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 » Introduction
 »  Recommendations ...
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  Table of Contents  
Year : 2020  |  Volume : 57  |  Issue : 2  |  Page : 129-138

Uro-oncology in times of COVID-19: The available evidence and recommendations in the Indian scenario

1 Department of Urology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Uro-oncology, Max Super Specialty Hospital, Saket, India
3 Department of Urology, All India Institute of Medical Sciences, New Delhi, India
4 Department of Uro-oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
5 Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission18-Apr-2020
Date of Decision27-Apr-2020
Date of Acceptance28-Apr-2020
Date of Web Publication17-May-2020

Correspondence Address:
Tushar A Narain
Department of Urology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijc.IJC_356_20

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 » Abstract 

The Corona Virus Disease-2019 (COVID-19), one of the most devastating pandemics ever, has left thousands of cancer patients to their fate. The future course of this pandemic is still an enigma, but health care services are expected to resume soon in a phased manner. This might be a long drawn process and we need to have policies in place, to be able to fight both, the SARS-CoV-2 virus and cancer, simultaneously, and emerge triumphant. An extensive literature search for impact of delay in management of various urological malignancies was carried out. Expert opinions were sought wherever there was paucity of evidence, in order to reach a consensus and come up with recommendations for directing uro-oncology services in the times of COVID-19. The panel recommends deferring treatment of patients with renal cell carcinoma by 3 to 6 months, except for those with ongoing hematuria and/or inferior vena cava thrombus, which warrant immediate surgery. Metastatic renal cell cancers should be started on targeted therapy. Low grade non-muscle invasive bladder cancers can be kept on active surveillance while high risk non-muscle invasive bladder cancers and muscle invasive bladder cancers should be treated within 3 months. Neoadjuvant chemotherapy should be avoided. Management of low and intermediate risk prostate cancer can be deferred for 3 to 6months while high risk prostate cancer patients can be initiated on neoadjuvant androgen deprivation therapy. Patients with testicular tumors should undergo high inguinal orchiectomy and be treated according to stage without delay, with stage I patients being offered surveillance. Penile cancers should undergo penectomy, while clinically negative groins can be kept on surveillance. Neoadjuvant chemotherapy should be avoided and adjuvant therapy should be deferred. We need to tailor our treatment strategies to the prevailing present conditions, so as to fight and defeat both, the SARS-CoV-2 virus and cancer. Protection of health care workers, judicious use of available resources, and a rational and balanced outlook towards different malignancies is the need of the hour.

Keywords: Bladder cancer, cancer, COVID-19, kindey cancer, open surgery, penile cancer, prostate cancer, robotic surgery, testicular tumor, urooncology

How to cite this article:
Narain TA, Gautam G, Seth A, Panwar VK, Rawal S, Dhar P, Talwar HS, Singh A, Jaipuria J, Mittal A. Uro-oncology in times of COVID-19: The available evidence and recommendations in the Indian scenario. Indian J Cancer 2020;57:129-38

How to cite this URL:
Narain TA, Gautam G, Seth A, Panwar VK, Rawal S, Dhar P, Talwar HS, Singh A, Jaipuria J, Mittal A. Uro-oncology in times of COVID-19: The available evidence and recommendations in the Indian scenario. Indian J Cancer [serial online] 2020 [cited 2021 Sep 23];57:129-38. Available from: https://www.indianjcancer.com/text.asp?2020/57/2/129/284474

 » Introduction Top

The COVID-19 disease, caused by SARS-CoV-2 virus, was declared a Public Health Emergency of International Concern (PHEIC) on the 30th January, 2020, and in no time, it accelerated to the status of a pandemic, by 11th March, 2020.[1] The virus, probably having its origin from a sea food market of an industrial town in Central China, has already inflicted almost 3 million people, and caused about two hundred thousand mortalities worldwide.[2] The USA, Italy, Spain, Germany, and France have been some of the worst affected countries, with their excellent healthcare system proving to be no match for this killer virus. Fortunately, the wrath of this virus has not been so severe in India till now, but it may well be the calm before the storm. India has already reported around 27000 cases with over 800 deaths, and the figures are still climbing. India is presently in a state of complete lockdown, with all healthcare services focused to curb the larger menace at hand. With only emergency services functional, cancer care has taken a back seat. This pandemic has left thousands of cancer patients to their fate, leaving them with no access to healthcare services. Cancer, in the background, continues to kill all this while. The future course of this pandemic is still an enigma, but it is expected that health care services will resume in a phased manner soon, once the peak flattens out. This might be a long drawn process and we need to have policies in place, to be able to fight both, the SARS-CoV-2 virus and cancer, simultaneously, and emerge triumphant. New guidelines, modified to the present times are the need of the hour. We carried out an extensive literature search, with discussions with senior uro-oncologists, medical oncologists, radiotherapists, and anesthetists, wherever available evidence was weak, in order to come up with recommendations for directing cancer care in the times of COVID-19.

