










































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2021 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Management Recommendations for  
Prostate Cancer During the COVID-19  
Pandemic: A Systematic Review
Alan de J. Martinez-Salas, Iñigo Navarro-Ruesga, Erick A. Rodenas-Gil, Jesus S. Muruato-Araiza,  
Aldo Jimenez-García, Irving Reyna-Blanco, Jorge G. Morales-Montor, Carlos Pacheco-Gahbler

Urology Division, Hospital General Dr Manuel Gea González, Mexico City, Mexico

Abstract

Introduction The COVID-19 pandemic has delayed screening, diagnostic workup, and treatment in prostate 
cancer (PCa) patients. Our purpose was to review PCa screening, diagnostic workup, active surveillance (AS), radical 
prostatectomy (RP), radiotherapy (RT), androgen deprivation therapy (ADT) and systemic therapy during the 
COVID-19 pandemic.

Materials and Methods We performed a systematic literature search of MEDLINE, EMBASE, Scopus, LILACS, 
and Web of Science, according to Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols 
(PRISMA-P) statement for relevant material published from December 2019 to February 2021.

Results Prostate biopsy can be delayed, except when high-risk PCa is suspected or the patient is symptomatic. 
Active surveillance is appropriate for patients with very low risk, low risk (LR) and favorable intermediate risk (FIR). 
RP and RT for high risk and very high risk can be safely postponed up to 3 months. Hypofractionated external beam 
RT (EBRT) is recommended when RT is employed. ADT should be used according to standard PCa-based indications. 
Chemotherapy should be postponed until the pandemic is contained.

Conclusions The international urological community was not prepared for such an acute and severe pandemic. 
PCa patients can be adequately managed according to risk stratification. During the COVID-19 pandemic, LR and 
FIR patients can be followed with active surveillance. Delaying RP and RT in high risk and locally advanced disease 
is justified.

Introduction

In December 2019, a series of acute atypical respiratory diseases occurred in Wuhan, China, caused by a novel 
coronavirus, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), responsible for the coronavirus 
disease 2019 (COVID-19) pandemic[1]. By the end of July 2020, 11.456 million confirmed COVID-19 cases and 530 
937 deaths had been reported globally, and by mid-March 2021, 120 million cases and 2.6 million deaths had been 
reported, according to the COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns 
Hopkins University[2]. Some studies have suggested that men with COVID-19 have a higher risk than women for 
SARS-CoV-2-related complications and death[3,4].

Prostate cancer (PCa) is the most frequently diagnosed urogenital neoplasm and is currently the second leading 
cause of cancer deaths in men in the United States and Europe[5,6].

Key Words Competing Interests Article Information

Androgen receptor antagonists, adjuvant 
chemotherapy, prostatic neoplasms, 
radiotherapy, SARS coronavirus

None declared. Received on January 20, 2021 
Accepted on March 27, 2021

Soc Int Urol J.2021;2(4):240–254

DOI: 10.48083/MBSB4196

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COVID-19 remains a challenge for health care 
professionals all around the globe. Radical treatment, 
such as radiotherapy with curative intent and surgical 
procedures, has been affected by this pandemic. Bhat et 
al. reported an increase of approximately 22% of PCa 
patients on the waiting list of radical prostatectomies 
in a robotic oncological center, revealing the negative 
effect of COVID-19 on surgical PCa treatment[7]. We 
performed a systematic review of the best management 
recommendat ions for PCa pat ients during t he 
COVID-19 pandemic, and sought to establish a 
foundation for PCa management in future pandemics. 
Our primary aim was to assess the evidence published 
to date with respect to the management of PCa with 
surger y, radiotherapy, androgen deprivation and 
systemic therapy, for all stages and risk stratification 
categories, since the beginning of COVID-19 pandemic. 
We also sought to determine whether studies on changes 
in PCa workup and management made because of the 
pandemic have provided adequately robust evidence 
to establish guidelines for PCa management in future 
pandemics.

Materials and Methods
Protocol development and registration
We registered our systematic review protocol in 
PROSPERO (Internat iona l Prospect ive Reg ister 
of  Sy s t em at ic  Re v ie w s ,  re g i s t r at ion  nu mb er 
CRD42020193332), following the PRISMA-P (Preferred 

Reporting Items for Systematic Reviews and Meta-
analyses Protocols) statement[8].

Eligibility criteria and literature search
We performed a systematic literature search using 
MEDLINE and EMBASE, Scopus, LILACS (Literatura 
Latinoamericana y del Caribe en Ciencias de la Salud), 
and Web of Science, including all indexed publications 
in English, Spanish, and French. We included recom-
mendations, systematic reviews, clinical trials, and case-
control, cohort, and cross-sectional studies related to 
the workup and management of PCa, patients (such as 
screening, diagnosis, any modality of treatment, radical 
prostatectomy (RP), radiation therapy (RT), androgen 
deprivation therapy (ADT), chemotherapy (ChT) and 
follow-up), from December 1, 2019, to February 28, 2021. 
Editorials, letters, and opinion articles were excluded.

Study selection and data extraction
Two independent investigators (AJMS and JSMA) 
performed the systematic literature search and screened 
all identified paper titles and abstracts. The full text of 
each identified article was reviewed by 3 independent 
investigators (AJMS, JSMA, INR). Any disagreement 
about individual study inclusion was resolved by a 
fourth investigator (EARG).

Information on included studies was entered into 
an Excel database. Information included the authors, 
country of research, publication title, date of publication, 
study design, indexed databases, management options 
studied in the publication methodology, outcome, and 
recommendations.

