European Association of Urology Guidelines Office Rapid Reaction Group: An Organisation-wide Collaborative Effort to Adapt the European Association of Urology Guidelines Recommendations to the Coronavirus Disease 2019 Era^☆

1. Introduction

The coronavirus disease 2019 (COVID-19) pandemic is unlike anything seen before by modern science-based medicine. As of April 14, 2020, there are 1 933 800 confirmed cases globally in 210 countries and 120 434 deaths [1]. Health systems globally have struggled. Anaesthetists and theatre teams have been redeployed, and intensive care units (ICUs) struggle with demands as the entire service is refocused on managing the acutely unwell. Added to this are the effects of social confinement and isolation. Staff at risk are removed from the workforce for their own health and some of them get sick, also limiting capacity. This brings into question whether the latest guidelines based upon the best evidence and published only 2 wk ago are relevant in this crisis.

As a scientific society and via the Guidelines, Section Offices, and the European Urology family of journals, we believe that it is important that we try to support urologists in this difficult situation. We aim to do this by providing tools that can facilitate decision making. Our goal is to minimise the impact and risks for both patients and health professionals delivering urological care, whenever possible, although it is clear that it is not always possible to mitigate them entirely. It should be understood that there may not be high-quality evidence for the compromises proposed, but we hope that this document will function as an important additional guide to the management of urological conditions during the current COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), based on the current European Association of Urology (EAU) guidelines.

2. Methods

The Guidelines Office commissioned a Rapid Reaction Group (GORRG) on March 19, 2020 to facilitate the development of adapted guidelines, to deal with a range of situations and priorities. Using the resources of the Guidelines Office, the panel chairmen, and panel members, in collaboration with other relevant EAU section offices plus the Executive Committee, the aim was to ensure an aligned organisation-wide consensus and response underpinned by the best knowledge at our disposal describing how to react to the urgent crisis impacting urological care and services.

All recommendations in the guidelines have been reviewed in light of the COVID-19 pandemic and have been adapted where appropriate. Panels also had access to and reviewed a range of national and local COVID-19 guidelines to ensure complementarity wherever possible. New evidence has been searched for by targeted (nonsystematic) screening of the available published literature, as well as including those recently accepted and in press with access provided by the publisher in strict confidence. The findings (mostly level 3/4 evidence) were discussed and approved by panel members across 21 EAU Guideline Panels using electronic communication. Regarding surgical approach that applies across several guidelines, it was decided that the GORRG will provide general recommendations instead of guideline-specific surgical approach recommendations in each disease area. All panels were provided the following specific terms of reference.

2.1. Protocol for adaptation of guidelines recommendations to COVID-19 period

2.1.1. Review of recommendations across four broad areas

• 1.
  Diagnosis

  • Imaging and/or tests
  • Invasive procedures
• 2.

  Surgical treatment and medical therapy

• 3.

  Follow-up/telemedicine (give updated recommendations on follow-up tailored for the COVID-19 era, with the aim of limiting as much as possible health care resources without losing our ability to timely diagnose disease recurrences/progressions)

• 4.

  Emergencies

2.1.2. Levels of priority

Panels were asked to provide tables with recommendations based on the level of priority, not necessarily covering all recommendations on the recently published updated EAU guidelines 2020 [2], but those that the panels felt were critical drivers of outcome and would especially be impacted by the current crisis, and always based on the highest level of evidence that was possible and referenced whenever possible to maintain a transparent link from evidence to adapted recommendation. In order to achieve this, the GORRG produced a colour-coded risk stratification tool (Table 1 ) for completion by guideline panels to aid them with the adaption of their recommendations:

Table 1.

Levels of priority.

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A&E = accident and emergency department.

Low priority: clinical harm (progression, metastasis, and loss of function) very unlikely if postponed for 6 mo (green colour)

Intermediate priority: cancel but reconsider in case of increase in capacity (not recommended to postpone for >3 mo): clinical harm (progression, metastasis, and loss of organ function) possible if postponed for 3 mo, but unlikely (yellow colour)

High priority: the last to cancel, prevent delay of >6 wk; clinical harm (progression, metastasis, loss of organ function, and deaths) very likely if postponed for >6 wk; (red colour)

Emergency: cannot be postponed for >24 h; life threatening—organ function threatening condition (black colour)

2.1.3. Criteria for prioritisation

The criteria established for prioritisation regarding procedure and disease are the following:

• •

  Impact of delay on primary outcomes (for instance overall survival in oncology, cancer-specific survival in oncology, risk of metastases, and kidney failure for transplant patients)

• •

  Possibility of alternative methods that could replace the procedure with less operating room requirement

• •

  Presence of comorbidities and/or increased risk of complications

• •

  Possibility of a threat to patient life if the procedure is not performed immediately.