 » Recommendations for the Surgeons Top

General guidelines

The various Royal Colleges of United Kingdom jointly issued a statement, the “Intercollegiate General Surgery Guidance on COVID-19”, on the 27th March, 2020.[3] The European Association of Urology (EAU) Robotic Urology Section (ERUS) also issued guidelines pertaining to triaging of robotic surgeries.[4] Individual countries are in different phases of the COVID-19 pandemic, and hence recommendations have to be tailored for a specific country and a specific geographical location based on the extent of disease in that region. An in-depth analysis of the recommendations and the prevalent conditions in Europe and the USA helped us reach a consensus for directing surgical care for patients in our country. The face of this pandemic is ever changing, and these recommendations may need to remain in a constant state of flux, serving as a skeleton for individual surgeons and institutions to frame their own policies.

Every patient, planned for a surgery, should undergo a general screening and ideally, a specific testing for the SARS-CoV-2 virus infection, regardless of their status of symptomatology. In view of the limited resources, the expenses involved, and the time a Reverse Transcription Polymerase Chain Reaction (RT-PCR) test takes, patients may be triaged before subjecting them to an investigation. All patients scheduled for a surgery should be prioritized depending on the urgency of the surgery. Disease requiring emergent intervention and high risk cancer patients, in whom deferral of initiation of treatment is clearly known to worsen survival should be given top priority. Postponing routine, non life-saving, non cancerous and reconstructive surgeries would minimize the patients' interactions with the health care system, reduce the stress on the already limited resources, allow conservation of Personal Protective Equipment (PPE) and help redirect the health care workers to tackle the bigger enemy. A surgery deemed urgent and indispensable, in a COVID-19 positive patient, should be deferred till the patient recovers, if possible. Health care workers, being the most prized assets at the moment, are ideally required to wear complete PPE, even if the patient tests negative, in view of false negative results. All standard precautions need to be maintained in the Operating Room (OR), with minimal personnel allowed inside, especially at the time of intubation and extubation. A dedicated OR should be available for operating COVID-19 positive patients, with a dedicated team of anesthesiologists, nursing staff and OR technicians, allowing complete records to be available, if the need for quarantine arises.

Preferred mode of surgery

Kwak et al. and Sawchuk et al., in separate studies, have suggested that the aerosols and smoke generated during surgeries can be laden with viral particles.[5],[6] Laparoscopic and robot assisted laparoscopic surgeries, both, entail development of large amount of aerosols and periodic evacuation of smoke from the abdominal cavity, which might facilitate spread of viral particles in the OR. Hence, robotic and laparoscopic surgeries should be limited to patients in whom the benefit of a minimally invasive approach overrides the risk of potential spread of viral particles through aerosols and smoke. Nevertheless, the SARS-Cov-2 virus has not yet been isolated from ascites fluid; hence its spread through aerosols can still be debated.

If a robotic surgery has to be undertaken, it should be performed at the lowest acceptable intra-abdominal pressure, and an air-seal system, which maintains a constant pressure, without the periodic need of venting the smoke, should be used. In institutes where the air-seal system is not available, minimal thermal energy should be used, so that the need of venting the smoke is restricted to minimum. Two way insufflators should be strictly avoided to prevent colonization of the insufflators with the virus. The surgeon console should ideally be placed in a separate room so as to allow minimal personnel to be in the OR. This would reduce the chances of a healthcare worker being exposed to a positive patient and would also allow a more judicious use of available PPE. The bedside surgeon and the anesthetist should follow all safety precautions and don proper PPE.

