Adopting Telehealth During The COVID-19 Era: The Urologist's Perspective.

OBJECTIVE: To evaluate the urology providers' (through a range of training levels) experience utilizing telemedicine given the rapid nationwide implementation of telemedicine in urology practices due to COVID-19. Several studies focusing on the patient's perspective have illustrated that telemedicine is comparable to traditional office visits in terms of cost, communication, and overall satisfaction. However, there is sparse data on the provider's experience. METHODS: With IRB approval, we assessed provider satisfaction with telemedicine at Urology programs in the U.S. through an electronic survey. The 25-question survey was based on the Patient Assessment of Communication of Telehealth which is a validated 33 question instrument that has been utilized to assess the quality of patient-provider communication in telemedicine. Experience with telemedicine was assessed in 2 categories: technical aspects and communication with patients. Variables were rated using a 5-point Likert Scale. RESULTS: There were 144 responses to the survey. 50% of providers reported not receiving any formal training in using telemedicine. This differed significantly by training level with 55% of attendings having had received training vs 20% of residents. Providers felt they would most benefit from training in billing (52%) rather than equipment use (33%) or communication (28%). 87% of providers felt comfortable discussing sensitive topics while only 55% felt comfortable using telehealth to schedule surgery (P < .001). CONCLUSION: Urology providers are generally satisfied with their experience communicating with patients via telemedicine and the majority would opt to continue utilizing telemedicine. Nevertheless, many providers are hesitant to schedule surgery via telemedicine. Providers would benefit from formal training in telemedicine.

Outcomes of EAU-endorsed Live Surgical Events over a 5-year Period (2015-2020) and Updated Guidelines from the EAU Live Surgery Committee.

CONTEXT: Live surgery events (LSEs) have been used in all surgical fields for education and training and to demonstrate new techniques. The European Association of Urology (EAU) live surgery guidelines were established in 2014. OBJECTIVE: To review the compliance of outcomes for procedures performed at EAU-affiliated LSEs with the 2014 guidelines and to establish updated guidelines for LSEs and semi-LSEs. EVIDENCE ACQUISITION: Patients from EAU-affiliated LSEs were included for all surgical procedures carried out between January 2015 and January 2020. All these events were pre-evaluated by the EAU Live Surgery Committee and met the criteria for an EAU LSE, with outcomes recorded and submitted to the registry. Data were collected for the type of procedure and for intraoperative and short- and long-term complications. EVIDENCE SYNTHESIS: A total of 246 procedures were performed across 18 LSEs, with an annual volume ranging from 19 to 74 procedures. These included 109 (44.3%) robot-assisted procedures, 21 (8.5%) laparoscopic procedures, 10 (4%) transurethral bladder procedures, 11 (4.4%) prostate enucleation procedures, 72 (29.2%) endourological procedures, and 23 (9.3%) andrology or reconstruction procedures. A total of 77 different surgical techniques and variations for 55 different types of surgery were performed as LSEs over the past 5 yr. There were 44 (17.8%) short-term complications and 11.3% (nine/79) long-term complications observed, with Clavien grade III/IV complications seen in 5.2% and 7.5% of cases over short- and long-term follow-up, respectively. CONCLUSIONS: The 5-yr outcomes for EAU LSEs show that they are safe and follow previous guidelines set by the panel. It seems likely that the fine balance between patient safety and educational value might be best achieved if LSEs are performed by local surgeons in their parent hospital with patients and staff they know, and that technological advances will make live streaming a seamless process. The current EAU Live Surgery Committee has updated the guidelines on LSEs and provided new guidelines for semi-live events. PATIENT SUMMARY: We reviewed 5-year outcomes for live surgery events endorsed by the European Association of Urology. We found that the operations carried out at these events were safe and followed the guidelines previously set. We have updated the guidelines and provided new guidelines for semi-live events.

Genitourinary Medical Oncology Expert Opinion Survey Regarding Treatment Management in the COVID-19 Pandemic.