Risk of bias and quality assessment
Individual study quality assessment was performed 
using the appropriate tool for the study design and 
methodology: STROBE (Strengthening the Report of 
Observational Studies in Epidemiology-II) for cohort, 
case-control, and cross-sectional studies[9], AGREE II 
(Appraisal of Guidelines for Research & Evaluation) for 
guidelines and recommendations[10], and AMSTAR-2 
(A Measurement Tool to Assess systematic Reviews) 
for systematic reviews and meta-analysis[11]. The risk 
of bias (RoB) was assessed using the ROBINS-I[12] for 
individual included non-randomized studies, and the 
ROBIS[13] for systematic reviews. All recommendations 
based on non-systematic reviews were managed as 
expert consensus; therefore, no RoB was evaluated for 
such publications.

Outcome and synthesis methods
We performed data synthesis for each element of PCa 
management, including screening and diagnosis, 
surgica l treatment, radiation t herapy, androgen 
deprivation therapy, and systemic therapy. This 
synthesis was conducted for each PCa risk group in 

Abbreviations 
ADT androgen deprivation therapy
ARAT androgen-receptor-axis-targeted therapies
AS active surveillance
BCR biochemical recurrence
ChT chemotherapy
EBRT external beam radiation therapy
FIR favorable intermediate risk
HR high risk
LR low risk
mCRPC metastatic castrate resistant PCa
mpMRI multi-parametric MRI
nmCRPC non-metastatic castration-resistant prostate cancer
PCa prostate cancer
PSADT PSA doubling time
RoB risk of bias
RP radical prostatectomy
RT radiation therapy
UIR unfavorable intermediate risk
VHR very high risk
VLR very low risk

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the National Comprehensive Cancer Network Prostate 
Cancer Guidelines Risk Stratification as well as for each 
stage group (localized, locally advanced, and metastatic 
PCa)[14].

To determine adequate level of evidence and quality 
of recommendations for each different PCa management 
strategy, publication quality of evidence was established, 
using the SIGN statement for the level of evidence[15]. 
The priority of management recommendations was 
based on the European Urological Association Rapid 
Reaction Group level of priorit y for COVID-19 
pandemic[16]: emergency priority, labeled as black 
(cannot be postponed > 24 hours because of life-
threatening condition); high priority, red (should 
not be delayed > 6 weeks, since clinical harm such as 
progression, metastasis, loss of organ function, and 
death may occur); intermediate priority, yellow (cancel, 
but reconsider in case of increased capacity; delay of > 3 
months may result in clinical harm and should therefore 
not be recommended); and low priority, green (clinical 
harm is very unlikely with delay of > 6 months).

Results
Literature search and study selection
The literature search identified 349 papers from the 
different databases. After duplicates and articles not 
eligible for screening were eliminated, a total of 142 
abstracts were screened, and 55 potentially eligible full 
text articles retrieved. Of these, 27 papers were excluded 
since outcomes were not documented; therefore, 28 
publications were included in our systematic review 
(Figure 1).

Study characteristics, quality, and level of 
evidence
Of the included publications, 4 were systematic 
reviews, 16 expert opinion and consensus-based 
recommendations (non-systematic reviews), 1 case-control, 
and 3 cross-sectional and 4 cohort studies. Regarding 
quality of evidence, most of the studies complied with 
more than two-thirds of the corresponding tool items. 
Table 1 summarizes characteristics, study design, 
PCa management approached during the COVID-19 
pandemic, results and recommendations, and SIGN 
level of evidence for each publication[15].

Publications obtained with original search strategy 
n = 349

EMBASE = 62
MEDLINE = 49
SCOPUS = 102
LILACS =  51

Web of Science = 85

IN
C

LU
S

IO
N

S
EL

EC
TI

O
N

S
C

R
EE

N
IN

G
ID

EN
TI

FI
C

A
TI

O
N

Screened publications (full abstract reading)
n= 142

Full text reading publications
n= 55

Included publications
n= 28

Excluded publications:  duplication or 
not related to subject

n = 207

Excluded publications: opinion, editorials, 
not related to main outcome

n = 87

Publications excluded after 
full text reading

n = 27

FIGURE 1.

PRISMA Flow Diagram

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TABLE 1. 

Characteristics of included publications 

Publication Country
Date of 

Publication
Methodology PCa management

Level of 
evidence 

[15]

RoB 
assessment

Kokorovic  
et al.[20]

Canada June 2020
Expert/consensus-based 

recommendations
Screening/diagnosis, 

AS, RP, RT, ADT
4 NA

Heldwein  
et al.[34]

International September 2020 Systematic review
Screening/diagnosis, 

RP, RT, ADT, ChT
2 ++ Lowa

Montopoli  
et al.[43]

Italy August 2020 Case/control ADT 2 - Moderateb

Gómez Rivas  
et al.[21]

Spain February 2020
Expert/consensus-based 

recommendations
Screening/diagnosis, 

RP, RT, ADT, ChT
4 NA

Larrea  
et al.[41]

Spain May 2020 Cross-sectional RT 3 NA

Simcock  
et al.[29]

International March 2020
Expert/consensus-based 

recommendations
AS, RT 4 NA

Amparore  
et al.[18] 

Italy May 2020 Systematic review
Screening/diagnosis, 

RP, RT, ADT, ChT
2 ++ Higha

Würnschimmel  
et al.[32]

Germany  May 2020 Cross-sectional RP 2 - NA

Popert  
et al.[17]

United Kingdom May 2020 Cross-sectional Screening/diagnosis 2 - NA

Zaorky  
et al.[42]

United States/ 
United Kingdom

March 2020 Systematic review RT 2 ++ Lowa

Méjean  
et al.[22]

France March 2020
Expert/consensus-based 

recommendations
Screening/diagnosis, 

RP, RT, ADT, ChT
4 NA

Wallis  
et al.[39]

International April 2020
Expert/consensus-based 

recommendations
RP, RT, ADT 4 NA

Narain  
et al.[23]

India April 2020
Expert/consensus-based 

recommendations
Screening/diagnosis, 

RP, RT, ADT
4 NA

Dovey  
et al.[24]

International May 2020
Expert/consensus-based 

recommendations
Screening/diagnosis, 
AS, RP, RT, ADT, ChT

4 NA

Katims  
et al.[36]

