Implications and effects of COVID-19 on diagnosis and management of prostate cancer.

PURPOSE OF REVIEW: The Coronavirus disease 2019 (COVID-19) pandemic has led to uncertainty on the optimal management for prostate cancer (PCa). This narrative review aims to shed light on the optimal diagnosis and management of patients with or suspected to have PCa. RECENT FINDINGS: Faecal-oral or aerosol transmission is possible during prostate procedures; caution must be in place when performing digital rectal examinations, transrectal ultrasound-guided prostate biopsies and prostate surgeries requiring general anaesthesia. Patients must also be triaged using preoperative polymerase chain reaction tests for COVID-19. COVID-19 has accelerated the adoption of multiparametric Magnetic Resonance Imaging (MRI), reducing the need for prostate biopsy unless when absolutely indicated, and the risk of COVID-19 spread can be reduced. Combined with prostate-specific antigen (PSA) density, amongst other factors, multiparametric MRI could reduce unnecessary biopsies in patients with little chance of clinically significant PCa. Treatment of PCa should be stratified by the risk level and preferences of the patient. COVID-19 has accelerated the development of telemedicine and clinicians should utilise safe and effective teleconsultations to protect themselves and their patients. SUMMARY: COVID-19 transmission during prostate procedures is possible. Patients with a Prostate Imaging-Reporting and Data System (PI-RADS) of <3 and PSA density <0.15 ng/ml/ml are deemed low-risk and are safe to undergo surveillance without MRI-targeted biopsy. Intermediate- or high-risk patients should be offered definitive treatment within four months or 30days of diagnosis to avoid compromising treatment outcomes; three-month courses of neoadjuvant androgen deprivation therapy can be considered when a delay of surgery is anticipated.

Effects of Delayed Radical Prostatectomy and Active Surveillance on Localised Prostate Cancer-A Systematic Review and Meta-Analysis.

External factors, such as the coronavirus disease 2019 (COVID-19), can lead to cancellations and backlogs of cancer surgeries. The effects of these delays are unclear. This study summarised the evidence surrounding expectant management, delay radical prostatectomy (RP), and neoadjuvant hormone therapy (NHT) compared to immediate RP. MEDLINE and EMBASE was searched for randomised controlled trials (RCTs) and non-randomised controlled studies pertaining to the review question. Risks of biases (RoB) were evaluated using the RoB 2.0 tool and the Newcastle-Ottawa Scale. A total of 57 studies were included. Meta-analysis of four RCTs found overall survival and cancer-specific survival were significantly worsened amongst intermediate-risk patients undergoing active monitoring, observation, or watchful waiting but not in low- and high-risk patients. Evidence from 33 observational studies comparing delayed RP and immediate RP is contradictory. However, conservative estimates of delays over 5 months, 4 months, and 30 days for low-risk, intermediate-risk, and high-risk patients, respectively, have been associated with significantly worse pathological and oncological outcomes in individual studies. In 11 RCTs, a 3-month course of NHT has been shown to improve pathological outcomes in most patients, but its effect on oncological outcomes is apparently limited.

How to manage patients with suspected upper tract urothelial carcinoma in the pandemic of COVID-19?

BACKGROUND: The pandemic of COVID-19 has disrupted the clinical pathway for patients with suspected upper tract urothelial carcinoma (UTUC). This aims to investigate the optimal management of UTUC during the pandemic by determining 1) Whether a three-month delay of RNU leads to worsened overall survival, 2) Whether radical nephroureterectomy (RNU) can be performed without prior diagnostic ureteroscopy (URS). METHODS: Consecutive patients with RNU performed for suspected UTUC in four hospitals in Hong Kong and Taiwan were included. Patients with histologically proven UTUC and with RNU performed within one year were dichotomized into early (≤3 months) and delayed (>3 months) RNU groups. Diagnostic performances of predictive models based on pre-URS factors (gross haematuria, suspicious or malignant urine cytology, and filling defect or contrast-enhancing mass on computed tomography), with or without URS, were analysed using receiver operating characteristics and area under curve (AUC). Overall survival was analysed using Kaplan-Meier method and multivariate Cox regression analysis. RESULTS: Between 2000 and 2019, 665 patients underwent RNU, and 491 of them had prior diagnostic URS. The early RNU group had a better overall survival (P = 0.015). Early RNU was associated with a better overall survival upon multivariate analysis (HR 1.55, 95% CI 1.03-2.33, P = 0.035). Large tumour size, multi-focal tumour, T2 or above disease, and positive nodal status were associated with a poorer overall survival. A combination of any 2 out of the 3 pre-URS factors achieved a positive predictive value of 99.5 to 100%. Presence of all 3 pre-URS factors achieved an AUC of 0.851 with URS, and AUC of 0.809 without URS. CONCLUSIONS: A delay of RNU for over 3 months was associated with poorer overall survival and has to be avoided despite the current COVID-19. We can also consider direct RNU based on clinical factors alone. This also avoids URS hospitalization and expedites the clinical pathway of UTUC.

Risks of AKI and Major Adverse Clinical Outcomes in Patients with Severe Acute Respiratory Syndrome or Coronavirus Disease 2019.