• •

  Possibility of a threat of permanent dysfunction of the organ system if the treatment is not performed

• •

  Probability of a risk of rapidly progressing severe symptoms that are time sensitive

The criteria derived from COVID-19 pandemic are as follows:

• •

  Current and projected COVID-19 cases in the facility and region; the final decisions should be made in consultation with the hospital, surgeon, patient, and other public health professionals

• •

  Supply of personal protective equipment (PPE) to the facilities in the system

• •

  Staffing availability

• •

  Bed availability, especially ICU beds

• •

  Availability of adjuvant treatments (ie, chemotherapy) without which the primary treatment is less/not effective

• •

  Ventilator availability

• •

  Health status and age of the patient, especially given the risks of concurrent COVID-19 infection during recovery

• •

  Urgency of the procedure

• •

  Risk of bleeding/transfusion—there is a lack of red blood cell units because blood donors do not go to the hospital. Co-morbidities such as chronic obstructive pulmonary disease should be taken into account; patients taking anticoagulants/antiplatelet therapy (due to increased risk for transfusion)

• •

  Length of hospitalisation

• •

  Risk of acquiring the COVID infection by the patient during the treatment course

• •

  Risk of contamination of the staff by asymptomatic but already positive patient

• •

  Capacity of COVID-19 testing

2.1.4. Peer-reviewing process

Once submissions of adapted recommendations were received from all 17 EAU Guideline Panels, the GORRG proceeded with a first round of peer review and ensured uniformity of the format of recommendations, checked for consistency, and limited duplication across panel recommendations.

Finally, a second-step peer-reviewing process was done by seven independent Section Office members (three experts in oncology and three in nononcology, and one to comment on both oncology and nononcology); we also sought peer-review comments from China, given the significant experience they have had with COVID-19 and being a few months ahead of Europe in terms of stage of pandemic and recovery.

After the second round of peer-review process, different recommendations have been released and these can be consulted in 17 guideline topics provided in Supplementary Tables 1–17.

3. Discussion

The guidance produced is based on expert opinion and consensus building across the EAU with contributions from all 250 members of the EAU Guidelines Office and with contributions from the 130 key opinion leaders forming the membership of the EAU Section Offices. It is important to emphasise that during the rapidly evolving COVID-19 pandemic, this guidance may further change and critically will require adaptation to local resources, health systems, and specific circumstances of each country or city, bearing in mind that different countries and indeed different cities are likely to be at different phases of the pandemic and national/local health system capacities must dictate the level of prioritisation implemented in line with local COVID-19 policies.

In addition, there are some overarching principles that should be emphasised (as presented in Table 2 ). In order to minimise the number of staff who become infected, all medical personnel should comply with the PPE regulations. If possible, patients should be asked whether they are at risk of COVID-19 prior to any visit in a practice or clinic or hospital setting. Patients who are currently known to be shedding COVID-19 virus should postpone any investigations of other symptoms unless they are thought to be life threatening. However, urologists working in hospitals treating COVID-19 patients may be required to perform urgent investigations on infected patients. In these cases, procedures should be performed in dedicated consultation or operating rooms following the hospital recommendation for staff PPE. Even following a negative COVID-19 test result, it is important to remember the relatively high risk of a false negative result and, as a consequence, ensure that all the necessary PPE tools and general recommendations to reduce COVID-19 transmission are adequately followed (Table 2) [3]. It is also prudent during this pandemic, in the absence of extensive community testing and effective isolation/quarantine strategies in place, that health professionals perform their duties on the presumption that all patients they treat are potentially infected with COVID-19 even if asymptomatic, given that there is increasing evidence of high infection rates in asymptomatic individuals in countries conducting extensive community testing of their citizens [4], [5]. In this regard, it is important to consider the risk not only for staff but also for the patients. Recent evidence from Wuhan reported a 20% mortality rate in asymptomatic patients who tested COVID positive after the surgical procedure [6]. Onset of symptoms was within 2.6 d, and 44.1% required ICU support. Out of 20 asymptomatic COVID-positive patients undergoing level 3 complexity procedures, which are equivalent to urological transabdominal or retroperitoneal interventions, seven died in ICU from acute respiratory distress syndrome (Table 2).

