Re: Riccardo Campi, Daniele Amparore, Umberto Capitanio, et al. Assessing the burden of nondeferrable major uro-oncologic surgery to guide prioritisation strategies during the COVID-19 pandemic: insights from three Italian high-volume referral centres. Eur Urol 2020;78:11-15.

COVID-19 has led to a public health emergency in Italy [1]. Campi et al [2] have reported very interesting data on the burden of major non-deferrable surgical procedures to treat genitourinary malignancies performed at three high-volume referral centers in Italy with the aim of guiding reorganization and prioritization of urological surgical practice during the COVID-19 pandemic [2]. Non-deferrable procedures were defined according to a recently published expert opinion on patient triage during the pandemic [3], and four were selected for their study: radical nephroureterectomy, radical cystectomy, and radical nephrectomy and prostatectomy for high-risk disease. Notably, these non-deferrable procedures accounted for approximately one-third of all cases treated over a 12-mo period, and approximately one-quarter of those procedures were performed in patients at high preoperative anesthesiology risk (American Society of Anesthesiologists [ASA] score ≥3) [2]. The latter figure is critical if we consider that cardiovascular, respiratory, and infective comorbidities and a need for intensive or semi-intensive postoperative care, blood transfusions and familiar assistance with eventual psychophysical support are all factors potentially affecting the selection of ideal candidates for major oncological procedures during this emergency period [1].

Unfortunately, Campi et al [2] disregarded the impact of another common uro-oncological procedure, transurethral resection of bladder tumor (TURB), that was included among the non-deferrable urological procedures by others [1], [3]. Moreover, the timely contribution by Campi et al [2] might have been enriched by consideration of another novel factor influencing the reorganization of surgical activities, namely fear of contracting COVID-19. It is likely that this could be viewed as one of the most common adverse events following the national lockdown in Italy from March 9, 2020. Patients might decline the opportunity to be operated on because of this fear, especially in a COVID-19 hospital, requesting postponement of their treatment. No data on this phenomenon are currently available.

We were forced to limit our surgical activity to urgent or high-priority uro-oncological cases starting from March 9, 2020. As of April 4, 2020, we identified 51 patients scheduled for non-deferrable oncological procedures according to previous criteria [1], [3], of which 24 were for major surgery and 27 for TURB. Fifteen patients (29%) had high anesthesiology risk (ASA score ≥3), but only seven (14%) were excluded because of a need for postoperative intensive care (2 cases with cT2 bladder cancer, 1 case with renal tumor with inferior cava involvement, 1 case with high-risk prostate cancer, and 3 cases with high-risk bladder cancer). Interestingly, 16/51 patients (31.3%) declined the planned treatment and asked to postpone it until after the pandemic, including 6/24 (25%) scheduled for major surgeries (3 cases of radical prostatectomy for high-risk disease and 3 cases of radical/partial nephrectomy for cT2 renal tumors) and 10/27 (37%) for TURB. The mean ± standard deviation age of these patients was 71 ± 8.1 yr.

The issue with patients declining treatment should be seriously considered in our clinical practice from both an organizational and a medicolegal standpoint, with many open questions regarding clinical re-evaluation and rescheduling. We strongly recommend that these patients be thoroughly informed about the risks related to delayed treatment.

The authors have nothing to disclose.