BACKGROUND: Severe acute respiratory syndrome (SARS) and coronavirus disease 2019 (COVID-19) are closely related. The effect of AKI on the clinical outcomes of these two conditions is unclear. METHODS: This retrospective, territory-wide cohort study used an electronic public healthcare database in Hong Kong to identify patients with SARS or COVID-19 by diagnosis codes, virologic results, or both. The primary endpoint was a composite of intensive care unit admission, use of invasive mechanical ventilation, and/or death. RESULTS: We identified 1670 patients with SARS and 1040 patients with COVID-19 (median ages, 41 versus 35 years, respectively). Among patients with SARS, 26% met the primary endpoint versus 5.3% of those with COVID-19. Diabetes mellitus, abnormal liver function, and AKI were factors significantly associated with the primary endpoint among patients with either SARS or COVID-19. Among patients with SARS, 7.9%, 2.1%, and 3.7% developed stage 1, stage 2, and stage 3 AKI, respectively; among those with COVID-19, 6.6%, 0.4%, and 1.1% developed stage 1, stage 2, and stage 3 AKI, respectively. In both groups, factors significantly associated with AKI included diabetes mellitus and hypertension. Among patients with AKI, those with COVID-19 had a lower rate of major adverse clinical outcomes versus patients with SARS. Renal function recovery usually occurred within 30 days after an initial AKI event. CONCLUSIONS: AKI rates were higher among patients with SARS than those with COVID-19. AKI was associated with major adverse clinical outcomes for both diseases. Patients with diabetes mellitus and abnormal liver function were also at risk of developing severe consequences after SARS and COVID-19 infection.

A Global Survey on the Impact of COVID-19 on Urological Services.

BACKGROUND: The World Health Organization (WHO) declared coronavirus disease-19 (COVID-19) as a pandemic on March 11, 2020. The impact of COVID-19 on urological services in different geographical areas is unknown. OBJECTIVE: To investigate the global impact of COVID-19 on urological providers and the provision of urological patient care. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional, web-based survey was conducted from March 30, 2020 to April 7, 2020. A 55-item questionnaire was developed to investigate the impact of COVID-19 on various aspects of urological services. Target respondents were practising urologists, urology trainees, and urology nurses/advanced practice providers. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was the degree of reduction in urological services, which was further stratified by the geographical location, degree of outbreak, and nature and urgency of urological conditions. The secondary outcome was the duration of delay in urological services. RESULTS AND LIMITATIONS: A total of 1004 participants responded to our survey, and they were mostly based in Asia, Europe, North America, and South America. Worldwide, 41% of the respondents reported that their hospital staff members had been diagnosed with COVID-19 infection, 27% reported personnel shortage, and 26% had to be deployed to take care of COVID-19 patients. Globally, only 33% of the respondents felt that they were given adequate personal protective equipment, and many providers expressed fear of going to work (47%). It was of concerning that 13% of the respondents were advised not to wear a surgical face mask for the fear of scaring their patients, and 21% of the respondents were advised not to discuss COVID-19 issues or concerns on media. COVID-19 had a global impact on the cut-down of urological services, including outpatient clinic appointments, outpatient investigations and procedures, and urological surgeries. The degree of cut-down of urological services increased with the degree of COVID-19 outbreak. On average, 28% of outpatient clinics, 30% of outpatient investigations and procedures, and 31% of urological surgeries had a delay of >8 wk. Urological services for benign conditions were more affected than those for malignant conditions. Finally, 47% of the respondents believed that the accumulated workload could be dealt with in a timely manner after the COVID-19 outbreak, but 50% thought the postponement of urological services would affect the treatment and survival outcomes of their patients. One of the limitations of this study is that Africa, Australia, and New Zealand were under-represented. CONCLUSIONS: COVID-19 had a profound global impact on urological care and urology providers. The degree of cut-down of urological services increased with the degree of COVID-19 outbreak and was greater for benign than for malignant conditions. One-fourth of urological providers were deployed to assist with COVID-19 care. Many providers reported insufficient personal protective equipment and support from hospital administration. PATIENT SUMMARY: Coronavirus disease-19 (COVID-19) has led to significant delay in outpatient care and surgery in urology, particularly in regions with the most COVID-19 cases. A considerable proportion of urology health care professionals have been deployed to assist in COVID-19 care, despite the perception of insufficient training and protective equipment.

A systematic review on COVID-19: urological manifestations, viral RNA detection and special considerations in urological conditions.

PURPOSE AND OBJECTIVE: We performed a systematic review on COVID-19 and its potential urological manifestations. METHODS: A literature search was performed using combination of keywords (MeSH terms and free text words) relating to COVID-19, urology, faeces and stool on multiple databases. Primary outcomes were the urological manifestations of COVID-19, and SARS-CoV-2 viral RNA detection in urine and stool samples. Meta-analyses were performed when there were two or more studies reporting on the same outcome. Special considerations in urological conditions that were relevant in the pandemic of COVID-19 were reported in a narrative manner. RESULTS: There were a total of 21 studies with 3714 COVID-19 patients, and urinary symptoms were absent in all of them. In patients with COVID-19, 7.58% (95% CI 3.30-13.54%) developed acute kidney injury with a mortality rate of 93.27% (95% CI 81.46-100%) amongst them. 5.74% (95% CI 2.88-9.44%) of COVID-19 patients had positive viral RNA in urine samples, but the duration of viral shedding in urine was unknown. 65.82% (95% CI 45.71-83.51%) of COVID-19 patients had positive viral RNA in stool samples, which were detected from 2 to 47 days from symptom onset. 31.6% of renal transplant recipients with COVID-19 required non-invasive ventilation, and the overall mortality rate was 15.4%. CONCLUSIONS: Acute kidney injury leading to mortality is common amongst COVID-19 patients, likely as a result of direct viral toxicity. Viral RNA positivity was detected in both urine and stool samples, so precautions are needed when we perform transurethral or transrectal procedures.