United States June 2020 Systematic review RP 2++ Higha

Obek  
et al.[25]

Turkey July 2020
Narrative review/ 
recommendations

Screening/diagnosis, 
RP, RT, ADT

4 NA

Tachibana  
et al.[40]

United States November 2020
Narrative review/ 
recommendations

RP, RT, ADT, ChT 4 NA

Tan  
et al.[31]

United Kingdom January 2021 Cohort RP 2+ Moderatea

Madan  
et al.[26]

United States August 2020
Narrative review/ 
Recommendations

Screening/diagnosis, 
RP, RT, ADT

4 NA

Caffo  
et al.[45]

Italy September 2020 Cohort ADT 2+ Higha

a ROBIS assessment tool[13] b ROBINS-I assessment tool[12]
ADT: androgen deprivation therapy; AS: active surveillance; NA: not applicable; PCa: prostate cancer; RoB: risk of bias; RP: radical prostatectomy;  
RT: radiation therapy.

continued on page 244

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Screening and diagnosis of PCa
Popert et al.[17] undertook a prospective cohort study 
of patients managed with prostate biopsy during the 
pandemic (April 2020) in the United Kingdom. They 
established a 3-level risk stratification:
• High risk (red): PSA density > 0.2ng/mL/cc and 

MRI suspicious lesions (Likert/PI-RADS 3, 4 and 5); 
biopsy should be performed within a month.

• Intermediate risk (amber): PSA density < 0.2 and 
suspicious lesions; biopsy within 3 months.

• Low risk (green): PSA density < 0.2 and no 
suspicious lesion; biopsy safely postponed 
indefinitely.

Amparore et al.[18] performed a systematic search 
of all urological association and society websites 
between April 8, and April 18, 2020, for guidelines on 
the management of urological pathologies during the 
pandemic. They concluded that prostate biopsies should 
be performed in men with suspected high-risk, locally 
advanced, or symptomatic PCa and this should be done 
without preceding MRI[19]. The remaining publications 
related to prostate biopsy are expert consensus 
recommendations[20–28]; most authors recommend 
that new PSA screening and continuation of diagnostic 

workup should not be performed until the pandemic is 
contained and suggest delaying prostate biopsy except in 
symptomatic patients[21–23], PSA > 10ng/mL[31,34,39], 
suspicion of cT3 disease, PSA doubling time (PSADT) 
< 6 months[24,27], or in case of medullary compression 
or obst r uct ive rena l fa i lure seconda r y to PCa 
suspicion[22,27]. A summary of recommendations for 
screening and diagnosis is provided in Table 2.

Active surveillance in PCa
Six papers (all of them being either narrative reviews 
or consensus-based recommendations) addressed the 
role of active surveillance (AS) in PCa patients and 
concluded that in very low risk (VLR), low risk (LR), 
and favorable intermediate risk (FIR) PCa patients, AS 
is an adequate management strategy[20,24,27,29,30]. 
For LR and FIR patients, Rodriguez-Sanchez et al. 
and Caicedo-Martinez et al. suggest implementation 
of AS while delaying RP and RT until the pandemic is 
controlled[27,30], and Kokorovic et al. suggest either 
AS or delaying RP up to 12 months[20]. Detti et al. 
recommend multi-parametric MRI (mpMRI) of the 
prostate instead of re-biopsy in patients on AS[28].  
A summary of recommendations for AS is provided in 
Table 3.

TABLE 1. 

Characteristics of included publications 

Publication Country
Date of 

Publication
Methodology PCa management

Level of 
evidence 

[15]

RoB 
assessment

Rodriguez-
Sanchez 
et al.[27]

International July 2020
Narrative Review/ 
recommendations

Screening/diagnosis, 
AS, RP, RT, ADT

4 NA

Barthwal  
et al.[44]

India July 2020
Narrative review/ 
recommendations

RT 4 NA

Caicedo-Martinez 
et al.[30]

Colombia July 2020
Narrative review/ 
recommendations

Screening/diagnosis, 
AS, RP, RT, ADT

4 NA

Detti  
et al.[28]

Italy February 2021
Expert/consensus-based 

recommendations
Screening/diagnosis, 

AS, RP, RT, ADT
4 NA

Diamand  
et al.[37]

International June 2020 Cohort RP 2++ Lowa

Lalani  
et al.[46]

Canada April 2020
Expert/consensus-based 

recommendations
ADT, ChT 4 NA

Shinder  
et al.[35]

United States May 2020
Expert/consensus-based 

recommendations
RP, ADT 4 NA

Ginsburg  
et al.[38]

United States October 2020 Cohort RP 2++ Lowb

a ROBIS assessment tool[13] b ROBINS-I assessment tool[12]
ADT: androgen deprivation therapy; AS: active surveillance; NA: not applicable; PCa: prostate cancer; RoB: risk of bias; RP: radical prostatectomy;  
RT: radiation therapy.

, Cont’d

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TABLE 2. 

Summary of prostate cancer screening and diagnostic evaluation recommendations  
during the COVID-19 pandemic 

Paper
Screening and diagnostic evaluation

New PCa screening Symptomatic or mPCa suspicion

Kokorovic et al.[20] New PSA screening and diagnostic workup should be delayed

Heldwein et al.[34]
Individual patient- based decision. Postpone until pandemic control; perform without MRI  

if suspicion of advanced disease

Gómez Rivas et al.[21]
New PSA screening and diagnostic workup  

should be delayed
In symptomatic disease perform biopsy

Amparore et al.[18] Delay until pandemic control Biopsy without previous MRI

Popert et al.[17] PSA density ≥ 0.2 ng/mL/cc and MRI Likert/PI-RADS 3, 4, 5 biopsy within 3 months, otherwise defer indefinitely

