that a delay of <3 mo is acceptable for T1b-T2 renal tumors. Another concern is metastatic renal cell carcinoma. The EAU panel discussed that cytoreductive surgery is controversial irrespective of the pandemic [
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      ]. Only two articles covered recommendations regarding adrenal masses, and both agreed that adrenal masses >4 cm or functional should be treated in <1 mo [4,8]. Orchiectomy for suspected testicular tumors is nondeferrable. While several authors suggested starting adjuvant radiotherapy or chemotherapy for stage I seminomas, the EAU guidelines recommended active surveillance as the first choice of management for stage I seminoma [
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      ]. Finally, concerning penile cancer, due to the lack of objective response and immunodeficiency from chemotherapy, palliative treatments and supportive care are recommended for metastatic penile cancer during the pandemic [
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      ]. The synthesis of recommendations for uro-oncology is provided in Table 2.
      Table 2Summary of guidelines: urologic oncology during COVID-19 pandemic.
      Prostate cancer
      Age/recommendationSurgeryRadiation
      Cancer risk
      LowIntermediateHighHigh riskMetastatic hormone sensitive
      Ficarra et al

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

      Nondeferrable
      Stensland et al
      • Stensland K.D.
      • Morgan T.M.
      • Moinzadeh A.
      • et al.
      Considerations in the triage of urologic surgeries during the COVID-19 pandemic.
      Safe delay 12 moSafe delay 12 moIf patient is ineligible for radiationConsider radiation (for intermediary risk = safe delay 12 mo)
      Mottrie

      Mottrie A. ERUS (EAU Robotic Urology Section) guidelines during COVID-19 emergency. https://uroweb.org/wp-content/uploads/ERUS-guidelines-for-COVID-def.pdf.

      To postponeHighMediumWeak
      USANZ

      USANZ. Guidelines for urological prioritisation during COVID-19. https://www.usanz.org.au/news-updates/our-announcements/usanz-announces-guidelines-urological-prioritisation-covid-19.

      Active surveillanceInitial ADT + deferred definitive treatmentAs planned
      Katz et al

      Katz E.G., Stensland K.S., Mandeville J.A., et al. Triaging office-based urology procedures during the COVID-19 pandemic. J Urol. In press. https://doi.org/10.1097/JU.0000000000001034.

      Delay 6-8 weeks
      Kutikov et al

      Kutikov A., Weinberg D.S., Edelman M.J., Horwitz E.M., Uzzo R.G., Fisher R.I. A war on two fronts: cancer care in the time of COVID-19. Ann Intern Med. In press. https://doi.org/10.7326/M20-1133.

      <50 yrSafe delay >3 moSafe delay >3 moProceed w/ immediate treatment. Delay <3 mo acceptableConsider starting androgen deprivation if significant delay
      50–70 yrBalance risk and benefits of immediate treatment
      >70 yrConsider starting androgen deprivation if significant delay
      Goldman and Haber

      Goldman HB, Haber GP. Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 era. J Urol. In press. https://doi.org/10.1097/JU.0000000000001067.

      Can be delayed beyond 12 wk
      Ahmed et al

      Ahmed K., Hayat S., Dasgupta P. Global challenges to urology practice during COVID-19 pandemic. BJU Int. In press. https://doi.org/10.1111/bju.15082.

      As planned
      Lalani et al
      • Lalani A.A.
      • Chi K.N.
      • Heng D.Y.C.
      • et al.
      Prioritizing systemic therapies for genitourinary malignancies: canadian recommendations during the COVID-19 pandemic.
      Can be delayed up to 6 mo
      Carneiro et al
      • Carneiro A.
      • Wroclawski M.L.
      • Nahar B.
      • et al.
      Impact of the COVID-19 pandemic on the urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period.
      PostponeConsider starting androgen deprivationConsider starting androgen deprivation
      Gillessen et al
      • Gillessen S.
      • Powles T.
      Advice regarding systemic therapy in patients with urological cancers during the COVID-19 pandemic.
      Commence where possible
      Ribal et al
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      Postpone treatment for 6-12 mo

      Active surveillance defer by 6 mo
      Surgery can be postponed until after pandemicTreat before end of 3 mo or can be postponed until after pandemic

      If patient anxious or N1, consider ADT + EBRT as alternative
      Treat before end of 3 mo (use immediate neoadjuvant ADT up to 6 mo followed by EBRT)Offer immediate systemic treatment to M1

      If low volume and planned ADT + EBRT, postpone EBRT until pandemic is no longer a major threat
      Summary44321
      Age/recommendationBladder cancerUpper tract U cancer
      Low gradeRefractory CISSuspected > cT1High-grade non–muscle invasiveMuscle invasiveMultimodality bladder sparingMetastatic first-line treatmentPresume low-risk (ureteroscopy or surgery)High-grade nephroureterectomyMetastatic first-line treatment
      Ficarra et al

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

      NondeferrableNondeferrableNondeferrableNondeferrable
      Stensland et al
      • Stensland K.D.
      • Morgan T.M.
      • Moinzadeh A.
      • et al.
      Considerations in the triage of urologic surgeries during the COVID-19 pandemic.
      Proceed w/ immediate treatmentProceed w/ immediate treatmentProceed w/ immediate treatment regardless of the receipt of neoadjuvant chemoProceed w/ immediate treatment
      Mottrie

      Mottrie A. ERUS (EAU Robotic Urology Section) guidelines during COVID-19 emergency. https://uroweb.org/wp-content/uploads/ERUS-guidelines-for-COVID-def.pdf.

