Table 1.
Suggested triage of surgical cases during the COVID-19 pandemic.
| Condition | Recommended surgeries | Rationale | Average length of stay |
|---|---|---|---|
| Oncology | |||
| Bladder cancer | • Cystectomy for MIBC, regardless of receipt of neoadjuvant chemotherapy | • Delaying cystectomy for MIBC by 90 d increases pN + rate [3], decreases OS and progression-free survival [4], and is associated with higher pathologic stage [5] | • 5–8 d (USA) [6], [7] |
| • Cystectomy for CIS refractory to third-line therapy | |||
| • TURBT for suspected cT1+ bladder tumors | • cT1 tumors are understaged in up to 50% of cases, representing a significant risk of missed MIBC [8] | • Outpatient procedure | |
| Testicular cancer | • Orchiectomy for suspected testicular tumors | • Limited data on survival after delay to orchiectomy [9], but orchiectomy is an outpatient procedure with potential OS benefit and should be prioritized [10] | • Orchiectomy: outpatient procedure |
| • Postchemotherapy RPLND | • To spare a ventilator and inpatient stay (RPLND), radiation post-orchiectomy can be encouraged when surveillance is not an option. Chemotherapy use should be balanced by concern for immunosuppression and increased risk of COVID-19 infection/sequelae | • RPLND: 4–6 d (open) [11] | |
| • Favor chemotherapy or radiation rather than RPLND when clinically appropriate | • 1–3 d (minimally invasive) [12] | ||
| Kidney cancer | • Nephrectomy for cT3+ tumors, including all patients with renal vein and/or IVC thrombi | • More advanced renal tumors, particularly with associated vein thrombi, may progress rapidly and create more complicated surgeries and adversely affect survival and/or surgical morbidity [13] | • Nephrectomy: 3 d [14] |
| • Planned partial or radical nephrectomy for cT1 masses should be delayed or other forms of ablative approaches should be considered in selected patients | • IVC thrombectomy: 5–10 d [15] | ||
| • Planned partial or radical nephrectomy for cT2 should be considered for delay based on patient considerations, such as age, morbidity, symptoms, and tumor growth rate | • For cT1–2 (stage I–II) masses, delaying surgery by 3 mo has not been associated with decreased CSS or OS | • 1–2 d (minimally invasive) | |
| • 2–4 d (open) [16] | |||
| Prostate cancer | • Most prostatectomies should be delayed | • Surgery for NCCN high risk may be considered, depending on patient age and disease risk. However, given the availability of other treatment modalities, these surgeries may receive lower prioritization than others on this list (as delay of treatment up to 12 mo, even for high risk disease, may not alter operative outcomes, cancer specific mortality, or other outcomes). | • 0–2 d [20] |
| • Shared decision-making to consider radiation therapy for NCCN high-risk disease | • Biochemical recurrence rates may be higher in high-risk men who delay definitive treatment, but there is not a clear cut-off time for this treatment benefit [17], [18], [19] | ||
| • Surgery for NCCN high-risk disease if patient is ineligible for radiation | |||
| • Selected high-risk patients and those with intermediate- or low-risk cancer should be delayed | |||
| UTUC | • Nephroureterectomy for high-grade and/or cT1+ tumors | • 3-mo delay to surgery for UTUC has been associated with disease progression for all patients, and with CSS for patients with muscle-invasive disease [9], [21] | • 1–4 d [23] |
| • Early-stage particularly invasive UTUC has a high risk of being understaged [22] | |||
| Adrenal tumors | • Adrenalectomy for suspected ACC or tumors >6 cm | • Adrenal masses >6 cm are much more likely to harbor carcinoma | • 0–1 d [25] |
| • Consider delay of adrenalectomy for less suspicious adrenal masses (<6 cm, favorable imaging characteristics) | • ACC progresses rapidly, and achieving R0 at surgery provides the best chance of survival. Delay may decrease resectability and affect survival [24] | ||
| Urethral/penile cancer | • Clinically invasive or obstructing cancers | • Data for these rare tumors are limited. Preventing lymph node metastases may spare significant patient morbidity. Furthermore, partial penectomy can be an outpatient procedure that puts a lower strain on hospital resources. | • Outpatient procedure |