Méjean et al.[22]
New PSA screening and diagnostic workup  

should be delayed
Biopsy in case of medullary compression 

Narain et al.[23]
New PSA screening and diagnostic workup  

should be delayed
Symptomatic disease or PSA ≥ 10 ng/mL  

perform biopsy

Obek et al.[25]
New PSA screening and diagnostic workup  

should be delayed

Do not delay biopsy ≥ 3 months in: PSA ≥ 20ng/mL, 
 DRE cT3 and PSADT ≤ 6 months

If suspicion of mPCa, perform first imaging studies,  
if confirmed initiate ADT, biopsy may be postponed

Madan et al.[26] Delay diagnostic workup until pandemic control, no time specified

Rodriguez-Sanchez et al.[27] Delay biopsy unless PSA ≥ 20 ng/mL, PSADT ≤ 6 months, T3 or symptomatic

EAU Rapid Response  
Priority Level

Low priority Intermediate priority

Recommendation 
summary

PCa screening and workup with PSA and MRI can be safely delayed until pandemic control; if suspicion of 
advanced, mPCa, or symptomatic, consider biopsy without MRI; if suspicion of mPCa, perform imaging studies first

DRE: digital rectal examination; EAU: European Association of Urology; mPCa: metastatic prostate cancer; MRI: magnetic resonance imaging; PCa: 
prostate cancer; PSA: prostate specific antigen; PSADT: PSA doubling time.

Surgical management of PCa
Tan et al. performed a retrospective analysis of 282 
patients who underwent RP between March and May 
2020, 99% by robotic surgery, and none of the patients 
had developed SARS-CoV-2 infection at the 30-day 
follow-up after surgery[31].

In Germany, Würnschimmel et al. performed a 
retrospective analysis of all surgically treated PCa 

patients, reporting a total of 784 patients, 447 (57%) 
patients before the pandemic (January and February 
2020) and 337 (43%) patients in the first month and a 
half of the pandemic before operating room shutdown 
(March and April 2020)[32]. Of a total of 784 patients, 
623 (79%) patients were ISUP (International Society 
of Urological Pathology) grades group 1, 2, and 3[33], 
corresponding to very low risk, low risk, favorable 
intermediate risk, and unfavorable intermediate risk.  

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TABLE 3.

Summary of active surveillance recommendations during the COVID-19 pandemic 

Paper
Active surveillance

VLR LR FIR

Kokorovic et al.[20] Delay RP up to 12 months or AS

Simcock et al.[29] AS

Dovey et al.[24] AS should be managed by telemedicine according to PSA, genomic testing, and MRI

Rodriguez-Sanchez et al.[27] Consider AS, no RP or RT should be considered during the pandemic, PSA testing may be postponed 3–6 months

Caicedo-Martinez et al.[30] AS indicated, delay RT until pandemic control

Detti et al.[28]
AS is preferred, consultation visits deferred by 6 months;  
if re-biopsy indicated during AS, consider mpMRI instead

EAU Rapid Response  
Priority Level

Low priority

Recommendation  
summary

In VLR, LR and FIR AS is an adequate management strategy

AS: active surveillance; EAU: European Association of Urology; FIR: favorable intermediate risk; LR: low risk; mpMRI: multi-parametric MRI;  
MRI: magnetic resonance imaging; PSA: prostate specific antigen; RP: radical prostatectomy; RT: radiation therapy; VLR: very low risk.

Of these, 352 patients were treated before the pandemic, 
and 271 during the first month of the outbreak. The 
authors reported no statistical difference related 
to complications and outcomes and no COVID-19 
infection amongst the patients treated during the 
pandemic, and therefore concluded that performing 
surgery in these patients is feasible when adequate safety 
measures are in place[32].

Heldwein et al. performed a systematic review of 
all urological management recommendations issued 
during the first months of the pandemic, including 
both consensus-based recommendations and opinion-
based recommendations. On the basis of a previous 
European Association of Urology (EAU) rapid reaction 
group statement[16], they proposed a 5-level, color-based 
triage for urological procedures priority: zero (red) for 
emergency: survivorship compromised if surgery not 
performed within hours; 1 (brown) proceed as planned, 
do not postpone: survivorship compromised if surgery 
nor performed within days; 2 (yellow), consider delaying 
up to 1 month: patient condition can deteriorate or 
survivorship be compromised if surgery not performed 
within 30 days or proceed as planned if COVID-19 
trajectory not in rapid escalation phase; 3 (green) safe 

delay 1 to 3 months: proceed as planned if COVID-19 
not in rapid escalation phase; 4 (blue) safe to delay > 3 
months. For VLR, LR, FIR, and UIR prostate cancer, 
radical prostatectomy was considered blue level priority; 
therefore, delaying > 6 months is justified[34].

In a systematic search of rapid response recommen-
dations and guidelines issued by European urological  
associations and societies, Amparore et al. found that 
all recommended delaying surgical management 
for low- and intermediate-risk prostate cancer[18].  
Méjean et al. recommend delaying of RP in low- and 
intermediate-risk PCa for at least 2 months[22], Narain 
et al. and Shinder et al. recommend delaying for up to 
6 months[23,35], and 3 consensus-based recommenda-
tions state non-specific time delay of surgical treatment 
on LR and FIR PCa until the COVID-19 pandemic is 
controlled[21,27,36].

In 2020, Diamand et al. and Ginsburg et al. published 
retrospective cohort studies of intermediate- and 
high-risk PCa patients who underwent RP before the 
COVID-19 pandemic[37,38]. Diamand et al. performed 
a European multicenter study of 926 patients who had a 
delay of surgical treatment after PCa diagnosis and found 
no upgrading, lymph node involvement, or biochemical 

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recurrence (BCR) associated with a 3-month delay of RP 
in intermediate- and high-risk PCa[37]. Ginsburg et al. 
studied 129 062 patients with the same characteristics 
and found no increase in adverse oncological outcomes 
after RP (upgrading, positive lymph nodes or need of 
adjuvant therapies) even after a 12-month delay[38].