The ultrasonic scalpels vaporize the tissue, producing large amounts of water vapor, aerosols and smoke, as has been reported by Zheng et al.[7] In his article highlighting the lessons learnt from China and Italy, he stated that the low temperature of the aerosols from ultrasonic shears were incapable of effectively deactivating the components of the SARS-CoV-2 virus.[7] Several researchers have separately shown the presence of active Corynebacterium, Human Immunodeficiency Virus and the Papilloma virus to be present in the smoke and aerosols generated from the electrosurgical instruments and were even capable of afflicting the health care providers, a testimonial to their persistent virulence.[8],[9],[10],[11] Another series from Taiwan characterized the smoke generated during the use of electrosurgical knife and concluded that the particle concentration of the smoke generated was much higher in laparoscopic surgery than in open laparotomies.[12] Hence it seems prudent to stick to the conventional open surgeries wherever feasible, maximize the use of surgical scalpel, use the lowest possible setting for electrocautery and prefer the traditional cautery over ultrasonic scalpels. Desufflation of the pneumoperitoneum should be aided by active suction of the gas via a closed circuit, and should be gradual to ensure minimal generation of aerosols.

Surgical training should be suspended in these times, and all surgeries should be performed by experts who are preferably beyond their learning curve. Standardized surgical techniques should be adopted with the aim of keeping the operating time to a minimum.

 » Recommendations for the Uro-Oncologists Top

“COVID will come and eventually go one day, cancer will stay, and will continue to kill”. It would not be prudent to become complacent and undermine the largest killer of all times. The current pandemic may continue for more than a year, like the Spanish flu of 1918, popularly called the La Pesadila, which continued for 2 years and affected about 500 million people worldwide.[13] It is the call of the hour to anticipate what lies ahead and formulate plans for management of various malignancies in a manner befitting the times, the COVID-19 has brought in.

Renal cell cancer

Mano et al. studied 1278 patients of renal cell cancer to assess the impact of delay in surgery on survival.[14] They concluded that in patients with T1b and higher tumors, the Surgical Waiting Time (SWT) had an impact. For tumors less than 4 cm, the SWT did not affect the outcomes, while for larger tumors, a SWT >3 months decreased the overall survival but did not affect the recurrence rates or Cancer Specific Survival (CSS).[14] Becker et al., in their series of small renal masses, reported no change in survival for a delay in nephrectomy of >3 months.[15] Bourgade went on to establish that there was no impact on disease specific survival even if the treatment was delayed upto 2 years for these small renal masses, measuring less than 4 cm.[16]

Asymptomatic patients with small renal masses can be kept on surveillance and curative therapy can be deferred for 6 months without risk of progression. Larger masses and those with symptoms should be treated, as a delay of >3 months would affect survival. Patients with concomitant Inferior Vena Cava thrombus and those with hematuria constitute the group with highest risk, and surgery for them should not be deferred.

Open surgery by an experienced surgeon with minimal use of electrocautery is the preferred treatment and for those patients insisting on a minimally invasive approach, all precautions, highlighted earlier should be followed. Angioembolization can be considered for patients with intractable hematuria, who are unfit for surgery, or who cannot undergo surgical extirpation because of the prevalent conditions; with a definitive therapy later.[17]

Follow up protocols following a curative therapy should be tailored according to the final histopathological report and can be increased to 3 to 6 months. The follow-up interval can be extended, with physical examinations done every 6 months and blood investigations with imaging reported telephonically at 3 months.

Arnaud Mejean, in his landmark study, the CARMENA trial, established the non-inferiority of sunitinib alone as compared with sunitinib plus cytoreductive nephrectomy (CN) in patients with metastatic renal cell cancer.[18] An update on this trial from American Society of Clinical Oncology (ASCO) 2019 annual meeting went on to even suggest a poorer survival for patients belonging to the International Metastatic Renal Cell Cancer Database Consortium (IMDC) poor risk group with CN.[19] A systematic review by Bhindi et al. resonated the poorer survival with cytoreductive nephrectomy in IMDC poor risk patients, while patients with good performance status and Good/Intermediate IMDC risk groups had a survival advantage with CN.[20] The SURTIME trial revealed that the sequence of CN and sunitinib did not affect Progression Free Survival (PFS) HR : 0.88 (95% CI, 0.56-1.37, P=0.569). The trial accrued poorly and has been through much criticism. However, in a secondary endpoint analysis, a strong Overall Survival (OS) benefit was observed in favor of the deferred CN approach in the Intention-to-Treat (ITT) population with a median OS of 32.4 (95%CI 14.5-65.3) months in the deferred CN arm vs. 15.0 (95% CI, 9.3-29.5) months in the immediate CN arm (HR: 0.57 (95%CI, 0.34-0.95, p=0.032)).[21]

