Tim Robinson found out that he had prostate cancer in March 2020, just as the United Kingdom went into lockdown in response to the COVID‐19 pandemic. He was told that he had a small, localised but potentially aggressive cancer that would require radical treatment. Over the next few weeks he had telephone consultations with specialists in surgery, radiotherapy and in focused ultrasound, at the end of which, in early April, in consultation with his doctors at University College London Hospital (UCLH), he determined that surgery was the most appropriate treatment. He was anxious to get on with the treatment for his cancer, but by then the UK in general and London in particular was reeling from the large numbers of COVID‐19 patients in hospital. He was told that his surgery would be delayed and he was started on hormone therapy until such time that it was safe for surgery to proceed.
The COVID‐19 pandemic has had a range of effects upon urological practice. While the timing and severity of the peak of the pandemic has varied from country to country, the response of the medical community has been broadly similar everywhere. The management of patients with COVID‐19 has taken precedence over almost everything else and urologists have been seconded to help with their care. At the same time, the general public appears to have become slightly scared of hospitals with emergency attendances markedly reduced. In England, attendances at Accident and Emergency departments fell by over 50% from over 2.1 million in January to just over 900 000 in April [https://www.england.nhs.uk/statistics/statistical‐work‐areas/ae‐waiting‐times‐and‐activity/ae‐attendances‐and‐emergency‐admissions‐2020‐21/]. In many countries the lack of ventilators resulted in surgical anaesthetic machines being repurposed, with theatre suites becoming impromptu intensive care units and with almost all elective surgery, including cancer surgery, being cancelled or delayed.
Cold site surgery
At UCLH the response to this crisis in cancer care, which was mirrored in many hospitals around the world, was to create a “super‐cold” site that was physically separate from the acute hospital, where only patients who had self‐isolated for two weeks and who had been proven by testing to be virus‐free, were admitted.
‘UCLH pulled out all the stops and when you're in other people's hands you just have to get on with it’
Tim Robinson was able to benefit from this facility, being admitted on 30th May for robot‐assisted radical prostatectomy and being discharged home the following day. Although his experience was different to any other hospital contact that he'd ever had before, given that all the medical and nursing staff wore gowns, masks, gloves (and often visors), in his words “UCLH pulled out all the stops and when you're in other people's hands you just have to get on with it”. The results of the first 500 surgical patients treated in this super‐cold site have just been published [https://www.medrxiv.org/content/10.1101/2020.06.10.20115543v1] with a 30‐day all‐cause mortality of 3/500, with 10 patients being diagnosed with COVID‐19, and no patient dying of COVID‐19.
Changes in clinical practice
In addition to “cold site surgery” COVID‐19 has necessitated other, different ways of providing medical care. Urological societies around the world have developed guidelines with the aim of prioritising urological surgery. Broadly speaking, the treatment of invasive bladder cancer, renal cancer, testicular cancer and penile cancer has been prioritised together with urological emergencies and obstructing ureteric calculi. In contrast, patients requiring prostate cancer surgery have found their treatment at least paused, while surgery for benign urological problems has almost ceased, at least for the time being [https://www.sciencedirect.com/science/article/pii/S2405456920301553]. Requirements for social distancing have led to widespread and rapid introduction of virtual consultations and telemedicine. As lockdown measures begin to ease the real challenge for the profession is to identify which patients really need face‐to‐face consultations, an issue that is particularly pertinent in patients consenting for surgery.