For high-risk (HR) and very high-risk (VHR) PCa 
patients, Würnschimmel et al., included 148 (19%) 
high-risk patients (ISUP 4 and 5) managed with 
radical prostatectomy, 83 (56%) before the pandemic 
and 65 (44%) during the first month of the pandemic. 
They reported no COVID-19 infections, and therefore 
suggested continuation of RP in high-risk patients with 
adequate COVID-19 safety measures[32]. Amparore 
et al. suggest not to continue RP for HR and locally 
advanced disease if possible[18]. Heldwein et al. 
concluded that RP for high-risk patients can be safely 
delayed between 1 and 3 months. If there is a delay of 
more than 3 months because of the pandemic, or if 
there is suspicion of lymph node involvement, ADT 
with or without RT can be initiated[34]. Most expert 
consensus-based published recommendations conclude 
that RP for high-risk patients can be safely delayed for 
between 2 and 6 months[21–28,35,39,40]. If further delay 
is expected, ADT should be considered until surgical 
management can be undertaken[21–26,40]. Katims et al., 
however, report that in high-risk patients there may be 
an increased risk of biochemical recurrence (HR 2.19; 
CI 95% 1.24 to 3.87; P = 0.007) and positive surgical 
margins (OR 4.08; CI 95% 1.52 to 10.9; P = 0.005) in case 
of > 9-month delay[36]. Summary of recommendations 
for surgical management is provided in Table 4.

Radiation therapy in PCa
Larrea et al. retrospectively reported on 100 oncology 
patients treated with external beam radiation therapy 
(EBRT). Only 9 had PCa. No stage or risk stratification 
of these patients is specified; however, 7 were treated 
with hypofractionated EBRT with curative intent, and 
the remaining 2 because of BCR, with no reports of 
COVID-19 infection in these patients[41].

For low- and intermediate-risk PCa patients, all 
publications agree on active surveillance and delay of 
any modality of treatment[18,20–30,34,39,40]. For high-
risk patients and locally advanced disease, 3 systematic 
reviews[18,34,42] conclude that if primary curative RT 
is planned, delay between 1 and 3 months is feasible. 
However, initiation of ADT should be immediate or 
as soon as possible: according to EAU priority, RT is 
considered level 2 (yellow)[34]. Three expert consensus-
based recommendations suggest the use of RT with 
ADT in HR localized and locally advanced disease for 
patients not eligible for RP, with immediate initiation 
of long deposit ADT[20,21]. A delay of up to 3 months 
is considered safe and feasible[16]; however, most 

expert consensus documents recommend delays of up 
to 6 months, with initiation of ADT while waiting for 
RT[25–28,30,41]. For postprostatectomy RT, adjuvant 
RT should not be initiated; instead, salvage RT is 
recommended[18,20,22,28,29,34,39,42,43]. Metastatic 
disease requiring palliative RT management should 
be undertaken as soon as possible on the basis of 
symptomatic disease or risk of fracture and medullary 
compression[20,21,28]. Regardless of PCa risk and stage, 
brachytherapy is not recommended, and the ideal EBRT 
treatment should be either hypofractionated or ultra-hy
pofractionated[18,20-22,25-30,34,39,41,44]. Follow-up 
with PSA testing after RT may be at 6-month intervals 
to reduce hospital exposure[27,30]. A summary of 
recommendations is provided in Table 5.

Androgen deprivation therapy in PCa
Montopoli et al.[43] performed a retrospective analytical 
study of all prostate cancer patients in Veneto, Italy, 
reporting a total of 118 SARS-CoV-2-positive cases: 4 
were on ADT, and the remaining 114 were not. No PCa 
risk or stage was specified, but the authors concluded 
that PCa patients on ADT have a significantly lower risk 
of COVID-19 infection (OR 4.05; 95% CI 1.55 to 10.59). 
Caffo et al.[45] performed a multicenter retrospective 
study in Italy (20 oncological centers), including 1433 
men with metastatic castration-resistant PCa (mCRPC), 
who continued oncological consultation during the 
pandemic (February to June 2020); 34 (2.3%) developed 
SARS-CoV-2 infection, all of them with ADT, 9 with 
concomitant chemotherapy, and 19 with concomitant 
androgen-receptor-axis-targeted therapies (ARAT). 
Thirteen patients (38.2%) died, 85.7% of whom had 
previously received 2 or more mCRPC therapies. The 
authors therefore concluded that mCRPC patients 
were at increased risk of SARS-CoV-2 infection 
and mortality, regardless of ADT[38]. All included 
recommendations and systematic reviews conclude 
that ADT in VLR, LR, and FIR prostate cancer is not 
recommended[18,20–30,34,35,39,42,43,46]. For UIR and 
HR, as well as for locally advanced disease (N1) eligible 
for radical curative treatment, when RP is delayed, ADT 
can be safely initiated when pandemic-related delay is 
expected to surpass 3 to 6 months and in cases of patient 
cancer-related anxiety[18,20–30,34,35,39,42,43,46]. 
Immediate ADT, preferably a long depot (3- or 
6-month duration) formulation, is recommended for 
hormone sensitive metastatic prostate cancer (mHSPC) 
[18,20–23,28,29,34,39,42,43,46]. For non-metastatic 
castration-resista nt prostate ca ncer (nmCR PC), 
ADT plus ARAT, such as abiraterone, enzalutamide, 
apalutamide, or darolutamide is recommended. Madan 
et al. recommend enzalutamide, since no concomitant 
steroid is needed[26]. For mCRPC, when no previous 
second-generation hormone therapy has been used, 
ARAT (except abiraterone) is recommended. In both 

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TABLE 4. 