If surgical procedures are unavoidable, it is recommended that all procedures should be performed by experienced urologists confident in the procedure. They should be performed with the minimum number of staff members, who should also be fully trained and experienced. Furthermore, no external observers should be present during the procedure (ie, fellows or students) [7]. Use of ultrasonic scalpels or electrical equipment producing surgical smoke should be discouraged because such smokes could carry the COVID-19 [8]. In previous studies, activated Corynebacterium, papillomavirus, and human immunodeficiency virus (HIV) have been detected in surgical smoke, and several doctors contracted a rare papilloma virus suspected to be connected to surgical smoke exposure. There is no reason to suppose that COVID-19 infection could not be spread in the same way. One study found that after using electrical or ultrasonic equipment for 10 min, the particle concentration of the smoke in laparoscopic surgery was significantly higher than that in traditional open surgery [8]. Thus, it is recommended to lower electrocautery power settings as much as possible. There is no conclusive evidence regarding the differences in risks of open versus laparoscopic surgery for the surgical team. However, laparoscopic surgery may be associated with a higher amount of smoke particles than open surgery [9]. On the contrary, minimally invasive surgery has the benefit of reducing the length of hospital stay and reducing the risks to the patient for contracting COVID-19 whilst in hospital. During laparoscopy, surgical smoke is released into theatre under pressure at several stages of surgery. It is advisable to keep intraperitoneal pressure as low as possible and to aspirate the inflated CO₂ as much as possible before removing the trocars (Table 2) [7], [8], [9].

The duration and frequency of shedding of COVID-19 virus in urine are unknown [10]. However, a recent study by Ling et al [11] reported limited persistence of SARS-CoV-2 nucleic acid in urine. These data do not prove a link between urine spillage and virus transmission. However, although no evidence of disease transmission through urine is demonstrated yet, urine sampling (for urine culture, dipsticks, and other analyses), urethral catheterisation, and endoscopic procedures (eg, transurethral resection of the prostate, transurethral resection of the bladder, ureteral stenting, etc.) should be executed with caution. As spills are inevitable, surfaces should be cleaned rapidly by using appropriate absorbent and by decontamination with chlorine (5000–10 000 mg/l) or another appropriate disinfectant (note that chlorhexidine is ineffective against COVID-19 and is not appropriate) [12]. Spills should be handled according to local guidelines. Similarly, in case of spillage leading to unwanted contact (ie, accidental exposure) with a member of the staff, appropriate measures should be taken following local protocols.

It is now clear that SARS-CoV-2 is present in the stools of COVID-19 patients. Therefore, the transmission during various procedures (eg, transrectal prostate biopsy and urinary diversions) might be possible [13]. Therefore, even if clear evidence of COVID-19 virus spreading through faeces is not demonstrated yet, it is preferable to minimise the risks of faecal transmissions.

Social distancing is the key player to fight against COVID-19 pandemic. We have a duty to avoid unnecessary outpatient visits and in doing so reduce the chance of virus transmission. Increasing use of telehealth may be an important way to continue to support patients and their carers during this crisis. It will be interesting to see if this change, born of necessity, is incorporated into urological practice beyond the pandemic (Table 2) [14], [15].

While it cannot be predicted when we will be able to revert back from the acute phase of the COVID-19 pandemic and resume more normal levels of urological care, we need to plan ahead on how the urological community should do this.

The most logical step will be to reverse back through the aforementioned prioritisation stages. During this process, we will need to confer with our fellow surgical (sub)specialities to prioritise the available surgical time and resources among all surgical patients.

Undoubtedly there will be cases where the optimal surgical treatment time point will be surpassed. These patients may be at risk of a suboptimal outcome or an increased psychological burden due to delayed surgery, and should be prioritised in the long waiting lists that we will undoubtedly be facing on the other end of this crisis.

