As the number of hospitalizations for COVID-19 in our region decreased in May, we were faced with the challenge of triaging and rescheduling surgeries that were postponed due to the pandemic. In order to approach that challenge in a way that most equitably served our patients, specialty, and institution, we developed a systematic approach for surgical prioritization. Our approach implicitly favored patients with more time-sensitive diagnoses, wherein a delay in surgery may alter their outcome. Consideration was also given to other factors, such as the date of initial diagnosis (particularly for oncologic cases) and the age of the patient (the younger the patient, the higher rank on the list).
Several other statements have offered guidance on how to approach prioritization of surgeries in light of limited hospital resources or operating room availability. Wallis et al. formulated a collaborative review of the risks associated with delayed treatment of urological cancers. Based on this review, patients with high-grade urothelial carcinoma, advanced kidney cancer, testicular cancer, and penile cancer should be prioritized as more urgent (4). Stensland et al. developed additional suggestions. Specifically, acute infections (i.e., abscesses and Fournier’s gangrene) and ischemic or traumatic conditions are considered urgent procedures warranting priority. Surgeries to correct benign prostatic hyperplasia, incontinence, and infertility are elective, and therefore less urgent (5).
Quaedackers et al. additionally described suggestions for postponed pediatric urologic surgeries. Similar to adults, benign scrotal and penile surgeries, as well as surgery for incontinence, uncomplicated urolithiasis, and vesicoureteral reflux can be safely delayed. Other conditions that may cause irreversible progression of disease, organ damage, or are life-threatening should be prioritized to continue. These include surgeries to correct complicated obstructions, testicular torsion, and oncological malignancies (6).
These sources were influential in developing our ranking system, but these sources lacked a guideline model for developing a prioritization list. Thus, our model develops an urgency prioritization system, largely based on these prior studies, as well as giving a large consideration to time-sensitive diagnoses during which a delay would alter outcome. This prioritization guideline was necessary as our location in the Bronx cancelled all nonemergent surgeries – thus, our backlog of surgical cases consisted of numerous critical and oncological, time-sensitive cases.
Urologists at the Cleveland Clinic developed a similar triaging system that focused on the potential harms that would result from delaying surgery (11). They assigned procedures to five tiers, with Tier Zero cases requiring emergency surgery and Tier Four cases consisting of nonessential procedures. Although we had a similar approach to triaging patients, our department, unlike the Cleveland Clinic, actually had to cancel all non-emergent surgeries as a result of the severe strain COVID-19 cases had on our hospital system. Thus, we had to prioritize a large backlog of patients awaiting surgeries that were not purely nonessential, and we have a system that was amply tested with the task of incorporating patients back into surgical practice.
Prachand et al. developed the MeNTS system, which assigns a numerical score to each patient for overall surgical prioritization (7). Scores are calculated by a number of variables, including but not limited to patient demographics, status and urgency of disease or diagnosis, and hospital and surgical resources required. Unlike previously referenced systems, surgeries requiring higher resource allocation will lose points in prioritization.
In contrast to MeNTS, our system is based on disease status and prognosis as a surrogate for surgical urgency. If hospital resources are a contributing variable, patients requiring more complex surgery, or who are more medically comorbid and at a high risk for surgical complication, may be penalized. While hospital resources are very important to consider, particularly when it comes to the ability to care for a patient during and after surgery, we fear this may lead to delay in surgery in select patients who require prompt intervention. Except for the first several weeks of the pandemic when hospital resources were markedly restricted, we do not feel a current significant need for including hospital resources as a major determinate in triaging surgical patients.
Our system has an advantage over guidelines that assign numeric scores for varying categories. Such systems have a potential misconception that all variables have equal numerical value. As acknowledged in the MeNTS article, not every aspect of a patient’s disease, procedure, or demand on the hospital system is quantitatively proportionate. While numerical scoring can still prove to be quite useful, it may give a false sense of objectivity due to significant subjectivity involved in assigning several of these numerical scores. Assigning class and subclass allows us to triage cases using only disease status and rationale for surgical urgency, without being skewed by the numeric values of many other variables that may not be of equal significance.
Another advantage to our approach is that these guidelines can remain relevant even after the COVID-19 pandemic has passed. Utilizing surgical guidelines that consider patient’s varying pathologies, disease status, as well as potential outcomes from a delay in surgery is extremely useful for surgical planning regardless of the current pandemic and resource limitations.
Our guideline system has some limitations to acknowledge. We based our system on the impact of delayed treatment on the diagnosis in question but did not consider the burden on resources necessary for particular surgical procedures or high-risk surgical candidates. At a time when ventilators and ICU beds are extremely limited, this could be a legitimate roadblock to performing complex surgeries on higher acuity patients despite the potentially aggressive nature of their disease. As discussed by Puliatti et al, cancer patients that we would consider Level 3 cases are at especially high-risk group for COVID-19 complications (12). If these patients are admitted to the hospital for a urologic surgery and are exposed to COVID-19, their disease course might require another hospitalization and consumption of limited resources. An alternative approach would be to encourage the use of chemotherapy and radiation on an outpatient basis; this approach considers the patient’s overall survival at a time when hospitalizations pose increased risks to patients (13). However, our system has the advantage in that it will allow adjustments to top-priority patients at any time to address the current state of hospital resource availability.
Although our rationales for determining surgical urgency are rooted in evidence-based knowledge and current standard practice, we faced another limitation in the lack of definitive data regarding the impact of delayed intervention on survival outcomes. For example, there are limited data on the impact of delayed radical orchiectomy on survival for testicular cancer. Due to logical concerns of metastasis and disease progression, it is still common practice to perform radical orchiectomy as early as possible despite a lack of survival data. Thus, some rationales are based on informed specialist opinion and common practice, which may decrease objectivity.