Methodology for triage of urologic surgical cases in the setting of a pandemic

Abstract

Background The first wave of the COVID-19 pandemic in March 2020 forced our healthcare system in the Bronx, New York to cancel nearly all scheduled surgeries. We developed a framework for prioritizing postponed urologic surgeries that was utilized once cases were permitted to be rescheduled. As many parts of our country experience first and second waves of this pandemic, our framework may serve as a resource for other centers experiencing restrictions on the scheduling of elective urologic surgeries. Methods As the COVID-19 pandemic started and peaked in New York, almost all of our scheduled urologic surgeries were cancelled. Each Urologist was asked to rank his/her cancelled surgeries by priority (Level 1—least urgent; Level 2—moderately urgent; Level 3—most urgent). A committee of Urologists assigned a subclass to Level 3 and 2 cases (3a—least urgent; 3b—moderately urgent; 3c—most urgent; 2a—lower priority; 2b—higher priority). The committee then reviewed cases by urgency to derive a final priority ranking. Results A total of 478 total urologic surgeries were canceled and categorized: 250 Level 1, 130 Level 2, 98 Level 3 (73 adult, 25 pediatric). Level 3c involved renal cell carcinoma ≥ T2b, high-grade bladder urothelial carcinoma, adrenal mass/cancer > 6 cm, testicular cancer requiring radical orchiectomy, and penile cancer. Level 3b involved T2a renal masses requiring nephrectomy, while high-risk prostate cancer and symptomatic nephrolithiasis were classified as 3a. Level 2 included testicular cancer requiring retroperitoneal lymph node dissection and complicated benign prostatic hyperplasia. Surgeries for urologic reconstruction, non-complicated nephrolithiasis, erectile dysfunction, and urinary incontinence were considered Level 1. Conclusions Our disease-specific approach to surgical rescheduling offers appropriate guidance for triaging urologic surgeries. Our system can provide guidance to other institutions as COVID-19 cases surge in different regions and with the growing second wave.

The Epidemic of COVID-19-Related Erectile Dysfunction: A Scoping Review and Health Care Perspective

“… • We are not in a position to currently criticize these historical moments, but certainly, as health managers, we also have a duty to think about these patients. √ Aboumohamed et al 2021 50 USA Urologist Survey • 478 total urologic surgeries were canceled and categorized: 250 Level 1, 130 Level 2, 98 Level 3 (73 adult, 25 pediatric). Level 3c involved renal cell carcinoma ≥ T2b, high-grade bladder urothelial carcinoma, adrenal mass/cancer > 6 cm, testicular cancer requiring radical orchiectomy, and penile cancer • Surgeries for urologic reconstruction, non-complicated nephrolithiasis, erectile dysfunction, and urinary incontinence were considered Level 1 √ Witherspoon et al 2020 51 Canada Urologist Survey • Physical examination has a limited role in the evaluation and management of ED and, therefore, this condition lends itself well to virtual visits • Including the partner (if applicable) in the virtual visit can help elucidate their overall treatment goals more easily √ Vaduganathan et al 2020 52 USA Retrospective Database Analysis • The modest decline for most common long-term therapies after peak could represent reduced contact with prescribing clinicians, restricted access to pharmacies, pharmacist rationing, loss of insurance from unemployment, or replete supplies from early stockpiling.…”

“… 56 , 57 Many elective surgeries for benign urological conditions such as ED were postponed during the COVID-19 outbreak. 48 , 49 , 50 , 69 One example summarizing shifts in men's urological care was published by the Canadian Urological Association. 51 It noted the massive shift in only offering surgeries for emergencies and urgent oncology cases with management shifting to mostly virtual care for male sexual health conditions.…”

Access to inflatable penile prosthesis surgery as indicated by distances traveled among US men with Medicare

“…Additionally, this study included some patients treated during the COVID-19 pandemic, which likely affected travel patterns. Many elective procedures (including IPP services) were severely curtailed during the first year of the pandemic to minimize possible COVID-19 exposure and redirect staff to COVID-19–related care, 26 , 27 which may have forced patients to delay IPP treatment or travel greater distances to receive IPP treatment. Finally, the findings from this database study may not be generalizable to all populations of patients with ED in the United States given that the study population does not include Medicare Advantage, other managed care enrollees, or individuals with other types of insurance.…”