Summary of radical prostatectomy recommendations during the COVID-19 pandemic 

Paper
Radical prostatectomy

VLR LR FIR UIR HR VHR

Kokorovic et al.[20] Delay up to 12 months or AS Delay 3 months

Heldwein et al.[34] Delay ≥ 6 months Delay 1–3 months

Gómez Rivas et al.[21] Delay, time not specified Delay 2–6 months; consider ADT if locally advanced

Amparore et al.[18] Delay indefinitely Delay 1–3 months, before if control of pandemic

Würnschimmel et al.[32] Safe to continue surgery planning, no infection among RP patients

Méjean et al.[22] Delay ≥ 2 months Delay 2 months

Wallis et al.[39] Delay, time not specified Delay 3–6 months

Narain et al.[23] Delay 6 months Delay, time not specified

Katims et al.[36] Delay ≥ 9 months
Delay of up to 3 months does not increase the risk  

of BCR nor negative oncological outcomes

Obek et al.[25] Delay between 6 and 12 months is safe
Delay of up to 6 months is safe for UIR and HR;  

consider ADT if further delay expected

Tachibana et al.[40] – Delay between 60 days and 12 months is safe

Tan et al.[31] RP was safe despite pandemic scenario, no patient developed COVID-19 on 30-day follow-up

Madan et al.[26] Delay until pandemic control, no time specified
Delay up to 6 months, consider neoadjuvant ADT  

for up to 6 months

Rodriguez-Sanchez et al.[27]
RP should not be considered  

during the pandemic
Delay unless PSADT ≤ 3 months,  
alternative for HR consider ADT

Detti et al.[28] If RP is planned, delay between 6 and 12 months Delay 6 months, neoadjuvant ADT is not recommended

Diamand et al.[37] A delay of RP up to 3 months has no impact on oncological outcomes in IR and HR

Shinder et al.[35] Delay ≥ 3 months
Delay of 3 months adequate cut-off in most HR; HR already on 
6-month delay should be managed as high priority, RP as soon 

as possible

Ginsburg et al.[38] RP can be safely postponed up to 12 months in IR and HR

EAU Rapid Response  
Priority Level

Low priority
Intermediate priority

High priority

Recommendation 
summary

RP in VLR, LR and FIR can be safely delayed ≥ 6 months; 
HR and VHR delay should be based on individual patient case

ADT: androgen deprivation therapy; AS: active surveillance; BCR: biochemical recurrence; EAU: European Association of Urology;  
FIR: favorable intermediate risk; HR: high risk; LR: low risk; RP: radical prostatectomy; PSADT: PSA doubling time; UIR: unfavorable intermediate risk; 
VHR: very high risk; VLR: very low risk.

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TABLE 5. 

Summary of radiation therapy recommendations during the COVID-19 pandemic 

Paper
Radiation therapy

VLR LR FIR UIR HR VHR mPCa

Kokorovic et al.[20] Delay, time not specified
Hypofractionated, delay, time not specified, initiate ADT immediately;  

short course RT in painful bone metastasis

Heldwein et al.[34] – Delay 3 months, initiate ADT in HR Delay indefinitely, initiate ADT

Gómez Rivas et al.[21] – Salvage RT is preferred
In case of symptomatic 

oligometastasis palliative  
RT can be used

Larrea et al.[41] RT is safe in hypofractionated ERBT modalities

Simcock et al.[29] AS
Delay 3–4 months with ADT 
initiation, hypofractionated

Delay, initiate instead ADT for 
mPCa, even if symptomatic

Amparore et al.[18] –
If patient anxiety, hypofractionated 

ERBT + ADT
-

Zaorky et al.[42] Delay until pandemic control
Delay up to 3 months, immediate 

ADT initiation

Delay, initiate ADT; in case 
of PSADT ≤ 3 months and RT 

beneficial, do not delay

Méjean et al.[22] – Follow national guidelines Delay, time not specified

Wallis et al.[39] – Delay 3 months; hypofractionated –

Narain et al.[23] –
PSA ≥ 20 ng/mL and locally 

advanced consider RT + ADT
–

Obek et al.[25] Delay between 6 and 12 months

Delay up to 6 months; consider 
ADT if further delay is expected; 

initiate within 6 weeks ADT + EBRT 
as curative treatment for locally 

advanced disease

–

Madan et al.[26]
Delay until pandemic control, no 

time specified
Delay up to 6 months, consider 

neoadjuvant ADT for up to 6 months
–

Rodriguez-Sanchez et al.[27]
RT should not be considered during 

the pandemic
Delay RT unless PSADT ≤ 3 months, 

alternative for HR consider ADT
–

Barthwal et al.[44] Brachytherapy should be avoided and converted to EBRT or ADT –

Caicedo-Martinez et al.[30]
If RT indicated delay, time not 

specified
ADT alone to delay RT for 6 months 

regardless of risk or stage
–

Detti et al.[28] –

For UIR, initiate ADT and delay 
EBRT 6 months; for HR consider 

ADT + EBRT, delaying RT for 
3–6 months while on ADT, 

hypofractionated

For low volume, initiate ADT; 
for high volume consider ADT 
or systemic therapy and single 

dose EBRT for symptomatic bone 
metastasis

EAU Rapid Response  
Priority Level

Low priority Intermediate priority

Recommendation 
summary

RT should not be used in VLR, LR and FIR; for HR and VHR eligible for RT, initiate ADT and safely  
postpone ≤ 3 months; hypofractionated ERBT is recommended; salvage RT is preferred

ADT: androgen deprivation therapy; AS: active surveillance; EAU: European Association of Urology; EBRT: external beam radiation therapy;  
FIR: favorable intermediate risk; HR: high risk; LR: low risk; mPCa: metastatic prostate cancer; PSA: prostate specific antigen; PSADT: PSA doubling time; 
RT: radiation therapy; UIR: unfavorable intermediate risk; VHR: very high risk; VLR: very low risk.

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cases (nmCRPC and mCRPC), AR AT should be 
initiated as soon as possible[18,20–23,29,34,39,42,43,46]. 
The use of corticosteroids is controversial, and Méjean 
et al. do not recommend it[22]. If indicated, the lowest 
possible dose should be used: prednisone 5 mg twice 
daily, decreasing to once daily if there are individual 
concerns, has been suggested[23,46]. A summary of 
recommendations for ADT is provided in Table 6.