BACKGROUND: The worldwide Coronavirus disease 2019 (COVID-19) public health pandemic has restructured clinical care of patients with cancer throughout the world. The specific changes in the management of genitourinary (GU) cancers in different cancer centers owing to COVID-19 are not known, and some clinical scenarios remain controversial. We conducted an opinion survey to determine what changes in cancer treatment strategies are occurring owing to the COVID-19 pandemic. MATERIALS AND METHODS: A 20-item online survey was sent on May 25, 2020 to 170 expert GU medical oncologists from Europe and North America. The survey solicited responses to changes in GU cancer management in the setting of the COVID-19 pandemic. Data was collected and managed via a secure REDCap Database. RESULTS: Surveys were completed by 78 (45.8%) of 170 GU oncologists between May 25, 2020 and June 25, 2020. Clinical practice changes owing to COVID-19 in at least one scenario were reported by 79.1% of responders, most pronounced in prostate cancer (71.8%) and least pronounced in urothelial cancer (23%). Preferences for change in management varied by country, with 78% (37/47) of United States oncologists indicating a change in their practice, 57% (4/7) of Canadian oncologists, and 79% (19/24) of European oncologists. CONCLUSIONS: This study suggests international practice changes are occurring in GU cancer care during the COVID-19 pandemic. The variability in practice changes between countries may reflect differences in COVID-19 case load during the time point of data collection. These results, based on expert opinion during this rapidly changing crisis, may inform the oncologic community regarding the effects of COVID-19 on GU cancer care.

How uro-oncology has been affected by COVID-19 emergency? Data from Piedmont/Valle d'Aosta Oncological Network, Italy.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) pandemic has dramatically hit all Europe and Northern Italy in particular. The reallocation of medical resources has caused a sharp reduction in the activity of many medical disciplines, including urology. The restricted availability of resources is expected to cause a delay in the treatment of urological cancers and to negatively influence the clinical history of many cancer patients. In this study, we describe COVID-19 impact on uro-oncological management in Piedmont/Valle d'Aosta, estimating its future impact. METHODS: We performed an online survey in 12 urological centers, belonging to the Oncological Network of Piedmont/Valle d'Aosta, to estimate the impact of COVID-19 emergency on their practice. On this basis, we then estimated the medical working capacity needed to absorb all postponed uro-oncological procedures. RESULTS: Most centers (77%) declared to be "much"/"very much" affected by COVID-19 emergency. If uro-oncological consultations for newly diagnosed cancers were often maintained, follow-up consultations were more than halved or even suspended in around two out of three centers. In-office and day-hospital procedures were generally only mildly reduced, whereas major uro-oncological procedures were more than halved or even suspended in 60% of centers. To clear waiting list backlog, the urological working capacity should dramatically increase in the next months; delays greater than 1 month are expected for more than 50% of uro-oncological procedures. CONCLUSIONS: COVID-19 emergency has dramatically slowed down uro-oncological activity in Piedmont and Valle d'Aosta. Ideally, uro-oncological patients should be referred to COVID-19-free tertiary urological centers to ensure a timely management.

Implementing Continuous Quality Improvement in an Integrated Community Urology Practice: Lessons Learned.

OBJECTIVE: To determine the effectiveness of 2 different continuous quality improvement interventions in an integrated community urology practice. We specifically assessed the impact of audited physician feedback on improving physicians' adoption of active surveillance for low-risk prostate cancer (CaP) and adherence to a prostate biopsy time-out intervention. MATERIALS AND METHODS: The electronic medical records of Genesis Healthcare Partners were analyzed between August 24, 2011 and September 30, 2020 to evaluate the performance of 2 quality interventions: audited physician feedback to improve active surveillance adoption in low-risk CaP patients, and audited physician feedback to promote adherence to an electronic medical records embedded prostate biopsy time-out template. Physician and Genesis Healthcare Partners group adherence to each quality initiative was compared before and after each intervention type using ANOVA testing. RESULTS: For active surveillance, we consistently saw an increase in active surveillance adoption for low risk CaP patients in association with continuous audited feedback (P < .001). Adherence to the prostate biopsy time-out template improved when audited feedback was provided (P < .001). CONCLUSION: The implementation of clinical guidelines into routine clinical practice remains challenging and poses an obstacle to the improvement of United States healthcare quality. Continuous quality improvement should be a dynamic process, and in our experience, audited feedback coupled with education is most effective.

