How ‘elective’ surgery is defined during the COVID-19 crisis

March 30, 2020

"While I understand there may be some hesitancy from the AUA to issue plain text examples of what an elective case is given the lack of hard data to support their conclusions and that in so many situations the details of a case can vary so much patient to patient, in this less-official non-AUA-sanctioned setting, I thought a list of what seems elective and what is more urgent would be helpful," writes Henry Rosevear, MD.

Dr. Rosevear is a urologist in community practice in Colorado Springs, CO. Urology Times blogs present opinions, advice, and news from urologists and other urology professionals. Opinions expressed by bloggers are their own, and do not necessarily reflect the views of Urology Times or its parent company, MJH Life Sciences.

I’ve never claimed to be the smartest urologist or the best urologic surgeon; I’ve missed too many diagnoses in clinic and seen my outcomes fail in comparison to the reported literature too many times to have any false pretenses about where I stand in the halls of urology. What I do know that I do well is ask questions. The question I’m asking today-one we all need to address quickly, given the unfolding COVID-19 crisis-is what defines “elective” surgery.

Colorado, where I practice, is preparing for a potential deluge of COVID-19 patients. When you look at modeling from the Imperial College of London (see news release and response team statement), we are facing a potential onslaught of patients that will easily outstrip our resources. If you have any question about what that means both personally and professionally, Google Italy and Spain’s current situation.

To prepare for this surge of patients, surgeons are being asked to delay all elective surgeries. Who is asking us? On March 14, the U.S. Surgeon General tweeted that hospital systems should consider stopping elective procedures. On March 18, the Centers of Medicare and Medicaid Services released guidelines to limit “non-essential” surgery and on March 20, Colorado Gov. Jared Polis announced a very strict policy significantly curtailing most surgeries and procedures as of March 23.

But again, my question is what is elective? Here is where my hope is to further a conversation that is already happening (just sign into the AUA’s Young Urologist Online Community to see a wonderful discussion on whether a prostate biopsy is elective) and to hopefully prod some of the powers that be into publishing some urology-specific guidelines with the understanding that all patients and situations are different.

Make no mistake, the AUA has provided some general guidelines, but I have yet to see any case-specific guidance. While I understand there may be some hesitancy from the AUA to issue plain text examples of what an elective case is given the lack of hard data to support their conclusions and that in so many situations the details of a case can vary so much patient to patient, in this less-official non-AUA-sanctioned setting, I thought a list of what seems elective and what is more urgent would be helpful.

Let’s start with easy stuff. (Note this is supposed to be a living list, I hope that as people read this they email Urology Times, which can update the list for easy reference.)

Vasectomy. While I understand that the usage of personal protective equipment is minimal and the risk of hospitalization is low, I know of no current condom shortage, so this one seems pretty elective.

Procedures for urinary incontinence. I know this is a broad category, there are many details hidden here, and incontinence is a major quality of life issue, but it is not a quantity of life issue. These should be delayed.

True emergencies. There are, of course, true emergencies in urology. Torsion, Fournier’s gangrene, septic stones, urinary obstruction requiring drainage, and in the pediatric world, incarcerated/strangulated hernias are on my short list of procedures that seem to go to the front of the line.

Prostate biopsy. Tough one. I realize we’re dealing with cancer, but I’m unsure how a delay in diagnosis of a few weeks impacts treatment. Will there be case reports where it does? Of course, but given that the procedure does carry between a 1% and 4% risk of sepsis, I don’t know if a biopsy is indicated now. This is clearly a moving target because while a delay of a few weeks may be OK, I’m unsure if that same logic applies to a delay of a few months. So this will need to be re-addressed once we have a better understanding of the true scope of this crisis.

Office cystoscopy. First you must ask, why are you doing it? Asymptomatic microscopic hematuria in a 95-year-old guy with a normal CT IVP? This likely can be delayed. Ongoing gross hematuria in a patient with a history of high-grade bladder cancer? Seems urgent to me. The overriding goal seems to be to do procedures that are necessary to keep patients out of the ER while minimizing harm. And let’s be honest, we do surveillance cystoscopies because the guidelines say we should. If the experts felt the intervals could be longer, they would be. Our job today is to balance those guidelines with the different world we are living in.

Stent pulls. Stents cause real damage if not removed within a few months. We all know that. Hence, delaying a few weeks may be reasonable unless that results in patients going to the ER with stent pain. I think these should be done as scheduled to prevent ER trips more than anything else.

Stone procedures. Clearly infected/septic stones or stones with uncontrollable pain need intervention. Where safely possible, the goal at the time of presentation should be to render patient stone free (infection not withstanding). But what about PCNLs? ESWL? That’s more complicated. If a patient is symptom free, you can certainly argue that the stone has likely been there for some time, so a delay of a few weeks likely won’t hurt. (Remember, the correct way to play a 20 in blackjack is to hold realizing that you do occasionally lose.). However, if this drags out for months, I’m not sure if delaying treatment that long is the correct decision.

Procedures for BPH. My gut says most of these can be delayed especially in men whose indication is quality of life symptoms. On the other hand, in situations where you are intervening for retention, the picture becomes more complicated because the risk of ongoing catheter drainage is not zero.

Cancer. I left cancer until the end on purpose. One of the most common reasons to be sued is “delay in diagnosis,” a thought that while not the most politically correct thing to say is certainly on many people’s minds. I’m not an SUO-trained oncologist, but here is a proposal I saw from one such fellowship-trained urologist that makes sense to me:

The following cases should proceed as planned:

• radical cystectomy for muscle-invasive bladder cancer after chemo (time sensitive)

• nephrouretectomy for high-grade urothelial cancer

• radical nephrectomy for cT2 or higher tumor

• cases that may be delayed a few weeks

• radical cystectomy for nonmuscle-invasive bladder cancer (NMIBC)

• nephroureterctomy for large, low-grade urothelial cancer

• robot-assisted prostatectomy for high-risk disease

• robotic partial nephrectomy for cT1b disease.

These cases can likely be delayed for a few months without significant risks:

• most robot-assisted prostatectomies

• partial nephrectomy for cT1a tumors

• TURBT in patient with history of low risk NMIBC.

 

Other categories

Trauma seems very case dependent, based on how much you need to do now versus later.

Reconstruction. My guess is these cases can be delayed, but again the details of the case seem vital.

Infertility. While I realize life goes on, these should be delayed.

I want to be blunt that I am not trying to pronounce judgment on any individual surgeon or group that deviates from these lists. I believe that under these extreme circumstances it is important to start the conversation and obtain input from all stakeholders on how to proceed. I checked the most recent edition of Campbell’s, and there is no chapter on how to be a urologist during a global viral pandemic.

Please wash your hands and stay safe!