Patients with metastatic renal cell cancer on presentation should undergo a tissue diagnosis followed by initiation of tyrosine kinase inhibitors. In patients belonging to good and intermediate risk groups according to the IMDC criteria, who may benefit from cytoreductive nephrectomy, the surgery can be deferred by 3 to 6 months without the risk of jeopardizing the overall survival [Table 1].
Table 1: Recommendations for renal cell cancer

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Bladder cancer

Bladder cancer has been one malignancy which has perturbed uro-oncologists worldwide, the most, during the times of the COVID-19. This stems from the aggressiveness of this malignancy and the well-known detrimental effects which a delay in the management of this malignancy, brings with it.

A systematic review on the role of active surveillance in low grade non muscle invasive bladder cancer (NMIBC) (Ta, T1a, <1 cm,<5 lesions) revealed a 15% upgradation and 10% upstaging at a median follow up of 32 months. Only 1 study in the analysis reported a 2% progression to muscle invasive disease.[22] Researchers, however, have not assessed the impact of delay in resection of high risk NMIBC. Nevertheless, the European Organization for Research and Treatment of Cancer (EORTC) Genito-Urinary Cancer Group has a scoring system with risk tables which predicts the risk of disease progression and recurrence, based on the tumor characteristics.[23],[24],[25] The European Association of Urology also stratifies patients with NMIBC into 3 risk groups based on their tumor characteristics and the risk of progression and recurrence.[25],[26] These models can be extrapolated to guide us in triaging patients with small bladder masses, for the emergent need for tumor resections, in these times. Bladder mass with gross hematuria is a true urological emergency and should be subjected to a transurethral resection of bladder tumor with cystofulguration without delay. Hemostatic radiotherapy to the bladder is an option in high risk conditions, where surgery needs to be deferred. Patients with low risk bladder tumors with no hematuria can be deferred for a few months, without much risk of progression, and decisions can be taken for resection, depending on the prevalent conditions. Patients with intermediate and high risk cancers should be dealt with caution as a prolonged delay to resection may lead to upstaging and worsening of survival. The group at highest risk of progression is the one with large, multiple and recurrent tumors.[26] These patients should undergo a resection without much delay.

Complete resections should be strived for during the initial surgery and restaging procedures should be avoided. Patients who warrant an intravesical immunotherapy can be deferred for 3 months to reduce exposure of cancer patients to the health care system [Table 2].
Table 2: Recommendations for non muscle invasive bladder cancer

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The European Organization for Research and Treatment of Cancer (EORTC) and the Medical Research Council (MRC) trial, and the Advanced Bladder Cancer (ABC) Meta-analysis Collaboration established the role of Neoadjuvant Chemotherapy (NACT) in muscle invasive (MIBC) and advanced bladder cancers, with an overall survival advantage of 6%.[27],[28] The American Urological Association (AUA) and the EAU guidelines recommend NACT for MIBC. The risk of immunosuppression with chemotherapy in times of the SARS-CoV-2 may outweigh the 6% benefit in overall survival. Liang et al. carried out a nationwide analysis of cancer patients in China, infected with the SARS-CoV-2, and concluded that cancer patients, and especially those on chemotherapy had much higher risk of having serious life events, and recommended postponement of chemotherapy and even surgery.[29] Zhang et al. studied the clinical characteristics of SARS-CoV-2 infected cancer patients in three hospitals in Wuhan, China and recommended avoiding immunosuppressive chemotherapy, or if inevitable, reducing the dosage, as it led to more number of deaths in these patients.[30] Taking clues from China, patients with muscle invasive bladder cancer should be counseled about the additional risks of NACT in the current scenario and may be considered for definitive surgical treatment.