Diagnosis and treatment of infertility in men: AUA/ASRM guideline part II.

PURPOSE: The summary presented herein represents Part II of the two-part series dedicated to the Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline. Part II outlines the appropriate management of the male in an infertile couple. Medical therapies, surgical techniques, as well as use of intrauterine insemination (IUI)/in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) are covered to allow for optimal patient management. Please refer to Part I for discussion on evaluation of the infertile male and discussion of relevant health conditions that are associated with male infertility. MATERIALS/METHODS: The Emergency Care Research Institute Evidence-based Practice Center team searched PubMed®, Embase®, and Medline from January 2000 through May 2019. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions. (Table 1) This summary is being simultaneously published in Fertility and Sterility and The Journal of Urology. RESULTS: This Guideline provides updated, evidence-based recommendations regarding management of male infertility. Such recommendations are summarized in the associated algorithm. (Figure 1) CONCLUSION: Male contributions to infertility are prevalent, and specific treatment as well as assisted reproductive techniques are effective at managing male infertility. This document will undergo additional literature reviews and updating as the knowledge regarding current treatments and future treatment options continues to expand.

Diagnosis and treatment of infertility in men: AUA/ASRM guideline part I.

PURPOSE: The summary presented herein represents Part I of the two-part series dedicated to the Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline. Part I outlines the appropriate evaluation of the male in an infertile couple. Recommendations proceed from obtaining an appropriate history and physical exam (Appendix I), as well as diagnostic testing, where indicated. MATERIALS/METHODS: The Emergency Care Research Institute Evidence-based Practice Center team searched PubMed®, Embase®, and Medline from January, 2000 through May, 2019. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions. (Table 1) This summary is being simultaneously published in Fertility and Sterility and The Journal of Urology. RESULTS: This Guideline provides updated, evidence-based recommendations regarding evaluation of male infertility as well as the association of male infertility with other important health conditions. The detection of male infertility increases the risk of subsequent development of health problems for men. In addition, specific medical conditions are associated with some causes for male infertility. Evaluation and treatment recommendations are summarized in the associated algorithm. (Figure 1) CONCLUSION: The presence of male infertility is crucial to the health of patients and its effects must be considered for the welfare of society. This document will undergo updating as the knowledge regarding current treatments and future treatment options continues to expand.

Refocusing cancer multidisciplinary team meetings in the United Kingdom: comparing urology with other specialties.

INTRODUCTION: Multidisciplinary team (MDT) meetings have been the gold standard of cancer care in the UK since the 1990s. We aimed to identify the views of urology cancer MDT members in the UK on improving the functioning of meetings and compare them with those of other specialties to manage the increasing demand on healthcare resources and enhance the care of complex cancer cases. METHODS: We analysed data from 2 national surveys distributed by Cancer Research UK focusing on the views of 2,294 and 1,258 MDT members about cancer MDT meetings. FINDINGS: Most breast, colorectal, lung and urology cancer MDT members felt meetings could be improved in the following areas: time for meeting preparation in job plans, streamlining of patients, auditing meeting decisions and prioritising complex cases. Most urology respondents (87%) agreed some patients could be managed outside a full MDT discussion, but this was lower for other specialties (lung 78%, breast 75%, colorectal 64%). CONCLUSIONS: To facilitate decisions on which patients require discussion in an MDT meeting, factors adding to case complexity across all tumour types were identified, including rare tumour type, cognitive impairment and previous treatment failure. This study confirms that urology MDT members are supportive of changing from reviewing all new cancer diagnoses to discussing complex cases but managing others with a more protocolised pathway. The mechanisms for how to do this and how to ensure the safety of patients require further clarification.

The Impact of the COVID-19 Pandemic on Urology Practice in Indonesia: A Nationwide Survey.

