Reply to Vincenzo Ficarra, Giuseppe Mucciardi, and Gianluca Giannarini's Letter to the Editor 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 Urol2020;78:11-15.

We read with interest the comments by Ficarra and colleagues [1] on our recently published paper [1], [2]. The authors offer several insights worth consideration in light of the complex, multifaceted natural history of the COVID-19 outbreak. Indeed, we now face the challenge of coping with current adaptations and forthcoming chronic phases of the pandemic from clinical, economic, and social perspectives.

The first issue regards the lack of inclusion of transurethral resection of bladder tumour (TURBT) in our analysis. We acknowledge the great impact of TURBT on urologists’ daily workload and health care resources even in times of emergency. Nonetheless, we focused our analysis on the burden of major uro-oncologic surgeries on the basis of their higher likelihood of impacting hospital resources [2]. Specifically, such procedures are associated with higher costs (especially for minimally invasive approaches), a greater need for anaesthesiology and intensive care, and a higher risk of complications and longer hospitalisation. Since many urology associations, including the European Association of Urology (EAU) [3], recently provided guidance on triage of TURBT cases in times of emergency, further analyses focused on the burden of this specific intervention might be worth investigation.

The second aspect highlighted by the authors is timely and remarkable[1]. The possibility that patients might decline oncologic surgeries, even if considered as high priority, represents an additional (currently misinvestigated) concern for effective organisation of surgical activities during the COVID-19 period and beyond. To provide an insight on this point from our academic centres, we assessed the proportion of cancer patients declining intervention between March 9 and April 22, 2020 because of their fear of COVID-19. Overall, this was the case for approximately one in 20 patients in Florence, one in five patients in Turin, and more than one-third of patients in Milan.

Notably, this “trend” mirrors the pattern of COVID-19 spread across Italian regions, probably reflecting different perceptions of the emergency by patients living in areas of the country not uniformly hit by COVID-19, as well as differential degrees of involvement of public opinion in the media.

We agree with Ficarra and colleagues that this issue should be seriously considered by urologists in light of its potential clinical and medicolegal implications [1]. Therefore, we believe that urologic cancer patients, especially those deserving higher priority procedures, should receive transparent counselling regarding the current “unknown unknowns” [4]. Although a universal template for the process of surgical informed consent remains elusive [4], the current unprecedented uncertainty should encourage our community to develop a uniform policy for COVID-19–specific informed consent in urology.

While considering the individual country, region, and hospital setting and the resources available, such consent must provide the foundation for shared decision-making, highlighting the need to balance priority, patient comorbidity, and the risk of contracting infection at the treating institution. In this context, centralisation of major cancer procedures (using a modified hub-and-spoke model [5]) may represent an opportunity for patients who might be denied high-priority surgery because of a lack of local intensive care resources.

The authors have nothing to disclose.