Lee et al. studied the effect of delay of surgery on survival in patients of bladder cancer and they showed a significant decrease in disease specific survival and overall survival with a delay of more than 93 days (3.1 months).[31] Fahmy et al., in their systematic review on the impact of a delay in surgical treatment on survival in bladder cancer, concluded that delays were associated with worse outcomes, with most of the studies suggesting a window of opportunity of less than 12 weeks from diagnosis to radical cystectomy.[32] The detrimental effect on survival for these patients with delays is significant and hence advanced bladder cancer patients should be offered curative treatments without much delay, and certainly within a 3 month period. The mode of surgery, whether open, laparoscopic and robotic can be discussed with the patient, keeping in mind, the views already elaborated earlier in the text.

Small muscle invasive tumors, which are ideal for bladder preservation protocol, can be offered a tri-modality treatment, as many oncologists believe that the immunosuppression associated with concomitant chemotherapy (CT) and radiotherapy (RT) would be less than that caused by the morbidity of a radical cystectomy. No evidence exists to support this view. Moreover, it can be debated that a concurrent CT-RT would require the patient to come to the radiation center every day for several weeks, hence increasing the chances of exposure of the cancer patient to the health care workers and hospital, besides the immunocompromised state, the chemotherapy would bring with itself. For larger tumors and those with perivesical spread, an upfront radical cystectomy should be offered.

Adjuvant chemotherapy for advanced cancers may be withheld and patients can be kept on surveillance. Immunotherapy with immune check point inhibitors (ICPI) is an option, but there is paucity of strong data as to how it compares with chemotherapy in terms of immunosuppression. Majority of adverse events associated with ICPIs are immune related adverse events (irAE); rash and colitis being the most common with CTLA-4 inhibitors and hypothyroidism and rash with PD-1 inhibitors. Immunosuppression only stems from the corticosteroids used for the treatment of the irAEs.[33] Hence, it would only be logical to presume a greater degree of immunosuppression with chemotherapeutic agents and avoid their use in the current times. Patients with metastatic tumors should have their chemotherapy deferred for at least the time, till their risk of contracting the SARS-CoV-2 goes reasonably low, or they may be started on ICPIs [Table 3].
Table 3: Recommendations for muscle invasive bladder cancer and upper tract urothelial carcinoma

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Prostate cancer

Prostate cancer, with its inherent indolent nature, and myriad of management options, is one malignancy which might bring some solace to uro-oncologists in the present times. Active screening should not be practiced. Patients having significant symptoms, or raised serum Prostate specific antigen (PSA) should only be investigated, and in others, without symptoms and low PSA, a diagnostic and therapeutic endeavor should be withheld. Patients with PSA <10 ng/ml and with mild lower urinary tract symptoms should be started on alpha blockers and evaluation be deferred for 3 to 6 months. Those with PSA >10 ng/ml and/or symptomatic patients should undergo a multiparametric Magnetic Resonance Imaging (mp MRI). The MRI protocol should also incorporate imaging the axial skeleton to do away with the need of an additional imaging. A transrectal ultrasound or MRI guided biopsy should be deferred. The PROMIS trial compared the diagnostic accuracy of mp MRI and Transrectal Ultrasound (TRUS) biopsy and found mp MRI to be more sensitive (93% vs 48%), albeit less specific, than the latter. It also had a 5% lower detection rate of clinically insignificant cancers, which is the need of the hour.[34] Prostate Specific Membrane Antigen-Positron Emission Tomography (PSMA-PET) can be avoided in the present times, provided the axial skeleton has been adequately imaged, or the PSA and clinical exam do not warrant a metastatic workup.

Non metastatic patients should be risk stratified based on the serum PSA levels, clinical exam findings along with the MRI findings. Low risk patients should be offered Active Surveillance (AS) and should be followed up with PSA levels and a MRI as per protocol. Patients insisting on a curative treatment and those who are unsuitable for AS should be further risk stratified. Surgical treatment in patients with low and intermediate risk disease may safely be deferred by 3 to 6 months, but those who fall in the high risk category may need to commence treatment sooner. Whereas, offering neoadjuvant Androgen Deprivation Therapy (ADT) to patients who are awaiting surgical treatment is an open question in these unusual circumstances, it would be reasonable to assume that the same should be offered only to high risk patients with a high chance of progression during the waiting period, and not indiscriminately, due to the complications and costs involved, along with the proven lack of benefit of these agents in a neoadjuvant set up prior to surgery.