      To postponeMediumWeakWeakWeakMediumWeak
      USANZ

      USANZ. Guidelines for urological prioritisation during COVID-19. https://www.usanz.org.au/news-updates/our-announcements/usanz-announces-guidelines-urological-prioritisation-covid-19.

      As plannedAs plannedAs plannedAs plannedConsider neoadjuvant chemo
      Kutikov et al

      Kutikov A., Weinberg D.S., Edelman M.J., Horwitz E.M., Uzzo R.G., Fisher R.I. A war on two fronts: cancer care in the time of COVID-19. Ann Intern Med. In press. https://doi.org/10.7326/M20-1133.

      <70 yrSafe delay >3 moProceed w/ treatment. Delay <3 mo acceptableProceed w/ treatment. Delay <3 mo acceptable
      >70 yrSafe delay >3 moBalance risk and benefits of immediate treatmentBalance risk and benefits of immediate treatment
      Goldman and Haber

      Goldman HB, Haber GP. Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 era. J Urol. In press. https://doi.org/10.1097/JU.0000000000001067.

      Delayed 4–12 wkScheduleScheduleDelayed beyond 4-12 wkSchedule
      Ahmed et al

      Ahmed K., Hayat S., Dasgupta P. Global challenges to urology practice during COVID-19 pandemic. BJU Int. In press. https://doi.org/10.1111/bju.15082.

      PriorityPriority
      Lalani et al
      • Lalani A.A.
      • Chi K.N.
      • Heng D.Y.C.
      • et al.
      Prioritizing systemic therapies for genitourinary malignancies: canadian recommendations during the COVID-19 pandemic.
      As plannedAdjuvant delayAdjuvant delay whenever possible
      Carneiro et al
      • Carneiro A.
      • Wroclawski M.L.
      • Nahar B.
      • et al.
      Impact of the COVID-19 pandemic on the urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period.
      DelayProceed w/ immediate treatmentProceed w/ immediate treatmentProceed w/ immediate treatmentNeoadjuvant chemo can be delayed for up to 6–8 wk, cystectomy delay for up 10 wkProceed w/ immediate treatment
      Gillessen et al
      • Gillessen S.
      • Powles T.
      Advice regarding systemic therapy in patients with urological cancers during the COVID-19 pandemic.
      Commenced where possibleCommenced where possible
      Ribal et al
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      Defer by 6 moTreat before end of 3 moTreat within <6 wkTreat within <6 wkTreat before end of 3 mo (consider omitting neoadjuvant chemo in T2/T3)Treat before end of 3 mo

      If palliative (consider only radio + chemo)
      Treat within <6 wk

      Chemo adjuvant for N+
      Not recommended to postpone >3 moTreat within <6 wkTreat before end of 3 mo
      Summary4222222311
      Age/

      recommendation
      Kidney cancerAdrenal
      SRM <4 cmT1b-T2T3Metastatic intermediate and poor riskCA suspected/symptomaticCA not suspected
      Ficarra et al

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

      Nondeferrable in selective casesNondeferrable
      Stensland et al
      • Stensland K.D.
      • Morgan T.M.
      • Moinzadeh A.
      • et al.
      Considerations in the triage of urologic surgeries during the COVID-19 pandemic.
      Delay <3 mo acceptable or other forms of ablative approachesDelay <3 mo acceptableProceed w/ treatmentProceed w/ immediate treatment
      Gillessen et al
      • Gillessen S.
      • Powles T.
      Advice regarding systemic therapy in patients with urological cancers during the COVID-19 pandemic.
      Commenced where possible
      Mottrie

      Mottrie A. ERUS (EAU Robotic Urology Section) guidelines during COVID-19 emergency. https://uroweb.org/wp-content/uploads/ERUS-guidelines-for-COVID-def.pdf.

      To postponeMediumMediumWeak
      USANZ

      USANZ. Guidelines for urological prioritisation during COVID-19. https://www.usanz.org.au/news-updates/our-announcements/usanz-announces-guidelines-urological-prioritisation-covid-19.

      >7 cm = as plannedAs planned
      Kutikov et al

      Kutikov A., Weinberg D.S., Edelman M.J., Horwitz E.M., Uzzo R.G., Fisher R.I. A war on two fronts: cancer care in the time of COVID-19. Ann Intern Med. In press. https://doi.org/10.7326/M20-1133.

      <50 yrSafe delay >3 moProceed w/ immediate treatment. Delay <3 mo acceptable
      50–70 yrSafe delay >3 moproceed w/ immediate treatment. Delay <3 mo acceptable
      >70 yrSafe delay >3 moBalance risk and benefits of immediate treatment
      Goldman and Haber

      Goldman HB, Haber GP. Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 era. J Urol. In press. https://doi.org/10.1097/JU.0000000000001067.