Collaborative research, big data and innovative treatment
One silver lining has been that the threat posed by COVID‐19 has stimulated international collaborative research like never before. While the general public has tended to focus upon the various attempts to develop a vaccine, one of the biggest concerns for surgeons were the early reports from Wuhan suggesting extremely high mortality for surgical patients developing COVID‐19 infection in the perioperative period. COVIDSurg is an international, prospective, observational study of outcomes for patients developing SARS‐CoV‐2 infection in the peri‐surgical period that has been run by the GlobalSURG collaborative team based at the University of Birmingham, UK. As of 30th July 2020, 41 500 participants had been registered (largely by surgical trainees) in 1005 centres in 86 countries and the first key data to come from COVIDSurg was published in The Lancet in May [https://www.thelancet.com/journals/lancet/article/PIIS0140‐6736(20)31182‐X/fulltext]. It showed that patients having surgery who have SARS‐CoV‐2 infection or who develop it in the immediate post‐operative period had a 30‐day mortality rate of 24%. Professor Grant Stewart from the University of Cambridge, who leads the Urology element of COVIDSurg points out that “This study of patients with peri‐surgical COVID‐19 infection has identified specific risk factors for death including male gender, age over 70 years, ASA grade 3‐5, cancer surgery and emergency surgery”.
Analysis of so‐called “big data” has also provided insight into many aspects of COVID‐19. The OpenSAFELY trial, using a health analytics platform covering 40% of all patients in England demonstrated similar risk factors for death from COVID‐19 including older age, deprivation, diabetes, severe asthma and ethnicity [https://www.nature.com/articles/s41586‐020‐2521‐4]. It is clear that even after adjustment for other factors, compared with people of white ethnicity, Black and South Asian people have a higher mortality risk.
‘Black and South Asian people have a higher mortality risk’
Similar use of big data suggests that BCG, a substance well known to urologists, might potentially be a useful agent in the fight against COVID‐19. The finding that incidence of COVID‐19 is almost ten‐fold lower in countries with BCG vaccination programmes compared to those that do not have such a program [Hegarty PK, Sandoval M, Dinardo AR, Zafikiris H, Kamat AM. National programs of BCG vaccinations are associated with lower reported incidence and mortality from COVID‐19. PLoS medicine. 2020 (in press)] suggests that somehow BCG might provide some additional immune‐stimulatory protection against COVID‐19. This has resulted in a number of trials being set up to test this hypothesis. In an Australian study called the BCG Vaccination to Protect Healthcare Workers Against COVID‐19 (BRACE) trial (NCT04327206) over 4000 healthcare workers in Australia will be randomized to receive either a single dose of BCG vaccination or no vaccine, with subsequent follow‐up over 12 months to determine the incidence of COVID‐19. The BCG As Defense Against SARS‐COV‐2 (BADAS) trial is similarly investigating BCG vaccination to protect healthcare workers against COVID‐19 with a similar design although there will also be a focus on high‐risk (elderly, obese, increased comorbidities) healthcare workers in the United States.
Urological training and education
In the early stages of the pandemic, urological trainees have often found themselves reallocated to the care of patients with COVID‐19. As a consequence, their surgical training has suffered, with reduced patient contact time, reduced surgical exposure and reduced urological experience [https://www.auajournals.org/doi/pdf/10.1097/JU.0000000000001155]. There has been much greater use of webinars and online education and in many countries certification examinations of been cancelled, with potential workforce consequences for the immediate future. The requirements of social distancing have resulted in the cancellation of almost all major urological conferences in 2020 although some societies have run virtual meetings using webcasts and webinars. However, given that these meetings have historically been a major source of income for many societies through advertising, commercial sponsorship and income from attendees, repeated cancellation of these meetings in future years might potentially affect the financial viability of these organisations.
‘The “new normal” appears to include the need for super‐cold surgical centres with increased use of telemedicine’
COVID‐19 has affected the delivery of healthcare around the world and will continue to do so some time to come. The “new normal” appears to include the need for super‐cold surgical centres with increased use of telemedicine, but it has also stimulated international collaborative research with potential benefits for the future. Amid these enormous changes, there are many patients like Tim Robinson, who have urological disease and who require the best treatment available. Happily he is now recovering from his recent surgery, thankful for the care provided for him at UCLH. Despite the additional difficulties and precautions that he endured, he is delighted that his cancer has been treated effectively and safely.