The deferred definitive therapy should be discussed with the patient. Most uro-oncologists, medical oncologists and radiation specialists agree to the fact that a radical prostatectomy would be the preferred treatment option in these times, as it avoids repeated exposure of the cancer survivor to the health care system. A robotic approach offers the best results with minimal post-operative morbidity and hospital stay. Although the CHHiP trial established moderate hypo-fractionation of radiotherapy as the standard of care for patients undergoing External Beam Radiotherapy (EBRT), and most centers have adopted the same, even an ultra-hypofractionation (35-36.5 Gy in 5 fractions) warrants repeated visits to the hospital.[35]

Follow up protocols following definitive treatment should be tailored according to the prevalent conditions and PSA levels should be obtained 3 to 6 months following surgery.

Patients with high suspicion of metastatic disease may be initiated on ADT. Hormonal therapy with 3 monthly or 6 monthly depot preparations of Luteinizing Hormone Releasing Hormone (LHRH) agonists should be preferred if treatment is started based on high suspicion, owing to their reversible nature. Prakash et al. in their study on the diagnostic accuracy of 68Ga PSMA PET-CT scan, concluded that in patients with high clinical suspicion of metastatic prostate cancer, PSMA PET could reliably diagnose the same, without the need of a biopsy, and patients could be started on upfront ADT.[36] Such a strategy can be adopted at centers where PET scan is easily available. Patients with high burden of metastases and Castrate Resistant Prostate Cancer (CRPC) patients can be offered Abiraterone or Enzalutamide therapy along with ongoing ADT. Five milligrams of Prednisolone given twice daily, can be continued along with Abiraterone therapy, because the risk of hypertension and hypokalemia without this drug is far greater than the minimal immunosuppression this dosage causes. In a review by Fizazi et al., the incidence of grade ≥3 Corticosteroid Associated-Adverse Events (CA-AE) were 5%, 5% and 4% for all patients, Abiraterone + Prednisolone (AA + P) group and Prednisolone (P) group alone The most common CA-AEs were hyperglycemia (7.4%, 7.8%, and 6.9% for all patients, AA + P, and P alone, respectively) and weight increase (4.3%, 3.9%, and 4.8%, respectively).[37] No data is available to suggest immunosuppression with this dosage, but if individual concerns exist, the dosage can be reduced to 5 mg once a day without much risk of hypertension or hypokalemia. Docetaxel chemotherapy should be avoided [Table 4].
Table 4: Recommendations for prostate cancer

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Testicular cancer

Testicular cancers need special consideration as most of the patients are young and our decisions are bound to have long lasting implications. Patients should undergo high inguinal orchiectomy without much delay along with cross sectional imaging of the retroperitoneum and chest together.[16] Tumor markers should be done 4 weeks following orchiectomy.

Patients with Stage I disease should be offered surveillance while those with Stage II A and B Non Seminomatous Germ Cell Tumor (NSGCT) should be offered 3 cycles of Bleomycin, Etoposide and Cisplatin (BEP) rather than a complete retro peritoneal lymph node dissection (RPLND), for the morbidity it entails, and the limited resources with which we are working in the present times. For patients with Seminoma, Dog-Leg radiotherapy appears to be a better option for patients with Stage II A and B, because of the immunosuppression that accompanies chemotherapy. Patients with metastatic disease (Stage II C and III) need to be started on BEP chemotherapy depending upon the International Germ Cell Cancer Collaborative Group (IGCCCG) risk stratification [Table 5] and [Table 6].
Table 5: Recommendations for non-seminomatous germ cell tumour (NSGCT)

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Table 6: Recommendations for Seminoma