      Can be delayed beyond 12 wkCan be delayed 4–12 wkScheduledCan be delayed up to 4 wkCan be delayed beyond 12 wk
      Ahmed et al

      Ahmed K., Hayat S., Dasgupta P. Global challenges to urology practice during COVID-19 pandemic. BJU Int. In press. https://doi.org/10.1111/bju.15082.

      PriorityPriority
      Lalani et al
      • Lalani A.A.
      • Chi K.N.
      • Heng D.Y.C.
      • et al.
      Prioritizing systemic therapies for genitourinary malignancies: canadian recommendations during the COVID-19 pandemic.
      Recommended
      Carneiro et al
      • Carneiro A.
      • Wroclawski M.L.
      • Nahar B.
      • et al.
      Impact of the COVID-19 pandemic on the urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period.
      DelayAvoid delayProceed w/ treatmentProceed w/ treatment
      Ribal et al
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      Defer by 6 moTreat before end of 3 moTreat within <6 wkTreat within <6 wk

      Consider starting on VEGFR TKI rather than immune checkpoint inhibitor therapy

      Cytoreductive for asymptomatic is controversial irrespective of the pandemic
      Summary432124
      Testicular cancerPenile cancer
      OrchiectomyPostchemo RPLNDMetastaticLocalMetastatic
      Stage 1 seminomaStage ≥ IIB seminoma or NSGCT
      Ficarra et al

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

      NondeferrableNondeferrableNondeferrable
      Stensland et al
      • Stensland K.D.
      • Morgan T.M.
      • Moinzadeh A.
      • et al.
      Considerations in the triage of urologic surgeries during the COVID-19 pandemic.
      Proceed w/ immediate treatmentFavor chemotherapy or radiationChemotherapy use should be balanced by concern for immunosuppressionProceed w/ immediate treatment
      USANZ

      USANZ. Guidelines for urological prioritisation during COVID-19. https://www.usanz.org.au/news-updates/our-announcements/usanz-announces-guidelines-urological-prioritisation-covid-19.

      As plannedConsider deferral if suggestive of slowly growing mature teratoma
      Kutikov et al

      Kutikov A., Weinberg D.S., Edelman M.J., Horwitz E.M., Uzzo R.G., Fisher R.I. A war on two fronts: cancer care in the time of COVID-19. Ann Intern Med. In press. https://doi.org/10.7326/M20-1133.

      Proceed w/ immediate treatmentProceed w/ immediate treatment
      Goldman and Haber

      Goldman HB, Haber GP. Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 era. J Urol. In press. https://doi.org/10.1097/JU.0000000000001067.

      ScheduleCan be delayed up to 4 wkSchedule
      Lalani et al
      • Lalani A.A.
      • Chi K.N.
      • Heng D.Y.C.
      • et al.
      Prioritizing systemic therapies for genitourinary malignancies: canadian recommendations during the COVID-19 pandemic.
      Minimum delay if possibleNot to initiate adjuvant chemotherapy(Stage II seminoma or good-risk GCT with COVID-19 diagnosis) discuss chemotherapy delay whenever possible
      Carneiro et al
      • Carneiro A.
      • Wroclawski M.L.
      • Nahar B.
      • et al.
      Impact of the COVID-19 pandemic on the urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period.
      As soon as possibleRadiotherapy whenever possible (stage 2 low-volume seminoma)
      Gillessen et al
      • Gillessen S.
      • Powles T.
      Advice regarding systemic therapy in patients with urological cancers during the COVID-19 pandemic.
      Curative intent commenced where possible
      Ribal et al
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      May be postponed 2–3 dTreat within <6 wkActive surveillance is the first choice of managementTreat within <24 hTreat within <6 wkConsider palliation instead
      Summary122024
      ADT = androgen deprivation therapy; CA = cancer; chemo = chemotherapy; CIS = carcinoma in situ; COVID-19 = coronavirus disease 2019; EBRT = external beam radiation therapy; GCT = germ cell tumor; NSGCT = nonseminomatous GCT; RPLND = retroperitoneal lymph node dissection; SRM = small renal mass; TKI = tyrosine kinase inhibitor; U = urothelial, USANZ = Urological Society of Australia and New Zealand; VEGFR = vascular endothelial growth factor receptor; w/ = with.

      4.3 Endourology

      Nine of the included guidelines (60%) contained recommendations related to endourology procedures. Obstructed or infected renal and ureteral stones should be considered emergencies, and decompression should be performed. However, there is a consensus that treatment of nonobstructed renal stones can be delayed for months. Nevertheless, it is important to note that patients with symptomatic ureteral/renal stone and those with pre-existing stent should be considered priorities. However, authors disagreed on the maximum waiting time ranging from 6–8 to 12 wk [

      Goldman HB, Haber GP. Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 era. J Urol. In press. https://doi.org/10.1097/JU.0000000000001067.