4. Conclusions

The EAU is a family of 19 000 members, and beyond our membership, the EAU feels a huge sense of responsibility towards each and every urologist globally, wherever they may be, appreciating that the EAU guidelines are now endorsed by national societies of 72 countries. This extended family ethos is even more important at a time like this when we are acutely aware of the despair that nations and their citizens are experiencing around the world. For instance, we realise that our colleagues and friends in Italy, Spain, France, UK, other EU member states and increasingly in the USA are being particularly impacted, whilst on the other side of the world, our friends in China, South Korea, and Japan look to rebuild and return to some form of new normality. Our thoughts are with each and every one of you. Despite these incredibly difficult times, key opinion leaders across the breadth of our membership have come together like never before to rapidly produce this publication on adapting EAU guideline recommendations to COVID-19 that we hope will fill an important urological practice void and assist urologist surgeons across the globe as they do their very best to deal with the crisis of our generation.

The EAU Guidelines Office COVID-19 recommendations can be consulted in Supplementary Tables 1–17.



 Author contributions: Maria J. Ribal had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Ribal, N’Dow, Cornford, Briganti, Knoll, Gravas, Babjuk, Harding, Breda, Bex.

Acquisition of data: Witjes, Mottet, Ljungberg, Rouprêt, Laguna, Salonia, Bonkat, Blok, Türk, Radmayr, Kitrey, Engeler, Lumen, Hakenberg, Watkin, Olsburgh, Hamid, Ribal, N’Dow, Cornford, Gravas, Babjuk, Harding, Breda, Bex.

Analysis and interpretation of data: None.

Drafting of the manuscript: Cornford, N'Dow, Ribal.

Critical revision of the manuscript for important intellectual content: Ribal, N’Dow, Cornford, Briganti, Knoll, Gravas, Babjuk, Harding, Breda, Bex, Rassweiler, Gözen, Pini, Liatsikos, Giannarini, Mottrie, Subramaniam, Sofikitis, Rocco, Xie, Witjes, Mottet, Ljungberg, Rouprêt, Laguna, Salonia, Bonkat, Blok, Türk, Radmayr, Kitrey, Engeler, Lumen, Hakenberg, Watkin, Olsburgh, Hamid, Darraugh, Shepherd, Smith, Chapple, Stenzl, Van Poppel, Wirth, Sønksen.

Statistical analysis: None.

Obtaining funding: None.

Administrative, technical, or material support: Darraugh, Shepherd, Smith.

Supervision: Ribal, N’Dow.

Other: None.



