Impact of COVID-19 on Uro-Oncological Patients: A Comprehensive Review of the Literature.

Background: The aim of this paper is to discuss the impact of COVID-19 on patients with urological malignancies (prostate cancer, bladder and upper tract urothelial cancer, kidney cancer, penile and testicular cancer) and to review the available recommendations reported in the literature. Methods: A review was performed, through the PubMed database, regarding available recommendations reported in the literature, to identify studies examining the impact of COVID-19 on treatment and clinical outcomes (including upstaging, recurrence, and mortality) for uro-oncological patients. Results: The COVID-19 pandemic dramatically changed the urological guidelines and patients' access to screening programs and follow-up visits. Great efforts were undertaken to guarantee treatments to high-risk patients although follow up was not always possible due to recurrent surges, and patients with lower risk cancers had to wait for therapies. Conclusions: Physically and mentally, uro-oncological patients paid a heavy price during the COVID-19 pandemic. Long term data on the "costs" of clinical decisions made during the COVID-19 pandemic are still to be revealed and analyzed.

Safety of uro-oncology practice and robot-assisted surgery during the peak of COVID-19 pandemic: A report from India.

Aim: The pandemic by novel coronavirus disease 2019 (COVID-19) is the biggest threat to global health care. Routine care of cancer patients is affected the most. Our institute, situated in Mumbai, declared as the hotspot of COVID-19 in India, continued to cater to the needs of cancer patients. We did an observational study to review the experience of managing uro-oncology patients and who underwent either open, endoscopic, or robot-assisted surgery for urological malignancy. Materials and Methods: During the peak of COVID-19 pandemic from March 21, 2020, to June 21, 2020, all the uro-oncology cases managed in our tertiary care hospital were analyzed. Teleconsultation was started for follow-up patients. All patients requiring surgery underwent reverse transcription-polymerase chain reaction for COVID-19. Institutional protocol was formulated based on existing international guidelines for patient management. Adequate personal protection and hydroxychloroquine prophylaxis were provided to health-care professionals. Results: During the study period, 417 outpatient consultations were made. Forty-nine patients underwent surgery for different urological malignancies. Majority of the surgeries were robot-assisted surgeries (59.2%, 29 patients), followed by endoscopic procedures (28.5%, 14 patients) and few open procedures (10.2%, five patients). Most of our patients were elderly males (mean, 62.5 years). With a median follow-up of 55 days (interquartile range, 32-77), there was no report of COVID-19 infection in any patient or health-care provider. Conclusions: We can continue treating needy cancer patients with minimal risk by taking all precautions. Our initial experience of managing uro-oncology cases during this pandemic is encouraging. Robotic surgeries can be safely performed.

Strategies to successfully prevent COVID-19 outbreak in vulnerable uro-oncology patient population.

PURPOSE: As COVID-19 pandemic persists with variants, and despite effective vaccination campaigns, breakthrough infections surge. We implemented strategies to protect vulnerable patients of the uro-oncologic outpatient clinic. We adopted proactive non-symptomatic risk reduction measures, which include non-symptomatic testing requirements for both patients and health care professionals (HCP), intensified patient tracing and contact reduction by implementation of digital health options. Here, we present our best practice example to safely guide oncology professionals and patients with metastasized genitourinary cancers through the current and future pandemics. METHODS: Solely for this purpose, we created a registry of collected data (current telephone numbers, e-mail addresses, vaccination status). We collected a nasopharyngeal swab from every patient upon presentation for treatment. We implemented bi-weekly RNA-PCR assay tests for HCP with patient contact, and limited personal contact at our facility through digital patient consultations. RESULTS: We started implementing our COVID prevention model at the beginning of the second wave in September 2020 and included 128 patients with urologic malignancies requiring systemic treatment. After COVID vaccination became available in December 2020, all of our HCP were fully vaccinated within 6 weeks and 97% of our patients (125/128) within 9 months. We performed 1410 nasopharyngeal swabs during in-house visits, thereby detecting two COVID-19 infections among our patients, who both survived and successfully continued treatment. To further reduce personal contact, half of our consultations were fully operated digitally, with 76% (97/128) of our patients participating in our digital health offers. CONCLUSION: The willingness of patients and HCPs to participate in the study allowed us to implement strict standards to prepare for the ongoing and future pandemics in outpatient cancer units. Next to general preventive measures such as frequent hand disinfection, wearing facial masks, and keeping distance, an important measure to protect vulnerable uro-oncology patients is the capability to perform virus genome sequencing to trace transmission chains.