      ,
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      ,
      • Metzler I.S.
      • Sorensen M.D.
      • Sweet R.M.
      • Harper J.D.
      Stone care triage during COVID-19 at the University of Washington.
      ]. A comparison of endourology recommendations between guidelines is displayed in Table 3.
      Table 3Summary of guidelines: endourology (urolithiasis) procedures during COVID-19 pandemic.
      Nonobstructing renal stoneNonobstructing ureteral stoneRenal colicStent removalStone with stent/nephrostomy tube or symptomaticObstructed kidney/infection
      Ficarra et al

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

      Postpone up to 6 moEmergency
      Stensland et al
      • Stensland K.D.
      • Morgan T.M.
      • Moinzadeh A.
      • et al.
      Considerations in the triage of urologic surgeries during the COVID-19 pandemic.
      up to 6–12 moEmergencyEmergency
      USANZ

      USANZ. Guidelines for urological prioritisation during COVID-19. https://www.usanz.org.au/news-updates/our-announcements/usanz-announces-guidelines-urological-prioritisation-covid-19.

      DelayDelayAs plannedAs plannedAs planned
      Katz et al

      Katz E.G., Stensland K.S., Mandeville J.A., et al. Triaging office-based urology procedures during the COVID-19 pandemic. J Urol. In press. https://doi.org/10.1097/JU.0000000000001034.

      Without delayConsider no delay
      Goldman and Haber

      Goldman HB, Haber GP. Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 era. J Urol. In press. https://doi.org/10.1097/JU.0000000000001067.

      Can be delayed beyond 12 wkScheduleCan be delayed up to 4 wkCan be delayed 4–12 wkEmergency
      Ahmed et al

      Ahmed K., Hayat S., Dasgupta P. Global challenges to urology practice during COVID-19 pandemic. BJU Int. In press. https://doi.org/10.1111/bju.15082.

      Urgent
      Carneiro et al
      • Carneiro A.
      • Wroclawski M.L.
      • Nahar B.
      • et al.
      Impact of the COVID-19 pandemic on the urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period.
      Managed clinicallyDelayNot to delayEmergency
      Proietti et al

      Proietti S., Gaboardi F., Giusti G. Endourological stone management in the era of the COVID-19. Eur Urol. In press. https://doi.org/10.1016/j.eururo.2020.03.042.

      DelayDelayManaged conservativelyDelayDelay but consider prioritiesNot to delay = only decompression
      Metzler et al
      • Metzler I.S.
      • Sorensen M.D.
      • Sweet R.M.
      • Harper J.D.
      Stone care triage during COVID-19 at the University of Washington.
      Postpone<2–4 wk<2–4 w (if recurrent ED visits)<4–8 wkEmergency
      Ribal et al
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      Clinical harm very unlikely if postponed >6 moClinical harm possible if postponed 3–4 mo, but unlikelyPain relief

      Avoid NSAIDs (ibuprofen) when possible
      Clinical harm very unlikely if postponed >6 mo (as soon situation allows)Clinical harm very likely if postponed >6 wkUrgent decompression of the collecting system (PCN or stent)
      Summary444320
      ED = emergency department; NSAID = nonsteriodal anti-inflammatory drug; PCN = percutaneous nephrostomy; USANZ = Urological Society of Australia and New Zealand.

      4.4 Laparoscopy and robotics

      Five of the 15 guidelines (30%) included recommendations for laparoscopic/robotic surgeries (Table 4). Some recommendations were made about the surgical technique and surgical team, such as lower electrocautery power settings to generate less smoke that could potentially transport the virus. Moreover, urologists can consider using lower pressure on insufflation system with integrated active smoke evacuation mode. In addition, presence in the operating room should be restricted to essential staff and the operating room team must wear full personal protective equipment.
      Table 4Summary of guidelines: robotic procedures during COVID-19 pandemic.
      Operation techniquePneumoperitoneum disinflationSurgical technique
      Mottrie

      Mottrie A. ERUS (EAU Robotic Urology Section) guidelines during COVID-19 emergency. https://uroweb.org/wp-content/uploads/ERUS-guidelines-for-COVID-def.pdf.

      Lower electrocautery power settingUse of system with integrated active smoke evacuation modeMinimum number of OR staff members

      Fellows temporarily suspended

      Adopt adequate PPE
      Ahmed et al

      Ahmed K., Hayat S., Dasgupta P. Global challenges to urology practice during COVID-19 pandemic. BJU Int. In press. https://doi.org/10.1111/bju.15082.

      Safety undeterminedPositive pressurization off
      Quaedackers et al

      Quaedackers JSLT, Stein R, Bhatt N., et al. Clinical and surgical consequences of the COVID-19 pandemic for patients with pediatric urological problems: statement of the EAU Guidelines Panel for Paediatric Urology, March 30 2020. J Pediatr Urol. In press. https://doi.org/10.1016/j.jpurol.2020.04.007.