| Endourology/stone disease | |||
| Stones | • For obstruction/infection | • When possible, stents can be placed at the bedside to spare a ventilator [26] | • Outpatient procedure (unless concurrent infection) |
| • Ureteral stent insertion | • Nephrostomy tubes can be placed under local anesthesia, sparing a ventilator | ||
| • Consideration for awake, bedside ureteral stent placement under local anesthesia | • If neither option is possible, an obstructed or infected upper tract is an emergency requiring intervention | ||
| • Consideration for nephrostomy tube | |||
| Indwelling ureteral stent | • Delay most procedures | • Removal can be simple for most stents left in place even for up to 6–12 mo, and endoscopic stent management is possible in most patients for indwelling times up to 30 mo [27] | • Outpatient procedure |
| BPH | • Delay BPH procedures (TURP, HoLEP, PVP laser, etc.) | • Urinary obstruction can be adequately treated via a urethral or suprapubic catheter without the need for a procedure under anesthesia | • TURP: 1–2 d [28] |
| Female urology/incontinence | |||
| Stress urinary incontinence, interstitial cystitis, overactive bladder, neurogenic bladder | • Delay all procedures | ||
| Nerve stimulator in place | • Second stage nerve stimulator placement or removal | • Nerve stimulators with externalized leads may have a high rate of infection if left in place and should be either internalized via second stage or removed, either of which can be performed under local anesthesia | • Outpatient procedure |
| Reconstructive surgery | |||
| Fistula with pelvic sepsis | • If systemic symptoms, diversion either with catheters/drains, or formal fecal stream diversion | • Fistula repairs are resource-intensive and should be delayed when possible | • Variable |
| • Delayed definitive repair unless clinical conditions would require immediate repair | |||
| Artificial urinary sphincter explants | • Infected explants, only | • Infected sphincters may progress rapidly to systemic infection and should be addressed emergently | • Variable |
| Urethral stricture | |||
| Urethral obstruction | • Delay all procedures | • Suprapubic tube or Foley catheter placement in association with urethral dilation or incision is urgent in those with impending or complete lower urinary tract obstruction | • Outpatient procedure |
| Prosthetic surgery | |||
| Erectile dysfunction | • Infected explants only | • Infected implants may progress rapidly to systemic infection and should be addressed on an emergency basis | • Variable |
| General urology | |||
| Soft tissue infection | • Acute infections only; scrotal abscesses, Fournier’s gangrene | • Variable | |
| Ischemia | • Shunting for priapism | • 1–3 d | |
| • Testicular detorsion/orchidopexy | |||
| Hemorrhage | • Clot evacuation for refractory gross hematuria | • 1–3 d | |
| Trauma | • Penile/testicular fracture repair | • Outpatient procedure | |
| • Ureteral injury | • 1–3 d | ||
| • Bladder perforation | |||
| Transplant | |||
| Renal transplantation | • Deceased donor transplants only | • Deceased donor transplants should proceed without delay | • 4–8 d [29] |
| • Live donor transplants delayed | • Live donor transplants should be delayed to spare resources and delay the requisite immunosuppression for recipients, which could have an impact on COVID-19 infection | ||
| Pediatrics | |||
| Acute torsion | • Scrotal exploration, orchidopexy | • Outpatient procedure | |
| GU obstruction | • Foley catheter/suprapubic tube placement | • Outpatient procedure | |
| Infertility | |||
| • Delay all procedures | |||
ACC = adrenocortical carcinoma; BPH = benign prostatic hyperplasia; CIS = carcinoma in situ; CSS = cancer-specific survival; GU = genitourinary; HoLEP = holmium laser enucleation of the prostate; IVC = inferior vena cava; MIBC = muscle-invasive bladder cancer; NCCN = National Comprehensive Cancer Network; OS = overall survival; PVP = photoselective vaporization of the prostate; RPLND = retroperitoneal lymph node dissection; TURBT = transurethral resection of bladder tumor; TURP = transurethral resection of the prostate; UTUC = upper tract urothelial carcinoma.