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Penile cancer

Patients presenting with a penile lesion or mass would require a biopsy, which can be performed in the out-patient setting. Patients with small Tis, Ta, and T1 lesions, the surgery for them can be deferred for 3 months. Balance has to be strived for between the risk of deferring surgery and risk of contracting the SARS-CoV-2 infection. The fact that delay in treatment of penile cancers could have a negative consequence has been shown in previous studies as done by Gao et al.[38] The results of their study showed that a delay by 3 months could result in increased lesion size, higher stage, increased lymph node positivity and decreased organ sparing, and a delay by 6 months would also result in an increased risk of metastasis in addition to other inferior clinical outcomes.[38] This is besides the fact that if upstaging occurs as a result of delay, patient would require a total amputation which could have devastating effects on his sexual potency. Radiotherapy, although an option for early T1 T2 cancers less than 4 cm involving the glans, should be avoided. Those with invasive tumors T2-T4, a partial or a total penectomy is to be performed [Table 7].
Table 7: Recommendations for penile cancer

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The Achilles heel in management of patients with penile cancer is the appropriate management of inguinal and pelvic lymph nodes. Patients with negative groins and who are at low (pT1-TisG1N0) or intermediate (pT1G2N0) risk for lymphovascular spread, can be kept on surveillance. Patients with negative nodes but at high risk of lymphovascular invasion (pT2-4, G3), either a modified Inguinal Lymph Node Dissection (mILND) or Dynamic Sentinel Lymph Node Biopsy (DSLNB) is warranted, but these procedures should be deferred for a period of 3 months, by the time the risk of the viral infection goes considerably low. DSLNB is preferred, if facilities exist over Inguinal Lymph Node Dissection (ILND) or static Sentinel Lymph Node Biopsy (SLNB). Radical ILND should be avoided to reduce the risks of flap necrosis and lymphocele formation. Frozen section histopathological examinations should be done during SLNB or ILND to determine the need for pelvic lymph node dissection, thus avoiding another surgery at a later date.[39] Patients with a clinically and histologically proven positive lymph nodes in groin (N1, N2) should undergo a complete ILND and Pelvic Lymph Node Dissection (PLND) with a contralateral staging procedure. The role of Video Endoscopic Inguinal Lymphnode (VEIL) surgery is debatable, and if imperative, should be restricted only to high volume centers.

Bulky and fixed nodal metastasis requires a multimodal treatment with almost all the guidelines favoring a neoadjuvant approach for improved surgical resectability and management of micro metastases. Patients with visceral metastases should be considered for palliative chemotherapy. Patients with large fungating masses may be considered for best supportive care.

 » The Final Word Top

None of us could have ever imagined the apocalypse this 100 nm virus would cause worldwide. Nevertheless, after a brief period of lockdown and isolation, it will soon be time for a resurrection. Cancer continued to kill slowly all this while when the SARS-CoV-2 was creating havoc worldwide, and it will continue to do so. We need to tailor our treatment strategies to the prevailing present conditions, so that we are capable of fighting and defeating both, the SARS-CoV-2 virus and cancer. Protection of healthcare workers, judicious use of available resources, and a rational and balanced outlook towards different malignancies is the need of the hour. We have tried to put forth some recommendations which individual surgeons, urologists and uro-oncologists can use to frame their policies depending upon the burden of the pandemic in their region.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

WHO 2020 WHO Timeline- COVID-19. Available from: https://www.who.int/news-room/detail/08-04-2020-who-timeline-covid-19. [Last accessed on 2020 Apr 08].  Back to cited text no. 1
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RCSE 2020 Intercollegiate General Surgery guidance on COVID -19 Update. Available from: https://www.rcsed.ac.uk/news-public-aff airs/news/2020/march/intercollegiate-gener al-surgery-guidance-on-covid-19-update. [Last accessed on 2020 Apr 08].  Back to cited text no. 3
Mottrie A. ERUS (EAU Robotic Urology Section) guidelines during COVID-19 emergency. Available from: https://uroweb.org/wp-content/uploads/ERUS-guidelines-for-COVID-def.pdf. [Last accessed on 2020 May 06].   Back to cited text no. 4
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Gloster HM, Roenigk RK. Risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts. J Am Acad Dermatol 1995;32:436-41.  Back to cited text no. 10
Hensman C, Baty D, Willis RG, Cuschieri A. Chemical composition of smoke produced by high-frequency electrosurgery in a closed gaseous environment. Surg Endosc 1998;12:1017-9.  Back to cited text no. 11
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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