      Use suction devices as much as possibleKeep intraperitoneal pressure as low as possible and aspirate the inflated CO2
      Carneiro et al
      • Carneiro A.
      • Wroclawski M.L.
      • Nahar B.
      • et al.
      Impact of the COVID-19 pandemic on the urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period.
      Pressure as low as possible + use filterPositive pressurization off

      Adopt adequate PPE
      Ribal et al
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      Electrosurgery units to the lowest settings

      Avoid or reduce use of monopolar electrosurgery, ultrasonic dissectors, and advanced bipolar
      Keep intraperitoneal pressure as low as possible and aspirate the inflated CO2 as much as possible before removing the trocarsAll nonessential staff should stay outside

      Surfaces should be decontamination with chlorine (5000–10 000 mg/l; note that chlorhexidine is ineffective against COVID-19 and is not appropriate)
      COVID-19 = coronavirus disease 2019; OR = operating room; PPE = personal protective equipment.

      4.5 Outpatient procedures (urological oncology, neurourology, female urology, and pediatric urology)

      Recommendations for ambulatory procedures are presented in Table 5. Not all experts recommended cystoscopy for immediate investigation of macroscopic hematuria, and a delay of 1–2 mo was recommended [
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      ]. Postponing prostate biopsy was not a consensus, and a case-by-case consideration should guide these decisions. Indeed, the Urological Society of Australia and New Zealand (USANZ) stated that Prostate Imaging Reporting and Data System (PIRADS) 4/5 should be managed as planned; EAU suggested that there should not be a delay of >6 wk for symptomatic patients [

      USANZ. Guidelines for urological prioritisation during COVID-19. https://www.usanz.org.au/news-updates/our-announcements/usanz-announces-guidelines-urological-prioritisation-covid-19.

      ,
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      ]. Stage 2 neuromodulation should be carried on due to the possibility of infection. Authors disagreed on the timing of treating mesh complications and fistula repair. Most pediatric urology surgeries can be postponed, except for some oncological conditions or those that may lead to loss of renal function.
      Table 5Summary of guidelines: outpatient procedures during COVID-19 pandemic (urologic oncology, neurourology, female urology, and pediatric urology).
      Uro-oncologyNeurourologyFemale urologyPediatric urology
      Bladder CAProstate biopsyNeurogenic cysto/BotoxUrodynamicsStage 2 sacral neuromodulationUrethral diverticula/mesh removal/sling incision/fistulaSlings, pelvic organ prolapse, sacral, pessary cleaning/exchange neuromodulation stage 1, artificial urethral sphincterPediatric: pyeloplasty with severe symptoms, posterior urethral valves. obstructed megaureter with loss of function, urolithiasis with recurring febrile infectionsReimplant, penile and benign testicular cases and buried penis, living donor renal tx
      Surveillance cystoscopyIntravesical BCG/chemotherapy induction or postoperativeIntravesical BCG/chemotherapy maintenance
      Low or intermediate riskHigh riskLow or intermediate riskHigh riskLow or intermediate riskHigh risk
      Ficarra et al

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

      PostponeDo not postponePostpone
      Stensland et al
      • Stensland K.D.
      • Morgan T.M.
      • Moinzadeh A.
      • et al.
      Considerations in the triage of urologic surgeries during the COVID-19 pandemic.
      Proceed w/ immediate treatmentDelayDelay
      Mottrie

      Mottrie A. ERUS (EAU Robotic Urology Section) guidelines during COVID-19 emergency. https://uroweb.org/wp-content/uploads/ERUS-guidelines-for-COVID-def.pdf.

      USANZ

      USANZ. Guidelines for urological prioritisation during COVID-19. https://www.usanz.org.au/news-updates/our-announcements/usanz-announces-guidelines-urological-prioritisation-covid-19.

      PIRADS 4/5 = as planned
      Katz et al

      Katz E.G., Stensland K.S., Mandeville J.A., et al. Triaging office-based urology procedures during the COVID-19 pandemic. J Urol. In press. https://doi.org/10.1097/JU.0000000000001034.

      Safe delay 3–6 moProceed w/ immediate investigationPatients should be prioritized for treatmentDelay indefinitelyStop and re-evaluate in 3 moSafe delay 3 mo, suggest transperineal

      Safe delay 3–6 mo (if low or intermediate PCa suspected)
      Delay for 3–6 mo GU tract dysfunctionWithout delayDelay 3–6 mo
      Goldman and Haber

      Goldman HB, Haber GP. Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 era. J Urol. In press. https://doi.org/10.1097/JU.0000000000001067.

      PSA >15 = can be delayed 4–12 wkNeurogenic = can be delayed up to 4 wkCan be delayed 4–12 wkScheduleCan be delayed 4–12 wkCan be delayed beyond 12 wkCan be delayed beyond 12 wk
      Carneiro et al
      • Carneiro A.
      • Wroclawski M.L.
      • Nahar B.
      • et al.
      Impact of the COVID-19 pandemic on the urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period.
      PostponeTreat as plannedTreat as plannedPostpone, suggestion under localDelay
      Quaedackers et al

      Quaedackers JSLT, Stein R, Bhatt N., et al. Clinical and surgical consequences of the COVID-19 pandemic for patients with pediatric urological problems: statement of the EAU Guidelines Panel for Paediatric Urology, March 30 2020. J Pediatr Urol. In press. https://doi.org/10.1016/j.jpurol.2020.04.007.