Chemotherapy in PCa
Five publications broached the subject of ChT in PCa 
patients during the COVID-19 pandemic, all of them 
consensus-based recommendations, advising against 
the use of docetaxel in metastatic disease. Méjean 
et al. recommend that in case of mCRPC, docetaxel 
or cabazitaxel may be used, but at a reduced dosage 
and with the concomitant use of granulocyte-colony 
stimulating factor (G-CSF)[20–22,26]. Lalani et al. 
recommend the use docetaxel in case of mCRPC 
patients who have previously received ADT + ARAT 
with inadequate response, and in case of bone metastasis 
prefer only the use of Radium-223[46]. A summary of 
recommendations is provided in Table 7.

Discussion
At the beginning of the pandemic, most institutions 
and countries issued non-specific and rapid response 
recom mend at ions; howe ver, a s t he pa ndem ic 
continued, new evidence and complete reviews and 
recommendations were published. The main objective 
of each country and individual health system during 
the COVID-19 pandemic has been to limit the spread 
of SARS-CoV-2 infection. Despite this, however, it 
is still necessary to provide individual management 
for urological oncology patients. Although Popert 
et al. reported no COVID-19-related infection in 
prostate biopsy patients, all systematic reviews and 
recommendat ions suppor t delay ing biopsy a nd 
diagnostic workup in PCa until the pandemic is 
contained[17]. Würnschimmel et al. and Tan et al. 
published studies about RP during the pandemic, 
and even though no SARS-CoV-2 infection occurred, 
it is evident that at least for patients with low- or 
intermediate-risk PCa, active surveillance can be an 
adequate and safe alternative[32,31]. For high-risk 
patients, a delay of 6 months may be safe. In cases of 
patient anxiety or symptomatic PCa, treatment may be 
indicated, either ADT alone or ADT + RT. For mHSPC, 
ADT is also recommended, while in nmCRPC and 
mCRPC, immediate ARAT is the treatment of choice.

The PIVOT and ProtecT trials proved that in 
localized PCa, particularly in low- and intermediate-
risk disease, curative treatment does not affect long-term 
mortality and survival on localized PCa, yet the ProtecT 
trial did find that active surveillance was associated 
with a higher incidence of biochemical recurrence 
and metastasis[47,48]. Although these studies report 
good outcomes in patients with non-metastatic PCa, 
oncological curative treatment in cases of UIR, HR 
and VHR, continues to be the desired treatment but 
the SARS-CoV-2 pandemic has in many cases delayed 
its provision. We can conclude from this systematic 
review that all modalities of radical treatment for non-
metastatic PCa can be safely delayed, and that ADT can 
be used as an alternative treatment during the pandemic 
in order to prevent SARS-CoV-2 infection.

The sudden onset of the COVID-19 pandemic led to 
the rapid publication of papers and recommendations, 
sometimes with inadequate methodology and low 
levels of evidence, as well as expert consensus-based 
recommendations. Because of this, few papers met 
our criteria, leaving a fairly small sample. The main 
limitation of our study is the lack of RoB analysis of 
expert consensus-based recommendations. This is due 
to absence of an adequate tool, as well as the absence of 
clinical trials and the impossibility of performing any 
meta-analysis because of the scarce information in each 
study.

Conclusions
The international urological community was not 
prepared for such a sudden and unprecedented global 
pandemic. Evidently an immediate emergency response 
was necessary to prevent and control SARS-CoV-2 
infections in patients with urological comorbidities 
needing treatment, such as prostate cancer patients; 
however, COVID-19 paralyzed urologic oncolog y 
departments in most countries. This systematic review 
suggested that low-risk and intermediate-risk PCa 
patients can be managed with active surveillance, that 
delaying surgical and radiation therapy treatment in 
high-risk and locally advanced disease is justified, and 
that ADT is an adequate treatment option for HR and 
metastatic disease.

It is very likely that there will be new pandemics with 
implications, effects, and long-term outcomes similar to 
those of COVID-19. We hope that the present review will 
establish a foundation for the management of prostate 
cancer in future emergency scenarios and pandemics.

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TABLE 6. 

Summary of androgen deprivation therapy recommendations during the COVID-19 pandemic 

Paper
Androgen deprivation therapy

UIR HR VHR mPca

Kokorovic et al.[20]
RT + ADT in locally advanced; 

hypofractionated
Oligometastatic HSPC ADT while delay RT; nmCRPC and  

mCRPC initiate ARAT

Heldwein et al.[34]
If significant RP delay or RT is planned,  

initiate immediately
Initiate ADT as soon as possible

Montopoli et al.[43] PCa patients on ADT have lower risk for SARS-CoV-2 infection (OR 4.05; 95% CI 1.55 to 10.59)

Gómez Rivas et al.[21]
ADT if RP is further delayed by  

uncontrolled pandemic
mHSPC initiate ADT; nmCRPC and mCRPC initiate ADT + ARAT

Simcock et al.[29] Initiate ADT even if RT delay

Amparore et al.[18] – Consider ADT if patient anxious about outcome

Zaorky et al.[42] Initiate ADT immediately if RT delay is planned

Méjean et al.[22]
ADT if RT or RP delay is foreseen in HR and 

locally advanced
HSPC initiate ADT; nmCRPC and mCRPC initiate ADT + ARAT

Wallis et al.[39] ADT if RT or RP is planned to be delayed ADT as soon as possible, mCRPC and nmCRPC along with ARAT