Impact of the COVID-19 pandemic on urological cancers: The surgical experience of two cancer hubs in London and Milan.

Objective: To report on the outcomes of urological cancer patients undergoing radical surgery between March-September 2020 (compared with 2019) in the European Institute of Oncology (IEO) in Milan and the South East London Cancer Alliance (SELCA). Materials and Methods: Since March 2020, both institutions implemented a COVID-19 minimal 'green' pathway, whereby patients were required to isolate for 14 days prior to admission and report a negative COVID-19 polymerase chain reaction (PCR) test within 3 days of surgery. COVID-19 positive patients had surgery deferred until a negative swab. Surgical outcomes assessed were: American Society of Anaesthesiologists (ASA) grade; surgery time; theatre time; intensive care unit (ICU) stay >24 h; pneumonia; length of stay (LOS); re-admission. Postoperative COVID-19 infection rates and associated mortality were also recorded. Results: At IEO, uro-oncological surgery increased by 4%, as compared with the same period in 2019 (n = 515 vs. 534). The main increase was observed for renal (16%, n = 98 vs. 114), bladder (24%, n = 45 vs. 56) and testicular (27%, n = 26 vs. 33). Patient demographics were all comparable between 2019 and 2020. Only one bladder cancer patient developed COVID-19, reporting mild/moderate disease. There was no COVID-19 associated mortality. In the SELCA cohort, uro-oncological surgery declined by 23% (n = 403 vs. 312) compared with the previous year. The biggest decrease was seen for prostate (-42%, n = 156 vs. 91), penile (-100%, n = 4 vs. 0) and testicular cancers (-46%, n = 35 vs. 24). Various patient demographic characteristics were notably different when comparing 2020 versus 2019. This likely reflects the clinical decision of deferring COVID-19 vulnerable patients. One patient developed COVID-19, with no COVID-19 related mortality. Conclusion: The COVID-19 minimal 'green' pathways that were put in place have shown to be safe for uro-oncological patients requiring radical surgery. There were limited complications, almost no peri-operative COVID-19 infection and no COVID-19-related mortality in either cohort.

Impact of COVID-19 crisis on medical care of patients with metastasized uro-oncologic disease under systemic cancer therapy: a multicenter study in German university hospitals.

PURPOSE: To date, over 4.2 million Germans and over 235 million people worldwide have been infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Uro-oncology (UO) patients are particularly vulnerable but in urgent need of life-saving systemic treatments. Our multicentric study examined the impact of the COVID-19 crisis on the medical care of UO patients in German university hospitals receiving ongoing systemic anti-cancer treatment and to detect the delay of medical care, defined as deferred medical treatment or deviation of the pre-defined follow-up assessment. METHODS: Data of 162 UO patients with metastatic disease undergoing systemic cancer treatment at five university hospitals in Germany were included in our analyses. The focus of interest was any delay or change in treatment between February 2020 and May 2020 (first wave of the COVID-19 crisis in Germany). Statistical analysis of contingency tables were performed using Pearson's chi-squared and Fisher's exact tests, respectively. Effect size was determined using Cramér's V (V). RESULTS: Twenty-four of the 162 patients (14.8%) experienced a delay in systemic treatment of more than 2 weeks. Most of these received immuno-oncologic (IO) treatments (13/24, 54.2%, p = 0.746). Blood tests were delayed or canceled significantly more often in IO patients but with a small effect size (21.1%, p = 0.042, V = 0.230). Treatment of patients with renal cell carcinoma (12/73, 16.4%) and urothelial carcinoma (7/32, 21.9%) was affected the most. CONCLUSIONS: Our data show that the COVID-19 pandemic impacted the medical care of UO patients, but deferment remained modest. There was a tendency towards delays in IO and ADT treatments in particular.