      As plannedPostpone
      Ribal et al
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      Defer by 6 moFollow-up before end of 3 moMay be abandonedTreat within <6 wkMay be abandonedTreat within <6 wkPostponed until the end of the pandemic (at least as long as the confinement is ongoing)

      Diagnose within <6 wk (biopsy without MRI if locally advanced or highly symptomatic)
      DeferredClinical harm very likely if postponed >6 wkClinical harm very unlikely if postponed 6 moClinical harm very likely if postponed >6 wkDefer by 6 mo

      Reimplant (<3 mo)
      Summary44424342423414
      BCG = bacillus Calmette-Guerin; CA = cancer; cysto = cystoscopy; COVID-19 = coronavirus disease 2019; MRI = magnetic resonance imaging; PCa = prostate cancer; PIRADS = Prostate Imaging Reporting and Data System; PSA = prostate-specific antigen; tx = transplant, USANZ = Urological Society of Australia and New Zealand; w/ = with.

      4.6 Kidney transplantation, infections, trauma, low urinary tract obstruction, and andrology

      All but one guideline provided recommendations for managing emergencies, which were grouped into infections, trauma/hemorrhage, benign prostatic hyperplasia and urethral stricture, transplantation, and andrology (Table 6). With respect to renal transplantation the EAU proposed that this be postponed for >3 mo [
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      ].
      Table 6Summary of guidelines: procedures of other subdisciplines during COVID-19 pandemic (transplantation, infections, trauma, low urinary tract obstruction, and andrology).
      TransplantationInfectionTraumaHemorrhageBPHUrethraAndrology
      Cadaveric renal txLiving donor renal txUrological abscess/wound washoutsurgical bleeding/traumaHematuria—macro (cystoscopy for)Clot retentionUrinary retention unable to place catheterBPH on self-catheterization or safe voidingUrethral stricture with imminent obstructionPenile fracturePriapismInfected prosthesis/devices (include artificial sphincter and penile implants)Acute torsionPenile prosthesis, infertility/non--CA scrotal surgery, vasectomy/circumcision, buried penis, Peyronies
      Ficarra et al

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

      EmergencyEmergencyEmergencyEmergencyEmergencyEmergencyEmergency
      Stensland et al
      • Stensland K.D.
      • Morgan T.M.
      • Moinzadeh A.
      • et al.
      Considerations in the triage of urologic surgeries during the COVID-19 pandemic.
      Proceed w/ immediate treatmentDelayProceed w/ immediate treatmentEmergencyEmergencyProceed w/ immediate treatmentDelayProceed w/ suprapubic tubeEmergencyProceed w/ immediate treatmentProceed w/ immediate treatmentDelay
      Mottrie

      Mottrie A. ERUS (EAU Robotic Urology Section) guidelines during COVID-19 emergency. https://uroweb.org/wp-content/uploads/ERUS-guidelines-for-COVID-def.pdf.

      UrgencyUrgency
      USANZ

      USANZ. Guidelines for urological prioritisation during COVID-19. https://www.usanz.org.au/news-updates/our-announcements/usanz-announces-guidelines-urological-prioritisation-covid-19.

      As plannedDelay of 1–2 moTURP only if not suitable for self-catheterization or indwelling catheterAs planned
      Katz et al

      Katz E.G., Stensland K.S., Mandeville J.A., et al. Triaging office-based urology procedures during the COVID-19 pandemic. J Urol. In press. https://doi.org/10.1097/JU.0000000000001034.

      Without delay
      Goldman and Haber

      Goldman HB, Haber GP. Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 era. J Urol. In press. https://doi.org/10.1097/JU.0000000000001067.

      EmergencyCan be delayed beyond 12 wkEmergencyEmergencyEmergencyEmergencyEmergencyCan be delayed beyond 12 wkScheduleEmergencyEmergencyEmergencyEmergencyCan be delayed beyond 12 wk
      Ahmed et al

      Ahmed K., Hayat S., Dasgupta P. Global challenges to urology practice during COVID-19 pandemic. BJU Int. In press. https://doi.org/10.1111/bju.15082.

      UrgentAs plannedUrgent
      Carneiro et al
      • Carneiro A.
      • Wroclawski M.L.
      • Nahar B.
      • et al.
      Impact of the COVID-19 pandemic on the urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period.
      EmergencyEmergencyEmergencyEmergencyEmergencyPostponePostponeEmergency
      Ribal et al
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      Clinical harm possible if postponed 3–4 mo but unlikely (case-by-case discussion)Clinical harm very unlikely if postponed 6 moLife-threatening situationLife-threatening situationDiagnose within <6 wkDiagnose within <24 hClinical harm very unlikely if postponed 6 moClinical harm very likely if postponed >6 wkTreat within <24 hClinical harm possible if postponed 3–4 mo but unlikely
      Summary24001004100004
      BPH = benign prostatic hyperplasia; CA = cancer; COVID-19 = coronavirus disease 2019; TURP = transurethral resection of the prostate; tx = transplant; USANZ = Urological Society of Australia and New Zealand; w/ = with.