Narain et al.[23]
Consider ADT if RP delay when risk of 

progression is suspected
ADT + ARAT if high volume mHSPC or CRPC

Obek et al.[25]
For locally advanced disease, encourage ADT 

+ EBRT as curative treatment and initiate 
within 6 weeks

–

Tachibana et al.[40]
Consider ADT for a 3-month duration  

when RP delays ≥ 3 months in HR
–

Madan et al.[26] –
Long depot ADT should be used, if ARAT,  

enzalutamide is preferred

Caffo et al.[45] –
mCRPC seem to have higher risk of SARS-CoV-2 and  

poor prognosis

Rodriguez-Sanchez et al.[27]
RP and RT should be deferred unless PSADT 
≤ 3 months, consider ADT as an alternative 

for HR
–

Caicedo-Martinez et al.[30]
ADT alone to delay RT for 6 months is 

recommended regardless of risk stratification 
or stage

–

Detti et al.[28] –
For low volume, initiate ADT; for high volume consider ADT or 
ARAT and single dose EBRT for symptomatic bone metastasis

Lalani et al.[46] –
In mHSPC and mCRPC docetaxel should be avoided as possible, 

ARAT + ADT should be used instead

EAU Rapid Response  
Priority Level

High priority

Recommendation 
summary

PCa patients on ADT seem to have a lower risk of SARS-CoV-2 infection; ADT should be immediately initiated 
when PCa-based indication exists; CRPC should also be managed with ARAT as soon as possible

ADT: androgen deprivation therapy; ARAT: androgen-receptor-axis-targeted; CRPC: castration-resistant prostate cancer; EAU: European Association of 
Urology; HR: high risk; HSPC: hormone sensitive prostate cancer; mCRPC: metastatic castration-resistant prostate cancer; mHSPC: metastatic hormone 
sensitive prostate cancer; mPCa: metastatic prostate cancer; nmCRPC: non-metastatic castration-resistant prostate cancer; PSADT: PSA doubling time; 
RP: radical prostatectomy; RT: radiation therapy; UIR: unfavorable intermediate risk; VHR: very high risk.

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TABLE 7. 

Summary of chemotherapy recommendations during the COVID-19 pandemic 

Paper
Chemotherapy

mPca

Kokorovic et al.[20] ChT during the pandemic is not encouraged

Gómez Rivas et al.[21] ChT during the pandemic is not encouraged

Méjean et al.[22] Preferably avoid, if used, cabazitaxel is preferred with concomitant G-CSF use

Madan et al.[26] Chemotherapy should not be recommended

Detti et al.[28]
For high volume consider ADT + systemic therapy other than ChT;  

for symptomatic bone metastasis consider single dose EBRT

Lalani et al.[46]
In mHSPC and mCRPC docetaxel should be avoided as possible,  

ARAT + ADT should be used instead

EAU Rapid Response  
Priority Level

Low priority

Recommendation 
summary

ChT is not recommended during the pandemic because of high infection risk

ADT: androgen deprivation therapy; ARAT: androgen-receptor-axis-targeted; ChT: chemotherapy; EAU: European Association of Urology; G-CSF: 
granulocyte-colony stimulating factor; mCRPC: metastatic castration-resistant prostate cancer; mHSPC: metastatic hormone sensitive prostate cancer; 
mPCa: metastatic prostate cancer.

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MC, et al. COVID-19: hypofractionation in the radiation oncology 
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Effect of Metallic Ureteric Stents on  
Magnetic Resonance Imaging: Implications  
for Malignant Ureteral Obstruction
Mahima Tellambura,1 Isaac Thangasamy,1,2 Kwang Chin,1 Declan Murphy1,3

1 Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia  2 Faculty of Medicine, University of Queensland, Australia   
3 The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia

Abstract

Metallic ureteric stents are increasingly used for the management of malignant ureteric obstruction, a commonly 
encountered complication in urological and other malignancies. However, there has been limited evaluation of 
complications associated with these stents, including those that might arise from the use of magnetic resonance 
imaging (MRI). While most devices are deemed nominally “MRI-safe,” their implication on the quality of imaging 
produced has not been evaluated in clinical trials, and in our practice, significant artefact has been encountered with 
some ureteric stents—specifically, the Teleflex Rüsch DD tumour stent—compromising image quality and diagnostic 
certainty.

Key Words Competing Interests Article Information

Ureteric stents, metallic stents, magnetic 
resonance imaging, malignant ureteric 
obstruction

None declared. Received on March 20, 2021 
Accepted on May 14, 2021

Soc Int Urol J.2021;2(4):256-258

DOI: 10.48083/ WLVR1509

In managing malignant ureteric obstruction, metal or 
metal-incorporating stents are an increasingly popular 
option, owing to evidence suggesting improved patency 
compared with conventional polymeric stents[1]. In our 
practice, 44% of patients undergoing ureteral stenting 
between March 2017 and March 2018 (n = 77) had one or 
more metallic stents inserted.

Depending on t he ma ligna nc y, a signif ica nt 
proportion of patients undergoing stenting will require 
further pelvic magnetic resonance imaging (MRI) for 
staging or re-staging. This is particularly the case in the 
management of rectal cancer. While all the stents are 
certified MRI-safe, their effect on the quality of MRI 
images produced has not been fully elucidated. MRI 
compatibility has largely focused on energy absorption 
and safety within MRI systems; however, their effect on 
the quality of diagnostic imaging has received limited 
mention.

Metals produce aberrancy within MRI images through 
several mechanisms[2,3]:

• Inhomogeneities in the strong magnetic field, 
pr o d u c e d  b y  p a r a m a g n e t i c /f e r r o m a g n e t i c  
components.

• Frequency-encoding misregistration, due to changes 
in frequency of dephasing.

• Signal loss, due to increase in the rate of T2 phase 
decay.

• Failure of fat suppression, owing to the effect of 
metallic implants on the resonance frequency of 
nearby fat. 

The following factors contribute to the extent of artefact 
formed[3]:
• The size of metallic implant.
• Specific composition of the implant.

• Artefact worsens with ferromagnetic implants  
(steel, iron) compared with those of paramagnetic 
or diamagnetic metals (titanium, platinum, 
copper).

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