COVID-19 pandemic impact on uro-oncological disease outcomes at an Italian tertiary referral center.

PURPOSE: To assess differences in referral and pathologic outcomes for uro-oncology cases prior to and during the COVID pandemic, comparing clinical and pathological data of cancer surgeries performed at an academic referral center between 2019 and 2020. METHODS: We collected data of 880 prostate biopsies, 393 robot-assisted radical prostatectomies (RARP) for prostate cancer (PCa), 767 trans-urethral resections of bladder tumor (TURB) and 134 radical cystectomies (RC) for bladder cancer (BCa), 29 radical nephro-ureterectomies (RNU) for upper tract urothelial carcinoma, 130 partial nephrectomies (PN) and 12 radical nephrectomies (RN) for renal cancer, and 41 orchifunicolectomies for testicular cancer. Data of patients treated in 2019 (before COVID-19 pandemic) were compared to patients treated in 2020 (during pandemic). RESULTS: No significant decline in uro-oncological surgical activity was seen between 2019 and 2020. No significant increase in time between diagnosis and surgery was observed for all considered cancers. No differences in terms of main pathologic features were observed in patients undergoing RARP, TURB, RNU, RN/PN, or orchifunicolectomy. A higher proportion of ISUP grade 3 and 4 PCa were diagnosed in 2020 at biopsy (p = 0.001), but this did not translate into worse pathological grade/stage at RARP. In 2020, more advanced disease features were seen after RC, including lymph node involvement (p = 0.01) and non-organ confined disease (p = 0.02). CONCLUSION: Neither decline in uro-oncologic activity nor delay between diagnosis and treatment was observed at our institution during the first year of COVID-19 pandemic. No significant worsening of cancer disease features was found in 2020 except for muscle-invasive BCa.

The Uro-oncology Patient and Vaccination Against SARS-CoV-2.

As of April 13, 2021, 137 million cases of COVID-19 and 2.95 million deaths have been reported worldwide. On December 21, 2020, the Pfizer-BioNTech vaccine was approved for use in the European Union, with efficacy of 95% protection against COVID-19 infection. Several other vaccines are at different stages of assessment by the European Medicines Agency. In addition to the elderly, oncology patients are a vulnerable population in which COVID-19 infection may be more severe. However, owing to the design of the initial studies, evidence on the safety and efficacy of vaccination against SARS-CoV-2 in these patients is scarce and recommendations are based on the opinion of associations, stakeholders, and experts via extrapolation of information and experience for other vaccines, especially influenza vaccines. Despite the limited evidence, the consensus is that SARS-CoV-2 vaccines are safe and vaccination of oncology patients and their close relatives is recommended, although efficacy may be lower in patients with an impaired immune response and the need for additional booster doses is not yet clear. Recommendations include avoiding the use of vaccines based on viral vectors for patients with an impaired immune response, deferring vaccination for immunosuppressed patients or administering the vaccine before immunosuppression, and avoiding chemotherapy receipt between the two doses of a vaccine or on the same day that the vaccine is administered. These recommendations can be extrapolated to urology patients and although evidence is lacking, there should not be greater interference with SARS-CoV-2 vaccines from androgen deprivation therapy or intravesical bacillus Calmette-Guérin. However, large studies to provide strong evidence for uro-oncology patients are needed. PATIENT SUMMARY: We looked at the effects of COVID-19 vaccination for patients with urological cancers. The consensus is that the vaccines are safe, and vaccination of cancer patients and their close relatives is recommended.