PURPOSE: This study aimed to investigate the impact of COVID-19 on urology practice in Indonesia. MATERIAL AND METHODS: This was a cross-sectional study using web-based questionnaire (Survey Monkey), which was distributed and collected within a period of three weeks. All practicing urologists in Indonesia were sent an e-questionnaire link via E-mail, WhatsApp Messenger application, and/or short message service, and the chief of residents in each urology centre distributed the e-questionnaire to urology residents. RESULTS: The response rate was 369/485 (76%) among urologists and 220/220 (100%) among urology residents. Less than 10 percent of the responses in each section were incomplete. There are 35/369 (9.5%) of urologists and 59/220 (26.8%) of urology residents had been suspected as COVID-19 patients, of whom seven of them were confirmed to be COVID-19 positive. The majority of urologists (66%) preferred to continue face-to-face consultations with a limited number of patients, and more than 60% of urologists preferred to postpone the majority (66%) or all elective surgery. Most urologists also chose to postpone elective surgery in patient with COVID-19-related symptoms and patient who required post-operative ICU-care. Urologist and urology residents reported high rates of using personal protective equipment, except for medical gowns and N95 masks, which were in short supply. Several uro-oncology surgeries were considered to be the top priority for Indonesian urologist during COVID-19 epidemic period. CONCLUSION: The COVID-19 pandemic has caused a decline in urology service in both outpatient clinic and surgery services with uro-oncological procedure as a priority to conduct.

Design of an assistance protocol for the restart of scheduled urologic surgery in a COVID-19 epidemic period. / Diseño de un protocolo asistencial para el reinicio de la cirugía urológica programada en periodo de epidemia COVID-19.

OBJECTIVE: Design a care protocol to restart scheduled surgical activity in a Urology service of a third level hospital in the Community of Madrid, in a safe way for our patients and professionals in the context of the SARS-CoV-2 coronavirus epidemic. MATERIAL AND METHODS: A multidisciplinary group reviewed the different recommendations of the literature, national and international health organizations and scientific societies, as well as their application to our environment. Once scheduled surgery has restarted, the patients undergoing surgery for complications related to COVID-19 are being followed up. RESULTS: Since the resumption of surgical activity, 19 patients have been scheduled, of which 2 have been suspended for presenting COVID-19, one diagnosed by positive PCR for SARS-CoV-2, and another by laboratory and imaging findings compatible with this infection. With a median follow-up of 10 days (4-14 days), no complications related to COVID-19 were detected. CONCLUSIONS: Preliminary results indicate that the protocol designed to ensure the correct application of preventive measures against the transmission of coronavirus infection is being safe and effective.

Urology during a Crisis: A Management Algorithm.

COVID-19 pandemic has affected more than a million people worldwide causing a public health crisis. Under these unique circumstances, urologists continue to provide essential healthcare services and support healthcare systems, by participating in the treatment of COVID-19(+) patients and sparing vital equipment and hospital beds. However, delivering medical care during the pandemic requires strategic planning for all surgical and outpatient activities. Proposed measures include rescheduling elective non-oncological surgeries and using a prioritization protocol for oncological surgeries according to hospital capacity. Following that, outpatient clinics could be partly replaced by telemedicine. Additionally, urologists should be trained in screening and treating patients with COVID-19 during their daily routine.  In order to efficiently provide their services, a management protocol for suspected or known COVID-19 urological patients should be implemented. Furthermore, preventive measures for the nosocomial dispersion of the virus and training on self-protective equipment is mandatory for all physicians. Finally, organizational planning for the best utilization of the staff is of utmost importance. Implementation and adaptation of the protocols according to local requirements and guidelines will ameliorate the quality of services and population's health status. Finally, enhancement of current practices will prepare health systems for future crisis.

Delivery of urological services (telemedicine and urgent surgery) during COVID-19 lockdown: experience and lessons learnt from a university hospital in United Kingdom.