      5. Discussion

      This systematic review aimed to synthesize available recommendations on risk/benefit ratio of delaying versus proceeding with the most commonly performed diagnostics and surgeries in urology during the COVID-19 crisis.
      Redirection of resources and the prioritization of medical care aims to allow continuity of appropriate and timely assessment and management for patients with high-risk conditions, while minimizing undue risk and strain from conditions for which care can be delayed safely. In this regard, feasibility of the health care infrastructure should be determined according to the availability of health system resources, such as intensive care unit (ICU) beds, ventilators, personal protective equipment, COVID-19 tests, and health care professionals. The use of good surgical judgment can reduce the burden on health care systems across the globe. Nonoperative management should be considered whenever it is clinically appropriate for the patient. These decisions can also help limit team staffing and optimize local health care capacity to respond to the crisis.
      Our systematic review of 15 clinical practice guidelines and recommendations across major urology subareas, and most routine conditions identified 761 separate recommendations for best urological practice during the COVID-19 crisis. The lack of standardization and differences among guidelines may result in skepticism about how to match resources with patient need. Some of this variation may be due to the date of publication amid the rapidly evolving case numbers and different available resources across different geographic areas.
      Three of 15 (20%) guidelines have been endorsed by a specific panel or society: EAU, EAU Robotic Urology Section (ERUS), and USANZ [

      USANZ. Guidelines for urological prioritisation during COVID-19. https://www.usanz.org.au/news-updates/our-announcements/usanz-announces-guidelines-urological-prioritisation-covid-19.

      ,
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      ,

      Mottrie A. ERUS (EAU Robotic Urology Section) guidelines during COVID-19 emergency. https://uroweb.org/wp-content/uploads/ERUS-guidelines-for-COVID-def.pdf.

      ].
      In this review, we noted a paucity of recommendations on management of urological conditions with a more prolonged crisis. Only one guideline stated that recommendations should be revised if the crisis had a duration of ≥3 mo [
      • Carneiro A.
      • Wroclawski M.L.
      • Nahar B.
      • et al.
      Impact of the COVID-19 pandemic on the urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period.
      ]. The American College of Surgeons (ACS) was referenced by the AUA web page. The ACS organized decision making into three different scenarios [

      American College of Surgeons. COVID-19 and surgery. https://www.facs.org/covid-19.

      ]. Phase 1 is the preparation phase for institutions and localities where COVID-19 cases are not in the rapid escalation phase, in which only a few patients are hospitalized, and beds and ICU ventilators not exhausted. In this setting, the regional leadership and surgical teams must plan to treat diseases as indicated, given that a delay in treatment could reduce the chance of being cured. Phase 2 and phase 3 are urgent settings where hospital resources are all routed to COVID-19. Pragmatically, four of the 15 papers provided the possibility of individualization of their recommendations according to different communities and hospital resources realities, using a tier system [

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

      ,

      Goldman HB, Haber GP. Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 era. J Urol. In press. https://doi.org/10.1097/JU.0000000000001067.

      ,
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      ,
      • Carneiro A.
      • Wroclawski M.L.
      • Nahar B.
      • et al.
      Impact of the COVID-19 pandemic on the urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period.
      ]. A number of variables should be considered, such as availability of resources, whether a particular local institution is assessed as a COVID-free hospital, capacity of ICU beds and ventilators, and whether the curve has flattened.
      Most of the articles reviewed are recommendations and not guidelines, primarily based on expert opinion. An exception is the EAU guidelines, which were a monumental effort proposed by a task force of 250 experts and provide evidence correlating the delay of treatment and clinical harm to survival or progression. In addition, the EAU clarifies that its guidelines are endorsed by national societies in 72 countries, providing a supporting document that urologists can use in teamwork and collaboration in their hospitals.
      According to Lei et al [

      Lei S., Jiang F., Su W., et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. EClinicalMedicine. In press. https://doi.org/10.1016/j.eclinm.2020.100331.

      ], seven of 34 (20.5%) patients died after elective surgeries in Wuhan. At presentation, these patients were asymptomatic carriers and probably were in incubation phase or were infected at the hospital.
      In many parts of the world, people have been asked to stay at home, and public health authorities made it mandatory to postpone elective surgery. Public health orders such as social distancing and lockdown appear to be effective at reducing the local spread of COVID-19. As the situation continues to evolve, including attempts at returning to the new normal and the threat of additional waves of infection being presented, these recommendations will require updating.
      Considering uro-oncology, the pandemic has reinforced the concept of active surveillance for low-risk genitourinary tumors. Conversely, there is evidence that a delay of >3 mo has a negative impact on the survival of patients with urothelial tumors, particularly those at high risk, and such tumors should be managed with priority. While the majority of the articles included recommendations to postpone treatment for low- and intermediary-risk PCa, the scope of recommendations regarding high-risk PCa varied. For example, Kutikov et al [

      Kutikov A., Weinberg D.S., Edelman M.J., Horwitz E.M., Uzzo R.G., Fisher R.I. A war on two fronts: cancer care in the time of COVID-19. Ann Intern Med. In press. https://doi.org/10.7326/M20-1133.

