Triaging Office Based Urology Procedures during the COVID-19 Pandemic

You have accessJournal of UrologyJU Forum1 Jul 2020Triaging Office Based Urology Procedures during the COVID-19 Pandemic Eric G. Katz, Kristian D. Stensland, Jessica A. Mandeville, Lara S. MacLachlan, Alireza Moinzadeh, Andrea Sorcini, Harras B. Zaid, Laura Bukavina, Lee Ponsky, and Sam S. Chang Eric G. KatzEric G. Katz Institute of Urology, Lahey Hospital and Medical Center, Burlington, Massachusetts , Kristian D. StenslandKristian D. Stensland Institute of Urology, Lahey Hospital and Medical Center, Burlington, Massachusetts , Jessica A. MandevilleJessica A. Mandeville Institute of Urology, Lahey Hospital and Medical Center, Burlington, Massachusetts , Lara S. MacLachlanLara S. MacLachlan Institute of Urology, Lahey Hospital and Medical Center, Burlington, Massachusetts , Alireza MoinzadehAlireza Moinzadeh Institute of Urology, Lahey Hospital and Medical Center, Burlington, Massachusetts , Andrea SorciniAndrea Sorcini Institute of Urology, Lahey Hospital and Medical Center, Burlington, Massachusetts , Harras B. ZaidHarras B. Zaid *Correspondence: 41 Mall Road, Burlington, Massachusetts telephone: 1-781-744-8420; FAX: 1-781-744-5429; E-mail Address: email protected Institute of Urology, Lahey Hospital and Medical Center, Burlington, Massachusetts , Laura BukavinaLaura Bukavina Case Western Reserve School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio , Lee PonskyLee Ponsky Case Western Reserve School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio , and Sam S. ChangSam S. Chang Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee View All Author Informationhttps://doi.org/10.1097/JU.0000000000001034AboutPDF Cite Export CitationSelect Citation formatNLMIEEEACMAPAChicagoMLAHarvardTips on citation downloadDownload citationCopy citation ToolsAdd to favoritesTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail The COVID-19 pandemic is placing an unprecedented strain on health care systems across the world. Hospitals and medical practices have been asked to acclimate to this ever-changing environment by diverting personnel and equipment to help with this crisis.1 Within the outpatient setting the COVID-19 pandemic arouses the particular public health concerns of disease exposure and use of resources. An active clinic environment increases traffic on the hospital campus as well as potential exposure of patients and health care personnel, and it violates contamination strategies such as social distancing. This is especially troubling with the older urological patient population, which is at higher risk for complications from exposure to COVID-19. Furthermore, there are concerns about resource utilization, especially of personal protective equipment, as supply chains fail to meet demands in many health care settings.2 Indeed, every effort should be taken to keep our patients at home, and the rapid expansion of telehealth will allow for many outpatient evaluations to be completed virtually for the foreseeable future.3 While recent guidelines have provided a framework for determining which urology operations should be safely delayed, many questions remain with regard to triaging office based procedures.4 As a representative collection of urologists from several institutions across the U.S. with expertise in different subspecialty fields of urology, we provide a framework to help triage office based procedures during the COVID-19 pandemic. These recommendations are based on the expert opinion of the authors. They are not intended to be strict guidelines, and are not endorsed by any specific society or panel from the American Urological Association. Furthermore, approaches to all of these urological problems must be tailored to individual settings, personnel and resources, and must always incorporate shared decision making between clinician and patient. The procedures evaluated are summarized in the Appendix. Based on the best available data, recommendations are made as to which procedural evaluations should continue owing to diagnostic yield and risk of missed/delayed treatment. This is not meant to be a complete and exhaustive list; rather, it encompasses some of the most commonly performed procedures in the outpatient setting. With regard to procedures targeted at the symptomatology of conditions, such as stress urinary incontinence (urethral bulking), interstitial cystitis (intravesical dimethyl sulfoxide instillation), lower urinary tract symptoms (UroLift®/Rezūm™) and overactive bladder (intravesical Botox, percutaneous tibial nerve stimulation, peripheral nerve evaluation for InterStim), we believe these can safely be delayed for at least 3 to 6 months depending on individual settings, availability of resources and shared decision making. Appendix Procedure Indication Recommendation Comments Diagnostic cystoscopy Gross hematuria Consider performing full evaluation without delay Diagnostic yield in finding bladder cancer or upper tract malignancy is high in this group Microscopic