Impact of COVID-19 Pandemic on Health-Related Quality of Life in Uro-oncologic Patients: What Should We Wait For?

PURPOSE: To investigate the health-related quality of life of uro-oncologic patients whose surgery was postponed without being rescheduled during the coronavirus disease 2019 (COVID-19) pandemic. PATIENTS AND METHODS: From the March 1 to April 26, 2020, major urologic surgeries were drastically reduced at our tertiary-care referral hospital. In order to evaluate health-related quality-of-life outcomes, the SF-36 questionnaire was sent to all patients scheduled for major surgery at our department 3 weeks after the cancellation of the planned surgical procedures because of the COVID-19 emergency. RESULTS: All patients included in the analysis had been awaiting surgery for a median (interquartile range) time of 52.85 (35-72) days. The SF-36 questionnaire measured 8 domains: physical functioning (PF), role limitations due to physical health (PH), role limitations due to emotional problems (RE), energy/fatigue (EF), emotional well-being (EWB), social functioning (SF), bodily pain (BP), general health perceptions (GHP). When considering physical characteristics as measured by the SF-36 questionnaire, PF was 91.5 (50-100) and PH was 82.75 (50-100) with a BP of 79.56 (45-90). For emotional and social aspects, RE was 36.83 (0-100) with a SF of 37.98 (12.5-90). Most patients reported loss of energy (EF 35.28 [15-55]) and increased anxiety (EWB 47.18 [interquartile range, 20-75]). All patients perceived a reduction of their health conditions, with GHP of 49.47 (15-85). Generally, 86% of patients (n = 43) noted an almost intact physical function but a significant emotional alteration characterized by a prevalence of anxiety and loss of energy. CONCLUSION: The lockdown due to the novel coronavirus that has affected most operating rooms in Italy could be responsible for the increased anxiety and decrement in health status of oncologic patients. Without any effective solution, we should expect a new medical catastrophe-one caused by the increased risk of tumor progression and mortality in uro-oncologic patients.

Scoping review: hotspots for COVID-19 urological research: what is being published and from where?

PURPOSE: Contemporary, original research should be utilised to inform guidelines in urology relating to the COVID-19 pandemic. This comprehensive review aimed to: identify all up-to-date original publications relating to urology and COVID-19, characterise where publications were from, and outline what topics were investigated. METHODS: This review utilised a search strategy that assessed five electronic databases, additional grey literature, and global trial registries. All current published, in-press, and pre-print manuscripts were included. Eligible studies were required to be original research articles of any study design, reporting on COVID-19 or urology, in any of study population, intervention, comparison, or outcomes. Included studies were reported in a narrative synthesis format. Data were summarised according to primary reported outcome topic. A world heatmap was generated to represent where included studies originated from. RESULTS: Of the 6617 search results, 48 studies met final inclusion criteria, including 8 pre-prints and 7 ongoing studies from online registries. These studies originated from ten countries according to first author affiliation. Most studies originated from China (n = 13), followed by Italy (n = 12) and USA (n = 11). Topics of the study included pathophysiological, administrative, and clinical fields: translational (n = 14), COVID-19-related outcomes (n = 5), urology training (n = 4), telemedicine (n = 7), equipment and safety (n = 2), urology in general (n = 4), uro-oncology (n = 3), urolithiasis (n = 1), and kidney transplantation (n = 8). CONCLUSION: This review has outlined available original research relevant to COVID-19 and urology from the international community. This summary may serve as a guide for future research priorities in this area.

Telehealth in Uro-oncology Beyond the Pandemic: Toll or Lifesaver?