      ] recommended that high-risk PCa should be treated immediately, Stensland et al [
      • Stensland K.D.
      • Morgan T.M.
      • Moinzadeh A.
      • et al.
      Considerations in the triage of urologic surgeries during the COVID-19 pandemic.
      ] recommended that these patients should not be operated and they should be referred to radiotherapy, and Ribal et al [
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      ] recommended that surgery can be postponed up to 3 mo or even after the COVID-19 situation has settled.
      It is important to note that patients with obstructing and infected stones should be managed, preferably by immediate decompression. In patients who have risk factors, such as pre-existing indwelling ureteral stent, symptomatic, recurrent emergency visits, solitary kidney, and bilateral ureteral calculi, close monitoring for clinical progression is warranted by telehealth, with a low threshold for additional evaluation.
      Most articles point toward taking precautions to avoid contamination in the operating room. The safety of the resterilization process of endourological materials is a concern. It is highly recommended to clean surfaces with appropriate disinfectants with proven activity against enveloped viruses (hypochlorite), as 0.02% chlorhexidine digluconate can be less effective [
      • Ribal M.J.
      • Cornford P.
      • Briganti A.
      • et al.
      EAU Guidelines Office Rapid Reaction Group: An organization-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era.
      ]. Numerous uncertainties remain in laparoscopic/robotic surgeries. It is a general recommendation to avoid generating aerosols through manipulation of the trocars and pneumoperitoneum. Concerns have also been raised about the use of electrocautery and positive pressurization rooms.
      In normal times, to proceed as planned to perform a cadaveric kidney transplantation is the rule. However, special attention is needed in emergency situations such as the COVID-19 pandemic. Proponents of postponement argue that renal transplantation is highly complex and may require intensive support from a multidisciplinary team, and resources directed to combat COVID-19 might be compromised.
      The timing of ambulatory cystoscopy for the diagnosis of macroscopic hematuria was an area of disagreement. Although most authors recommend proceeding with investigation of macrohematuria, two guidelines (USANZ and EAU) suggest a delay between 1 and 2 mo.
      Management of emergencies (eg, ischemic testicular torsion, low-flow priapism, clot retention, and trauma) should not be delayed.
      There are several limitations in our systematic review. Although these guidelines reflect an impressive effort to quickly provide guidance to urologists during a rapidly evolving emergency, the methodological quality of most guidelines was considered to be low to moderate. The level of evidence did not differ much between guidelines, and all of them were based on expert opinions. No grading of recommendations was reported. Indeed, this review highlights the need for high-quality guidelines that could be referenced in the case of future pandemics or other major emergencies. In this review, we attempted to classify recommendations in a similar fashion to Goldman and Haber’s [

      Goldman HB, Haber GP. Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 era. J Urol. In press. https://doi.org/10.1097/JU.0000000000001067.

      ] priority tiers.

      6. Conclusions

      Multiple published recommendations exist to guide urology teams during the COVID-19 crisis. Recommendations support the use of active surveillance in lower-risk tumors (low-risk PCa, low-grade bladder cancer, and small renal masses), as well as considering omission of systemic therapies (neoadjuvant or adjuvant treatments) or cytoreductive nephrectomy in some advanced cases. Moreover, there was consensus to propose medical expulsive therapy for uncomplicated ureteral stones, but that infection and/or obstruction of the kidneys with a real risk of urosepsis or functional sequelae must be treated accordingly. Intravesical clots in active hematuria, infected implants, or postoperative hemorrhagic and ischemic complications are considered urological emergencies and must be treated immediately even at a time of pressure to the local health system.
      Author contributions: Flavio Lobo Heldwein had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
      Study concept and design: Heldwein, Lima, Carneiro, Wroclawski.
      Acquisition of data: Heldwein, Wroclawski.
      Analysis and interpretation of data: Heldwein, Loeb.
      Drafting of the manuscript: Heldwein, Loeb.
      Critical revision of the manuscript for important intellectual content: Sridhar, Loeb, Teoh.
      Statistical analysis: Heldwein.
      Obtaining funding: None.
      Administrative, technical, or material support: None.
      Supervision: Wroclawski, Heldwein.
      Other: None.
      Financial disclosures: Flavio Lobo Heldwein certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: Flavio Lobo Heldwein received honorarium from Janssen. Stacy Loeb reports reimbursed travel from Sanofi and equity in Gilead. Fabio Sepulveda Lima reports reimbursed travel from Boston Scientific. Jeremy Yuen-Chun Teoh received honorarium from Olympus and Boston Scientific, travel grants from Olympus and Boston Scientific, and research grants from Olympus and Storz.
      Funding/Support and role of the sponsor: Stacy Loeb is supported by the Edward Blank and Sharon Cosloy-Blank Family Foundation.

      Appendix A. Supplementary data

      The following are Supplementary data to this article:

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