BACKGROUND AND AIMS: Our departmental planning for COVID-19 was actioned a week before the lockdown (13th March 2020). We look at a 7- week lockdown activity for all scheduled outpatient clinics and urgent procedures. METHODS AND RESULTS: A total of 2361 outpatient clinic slots (52.6% oncology slots and 47.4% benign urology slots) were scheduled during this period. The oncology slots included 330 (26.5%) flexible cystoscopy, 555 (44.7%) prostate cancer and 357(28.8%) non-prostate cancer slots. The benign urology slots included 323 (28.8%) andrology, 193 (17.2%) stones and 603 (54%) lower urinary tract symptoms (LUTS) slots. Of the total oncology outpatient slots (n = 1242), 66.3% were virtual consultations, 20% were face-to-face and 13.6% were cancelled. Of the total benign outpatient slots (n = 1119), 81% were virtual consultations, 9.7% were face-to-face and 9.3% were cancelled. A total of 116 anaesthetic surgical procedures were carried out, of which 54 (46.5%) were oncological procedures, 18 (15.5%) were benign urological procedures, and 44 (38%) were diagnostic procedures. CONCLUSIONS: Hospitals and urologists can benefit from the model used by our hospital to mitigate the impact and prioritise patients most in need of urgent care. Reorganisation and flexibility of healthcare delivery is paramount in these troubled times and will allow clinical activity without compromising patient safety.

Urological Services in the Era of COVID-19.

INTRODUCTION: On 11 March 2020, the World Health Organization (WHO) declared a pandemic. Since then hospitals have reduced inpatient and outpatient workflow and cancelled or suspended all non-emergent and routine surgical procedures. Our objective is to determine whether, during the COVID-19 period, there has been any modification in urological services. MATERIALS AND METHODS: We retrospectively studied the data from January-May 2020 and 2019 about the variables: number of operations, waiting list, visits in outpatient department, bladder instillations and urological emergencies and admission rates. RESULTS: Cancer cases high-risk for stage progression and surgical emergencies, were elected to proceed directly to treatment. The number of the operations was reduced by 43-65% from March-May 2020. Our surgical list had a waiting time of 6-8 weeks before the pandemic and now the waiting time has expanded to 12 weeks. Urological emergencies were reduced about 23-57%. Admission rates were dropped 10-51%. Visits in outpatient clinics were reduced 100-50% and outpatient procedures for elective cases were all deferred. Unfortunately, the hospital did not offer synchronous telehealth appointments. Bladder instillations of BCG or chemotherapeutics were not suspended but start of new cases had a delay of 2-3 weeks. There were no cases of COVID-19 in our department. CONCLUSION: All the variables of our urologic practice were affected during the COVID era. The impact of the reduced model of outpatient and inpatient workflow on the health of our patients is unknown. However, longer waiting lists are expected. It is obvious that healthcare providers should adopt a new healthcare model.

Implementation and strategies to ensure adequate coordination within a Urology Department during the COVID-19 pandemic.

PURPOSE: to provide an update on the management of a Urology Department during the COVID-19 outbreak, suggesting strategies to optimize assistance to the patients, to implement telemedicine and triage protocols, to define pathways for hospital access, to reduce risk of contagious inside the hospital and to determine the role of residents during the pandemic. MATERIALS AND METHODS: In May the 6th 2020 we performed a review of the literature through online search engines (PubMed, Web of Science and Science Direct). We looked at recommendations provided by the EAU and ERUS regarding the management of urological patients during the COVID-19 pandemic. The main aspects of interest were: the definition of deferrable and non-deferrable procedures, Personal Protective Equipment (PPE) and hospital protocols for health care providers, triage, hospitalization and surgery, post-operative care training and residents' activity. A narrative summary of guidelines and current literature for each point of interest was performed. CONCLUSION: In the actual Covid-19 scenario, while the number of positive patients globally keep on rising, it is fundamental to embrace a new way to deliver healthcare and to overcome challenges of physical distancing and self-isolation. The use of appropriate PPE, definite pathways to access the hospital, the implementation of telemedicine protocols can represent effective strategies to carry on delivering healthcare.