BACKGROUND: Telehealth services are rapidly embraced in uro-oncology due to the current coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE: To determine patients' perspective on adoption of telehealth as a response to the pandemic and its sustainability in the future. DESIGN, SETTING, AND PARTICIPANTS: Following a COVID-19 outbreak, 101 patients with advanced genitourinary cancers are currently managed "virtually" for therapy administration at our tertiary care unit. They were surveyed about the current situation, and current and long-term employment of telehealth. INTERVENTION: Rapid implementation of virtual patient management. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Patients' perception of anxiety of COVID-19 and cancer, perspective on telehealth measures as a reaction to the current COVID-19 pandemic, and long-term acceptance were used as outcomes. Wilcoxon matched-pair signed rank test, chi-square test, and Mann-Whitney U test were performed. RESULTS AND LIMITATIONS: Of 101 patients, 92 answered the questionnaire, with 71 (77.2%) responding virtually by e-mail or phone call. Anxiety of cancer (6/10, interquartile range [IQR] 3-8) superseded that of COVID-19 (four/10, IQR 2-5.25, p<0.001), and patients oppose temporary treatment interruption. Of the patients, 66.0% perceive their susceptibility to COVID-19 as equal to or lower than the general population and 52.2% believe that COVID-19 will not affect their therapy. In future, patients (62.6%) prefer to maintain in-person appointments as opposed to complete remote care, but accept remote care during the pandemic (eight/10, IQR 5-9). Beyond the crisis, maintaining telehealth has low preference rates (four/10, IQR 2-7), with high acceptance for external laboratory controls (60.9%) and online visit management (48.9%), but lower acceptance for remote treatment planning including staging discussions (44.6%) and for referral to secondary care oncologists (17.4%). CONCLUSIONS: Despite the pandemic, cancer remains the key concern and patients are not willing to compromise on their treatment. Rapid implementation of telehealth is tolerated well during the need of social distancing, with a clear "red line" concerning changes in existing patient-physician relationships. Balancing future implementation of telehealth while considering patients' demand for personal relationships will ensure human dignity in uro-oncology. PATIENT SUMMARY: We queried patients with genitourinary cancers treated in an almost virtual setting following a local coronavirus outbreak. Acceptance of telehealth during the current situation is high; however, long-term implementation of the adapted services is less favored. We deduce that patient-physician relationship is crucial for cancer patients and needs to be balanced against measures for social distancing to forge the future management.

Uro-oncology in times of COVID-19: The available evidence and recommendations in the Indian scenario.

The Corona Virus Disease-2019 (COVID-19), one of the most devastating pandemics ever, has left thousands of cancer patients to their fate. The future course of this pandemic is still an enigma, but health care services are expected to resume soon in a phased manner. This might be a long drawn process and we need to have policies in place, to be able to fight both, the SARS-CoV-2 virus and cancer, simultaneously, and emerge triumphant. An extensive literature search for impact of delay in management of various urological malignancies was carried out. Expert opinions were sought wherever there was paucity of evidence, in order to reach a consensus and come up with recommendations for directing uro-oncology services in the times of COVID-19. The panel recommends deferring treatment of patients with renal cell carcinoma by 3 to 6 months, except for those with ongoing hematuria and/or inferior vena cava thrombus, which warrant immediate surgery. Metastatic renal cell cancers should be started on targeted therapy. Low grade non-muscle invasive bladder cancers can be kept on active surveillance while high risk non-muscle invasive bladder cancers and muscle invasive bladder cancers should be treated within 3 months. Neoadjuvant chemotherapy should be avoided. Management of low and intermediate risk prostate cancer can be deferred for 3 to 6months while high risk prostate cancer patients can be initiated on neoadjuvant androgen deprivation therapy. Patients with testicular tumors should undergo high inguinal orchiectomy and be treated according to stage without delay, with stage I patients being offered surveillance. Penile cancers should undergo penectomy, while clinically negative groins can be kept on surveillance. Neoadjuvant chemotherapy should be avoided and adjuvant therapy should be deferred. We need to tailor our treatment strategies to the prevailing present conditions, so as to fight and defeat both, the SARS-CoV-2 virus and cancer. Protection of health care workers, judicious use of available resources, and a rational and balanced outlook towards different malignancies is the need of the hour.