hematuria with risk factors (smoking history, occupational/chemical exposure, irritative voiding symptoms) Consider delaying evaluation up to 3 months unless patient is symptomatic Diagnostic yield for urinary tract malignancy is increased in this setting compared to asymptomatic patients, especially when multiple risk factors are present Microscopic hematuria without risk factors Delay evaluation for 3 months or longer as necessary Risk of urinary tract malignancy in a diverse patient cohort with asymptomatic microscopic hematuria is low Surveillance cystoscopy Assessment of response to treatment or surveillance of high risk nonmuscle invasive bladder cancer (NMIBC) within 6 months of initial diagnosis Consider performing evaluation without delay There is a high risk of recurrence and/or progression within the first 6 months of diagnosis Assessment of response to treatment or surveillance of high risk NMIBC beyond 6 months of initial diagnosis Consider delaying evaluation up to 3 months High risk patients with stable disease may be at lower risk for relapse Assessment of response to treatment or surveillance of low/intermediate risk NMIBC regardless of when diagnosis was made Delay evaluation for 3-6 months Tumor recurrence in this group is low Induction intravesical bacillus-Calmette Guérin (BCG) chemotherapy High risk or intermediate NMIBC These patients should be prioritized for treatment, though they may also require a delay in therapy depending on local needs/resources Induction intravesical therapy provides a significant benefit by reducing disease recurrence and progression Maintenance intravesical BCG/chemotherapy High risk NMIBC Stop maintenance therapy and re-evaluate its use/need in 3 months While maintenance therapy is important, the most significant benefit from intravesical treatment is likely during the induction course Intermediate risk NMIBC Delay indefinitely Prostate biopsy Risk factors for high risk prostate cancer, including prostate specific antigen (PSA) greater than 20, rapid PSA doubling time less than 6 months, digital rectal examination concerning for clinical T3 disease, and/or local or systemic symptoms Attempt to obtain magnetic resonance imaging initially; delay biopsy up to 3 months; if performing biopsy, suggest transperineal biopsy, if possible, to minimize infectious risks and fecal exposure Delay in diagnosis of high risk prostate cancer by 3 months is unlikely to change long-term oncologic outcome No risk factors for high risk prostate cancer and/or routine biopsy for established patients on active surveillance Delay 3-6 months Delay in diagnosis of intermediate risk prostate cancer by 3-6 months is unlikely to change long-term oncologic outcome Androgen Deprivation Therapy Prostate cancer Delay 6-8 weeks Delay in treatment is unlikely to change oncologic outcome or symptomatology Cystoscopy and ureteral stent removal Indwelling ureteral stent after ureteroscopy Consider performing without delay Risk of encrustation, urinary tract infections, ongoing symptoms requiring emergency room visit or hospital admission, retained/forgotten stent should be minimized Exchange of chronic Foley/suprapubic catheter Indwelling catheter Extend exchange intervals for additional 2-4 weeks if no history of encrusted catheter, difficult exchange, recurrent urinary tract infections Urodynamics Evaluation of genitourinary tract dysfunction Delay for 3-6 months Pessary cleaning/exchange Stress urinary incontinence, pelvic organ prolapse Delay for up to 3 months if no evidence of vaginal wall erosion or ulceration Risk of rectovaginal or vesicovaginal fistula References 1. World Health Organization: Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). Available at https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf. Accessed March 22, 2020. Google Scholar 2. Centers for Disease Control and Prevention: Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States. Available at https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-hcf.html. Accessed March 22, 2020. Google Scholar 3. : Virtually perfect? Telemedicine for Covid-19. N Engl J Med. Available at https://www.nejm.org/doi/full/10.1056/NEJMp2003539. Accessed March 22, 2020. Google Scholar 4. : Consideration in the triage of urologic surgeries During the COVID-19 pandemic. Eur Urol 2020; doi: 10.1016/j.eururo.2020.03.027. Crossref, Google Scholar © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited bySmith J (2020) This Month in Adult UrologyJournal of Urology, VOL. 204, NO. 1, (1-3), Online publication date: 1-Jul-2020. Volume 204Issue 1July 2020Page: 9-10 Advertisement Copyright FAX: 1-781-744-5429; E-mail Address: email protected More articles by this author Laura Bukavina Case Western Reserve School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio More articles by this author Lee Ponsky Case Western Reserve School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio More articles by this author Sam S. Chang Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...