Implementation and strategies to ensure adequate coordination within a Urology Department during the COVID-19 pandemic

ABSTRACT Purpose: to provide an update on the management of a Urology Department during the COVID-19 outbreak, suggesting strategies to optimize assistance to the patients, to implement telemedicine and triage protocols, to define pathways for hospital access, to reduce risk of contagious inside the hospital and to determine the role of residents during the pandemic. Materials and Methods: In May the 6th 2020 we performed a review of the literature through online search engines (PubMed, Web of Science and Science Direct). We looked at recommendations provided by the EAU and ERUS regarding the management of urological patients during the COVID-19 pandemic. The main aspects of interest were: the definition of deferrable and non-deferrable procedures, Personal Protective Equipment (PPE) and hospital protocols for health care providers, triage, hospitalization and surgery, post-operative care training and residents' activity. A narrative summary of guidelines and current literature for each point of interest was performed. Conclusion: In the actual Covid-19 scenario, while the number of positive patients globally keep on rising, it is fundamental to embrace a new way to deliver healthcare and to overcome challenges of physical distancing and self-isolation. The use of appropriate PPE, definite pathways to access the hospital, the implementation of telemedicine protocols can represent effective strategies to carry on delivering healthcare.

Forecasting the Future of Urology Practice: A Comprehensive Review of the Recommendations by International and European Associations on Priority Procedures During the COVID-19 Pandemic.

CONTEXT: The unprecedented health care scenario caused by the coronavirus disease 2019 (COVID-19) pandemic has revolutionized urology practice worldwide. OBJECTIVE: To review the recommendations by the international and European national urological associations/societies (UASs) on prioritization strategies for both oncological and nononcological procedures released during the current emergency scenario. EVIDENCE ACQUISITION: Each UAS official website was searched between April 8 and 18, 2020, to retrieve any document, publication, or position paper on prioritization strategies regarding both diagnostic and therapeutic urological procedures, and any recommendations on the use of telemedicine and minimally invasive surgery. We collected detailed information on all urological procedures, stratified by disease, priority (higher vs lower), and patient setting (outpatient vs inpatient). Then, we critically discussed the implications of such recommendations for urology practice in both the forthcoming "adaptive" and the future "chronic" phase of the COVID-19 pandemic. EVIDENCE SYNTHESIS: Overall, we analyzed the recommendations from 13 UASs, of which four were international (American Urological Association, Confederation Americana de Urologia, European Association of Urology, and Urological Society of Australia and New Zealand) and nine national (from Belgium, France, Germany, Italy, Poland, Portugal, The Netherlands, and the UK). In the outpatient setting, the procedures that are likely to impact the future burden of urologists' workload most are prostate biopsies and elective procedures for benign conditions. In the inpatient setting, the most relevant contributors to this burden are represented by elective surgeries for lower-risk prostate and renal cancers, nonobstructing stone disease, and benign prostatic hyperplasia. Finally, some UASs recommended special precautions to perform minimally invasive surgery, while others outlined the potential role of telemedicine to optimize resources in the current and future scenarios. CONCLUSIONS: The expected changes will put significant strain on urological units worldwide regarding the overall workload of urologists, internal logistics, inflow of surgical patients, and waiting lists. In light of these predictions, urologists should strive to leverage this emergency period to reshape their role in the future. PATIENT SUMMARY: Overall, there was a large consensus among different urological associations/societies regarding the prioritization of most urological procedures, including those in the outpatient setting, urological emergencies, and many inpatient surgeries for both oncological and nononcological conditions. On the contrary, some differences were found regarding specific cancer surgeries (ie, radical cystectomy for higher-risk bladder cancer and nephrectomy for larger organ-confined renal masses), potentially due to different prioritization criteria and/or health care contexts. In the future, the outpatient procedures that are likely to impact the burden of urologists' workload most are prostate biopsies and elective procedures for benign conditions. In the inpatient setting, the most relevant contributors to this burden are represented by elective surgeries for lower-risk prostate and renal cancers, nonobstructing stone disease, and benign prostatic hyperplasia.