 Financial disclosures: Maria J. Ribal certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: Maria J. Ribal received company speaker honorarium from Janssen Laboratories, Olympus Iberia S.A.U., Astellas Pharma S.A., and Ipsen Pharma; and holds a patent for “Method for non-invasive diagnosis of bladder cancer”, European Patent Office (grant number: 13382030.8-1403; entity holder: Fina Biotech, S.L.U. June 2007). Philip Cornford is a company consultant for Astellas, Ipsen, and Ferring; received company speaker honoraria from Astellas, Janssen, Ipsen, and Pfizer; participated in trials run by Ferring; and received fellowships and travel grants from Astellas and Janssen. Alberto Briganti is a company consultant for Astellas, Janssen, Opko Health, MDx Health, and Bayer; received company speaker honorarium from Astellas and Ferring; and received research support from Sandoz. Thomas Knoll is a company consultant for Storz Medical, Dornier, Olympus, and Boston Scientific; received company speaker honorarium from Boston scientific; received fellowship/travel grants from Cook; and received research support from Dornier. Stavros Gravas is a company consultant for Astellas and GSK; and has received speaker honorarium from Astellas, Pierre Fabre, and Ferring. Marek Babjuk is a company consultant for Astellas; received company speaker honoraria or consultancy fees from Ipsen Pharma s.r.o., Janssen, Olympus, and Astellas; holds an advisory board position for Ferring; and participates in trials run by Hamlet Pharma, Ferring, and Sotio. Christopher Harding is a company consultant for Teleflex Medical; received speaker honorarium from Astellas, Allergan, and Medtronic; received travel grants from Medtronic and research grants from NIHR and The Urology Foundation; and participated in a trial by Medtronic. Axel Bex has participated in a trial run by BMS. Evangelos Liatsikos is a company consultant for CooK Medical; received speaker honoraria from Boston Scientific and Karl Storz, and participates in clinical studies run by Cook Medical. Alex Mottrie is the CEO of ORSI Academy and holds equity interest in Intuitive. Li-Ping Xie participates in trials run by IPSEN (PRIORITI study) and Olympus (TVERP study) as the primary investigator. Alfred J. Witjes is a company consultant for Spectrum, Tocagen, BioClin, Sanofi Aventis, Biocancell Ltd., and Nucleix Ltd.; received honoraria or consultation fees from Taris Biomedical, BMS, MSD Global Medical Affairs, and Roche Nederland B.V.; and participated in trials run by Taris, Cepheid, Arquer, and MEL Amsterdam. Nicolas Mottet is a company consultant for Janssen, GE, BMS, Sanofi, and Astellas; has received speaker honoraria from Astellas, Pierre Fabre, Steba, Janssen, and Ferring; and has received fellowships and travel grants from Astellas, Ipsen, Sanofi, Janssen, and Roche. Börje Ljungberg has received speaker honoraria from Pfizer, Ipsen, and BMS; has participated in studies run by Janssen, Astellas, and Medivation; and is a company consultant for Janssen, Novartis, and Ipsen Nordic. Morgan Rouprêt receives company speaker honorarium from Roche, Zambon, Ipsen Pharma, Janssen, and Astellas; receives research support from GSK, Pfizer, and Roche; receives consultancy fees from Lilly, GSK, Ipsen, Astellas, Takeda, Sanofi Pasteur, and Medac; receives company speaker honorarium from Roche and Zambon; and participates in studies by Pfizer and Roche. Gernot Bonkat has received speaker honoraria from Vifor Pharma, Bionorica, and IBSA; has received fellowship and travel grants from Vifor Pharma, Eli Lilly, and Astellas; and is a company consultant for Janssen-Cilag, Zambon, IBSA, and Vifor Pharma. Noam D. Kitrey has received speaker honorarium from Astellas and Pfizer; has participated in trials run by Astellas and Ipsen; and has received fellowship and travel grants from Pfizer. Nicolaas Lumen received company speaker honorarium from Bayer and Janssen; participated in trials run by Janssen, Roche, Pfizer Belgium, and AstraZeneca N.V.; and received grant/research support from Bayer and Janssen. Rizwan Hamid received company speaker honorarium from Allergan and Laborie; participated in trials run by IPSEN and Medtronic; received honoraria from Contura and grant/research support from Allergan. Christopher R. Chapple is a consultant for Astellas, Bayer, Contura, Ferring, Pierre Fabre, Symimetic, and Urovant Sciences; received speaker honorarium from Astellas and Lupin; is an author for Allergan, Astellas, and Ferring; is an investigator for Astellas and Bayer; and is a co-patent holder for Symimetic. Arnulf Stenzl is a company consultant/advisor for Ipsen Pharma, Roche, Janssen, Alere, Bristol-Myers Squibb, Stebabiotech, Synergo, and Ferring; received speaker honorarium from Janssen, Ipsen Pharma, Sanofi Aventis, CureVac, Astellas, Amgen, and AstraZeneca; participates in clinical studies by Johnson & Johnson, Roche, Cepheid, Bayer AG, CureVac, Immatics Biotechnologies GmbH, and GemeDx Biosciences; and received research grants from AmgenInc, Immatics biotechnologies GmbH, Novartis AG, and Karl Storz AG. Jens Sønksen holds equity interests in Multicept A/S, Frederiksberg, Denmark. Jens J. Rassweiler, Ali S. Gözen, Giovannalberto Pini, Gianluca Giannarini, Bernardo M.C. Rocco, Ramnath Subramaniam, Nikolaos Sofikitis, Julie Darraugh, Emma Jane Smith, Robert Shepherd, Bertil F.M. Blok, Alberto Breda, Daniel S. Engeler, Oliver W. Hakenberg, Nick Watkin, Maria Pilar Laguna, Christian Radmayr, Andrea Salonia, Christian Türk, Jonathon Olsburgh, Hendrik van Poppel, Manfred Wirth, and James N’Dow have nothing to declare.



 Funding/Support and role of the sponsor: None.

Associate Editor: James Catto

Appendix A. Supplementary data

The following is Supplementary data to this article: