The Ideal Elective Surgery During a Pandemic

This article explains how David Silver, MD, chief of urology and director of the Prostate Center at Maimonides Medical Center, changed his treatment decisions amid the pandemic, and highlights the use of the new CPT code for high intensity focused ultrasound that now allows hospitals to bill Medicare and private insurers for reimbursement of the procedure.

Back in April 2020, it was all hands-on deck in caring for COVID-19 patients at Maimonides Medical Center in Brooklyn, NY, where the number of severe COVID-19 cases was even higher than in neighboring Manhattan.

Maimonides, the largest medical center in Brooklyn, is ordinarily a 710-bed teaching hospital.  But the hospital had been entirely transformed into a COVID-19 care facility, increasing to more than 1400 beds, including 400 ICU beds. Apart from trauma, the only patients that were seen in the ER were patients exhibiting severe COVID-19 symptoms, including fever of 100.5 or higher and shortness of breath.  And patients with temperatures exceeding 101 or having severe difficulty breathing were being hospitalized. 

All non-urgent and elective treatments were on hold until COVID-19 was under control.

David Silver, MD, is Chief of Urology and Director of the Prostate Center at Maimonides Medical Center.  Ordinarily, Dr Silver’s 10 surgeons and staff of over 20 employees provide the full range of urologic specialty care to dozens of patients daily. But last April the office limited staffing to one to two physicians daily, and only saw emergent cases, while the remaining physicians and staff are redeployed to the ICU. Telemedicine took the place of onsite patient visits.  

For Dr Silver’s patients newly diagnosed with prostate cancer, the cancer diagnosis combined with the inability to take action during the pandemic, was particularly stressful. In addition to reassuring patients they could afford to wait a few months since prostate cancer is among the slowest-growing of all cancers, department staff were on hand to counsel patients during the delay.

Within several months, the state of New York began lifting certain restrictions and elective procedures were limited to high risk patients. As the State opened up elective surgeries for intermediate and low risk patients, Maimonides eventually resumed non-COVID surgical care unabated, even during the most recent surge in COVID-19 during the December holidays. 

To safely treat all Maimonides patients, the hospital established separate streams for COVID and non-COVID patients.  COVID-19 patients now enter the ER, are rapidly tested, and if positive sent up to a special ward and isolated from the general patient population.

Dr Silver’s prostate cancer patients in need of elective surgery are still evaluated through telemedicine. Following the initial appointment, they are scheduled for further tests and pre-op evaluation at one of the campus buildings, separate from the main hospital and away from COVID patients. 

Even though prostate cancer patients are anxious to receive treatment they still want to minimize their exposure to anyone outside their COVID bubble. One procedure that is especially attractive to patients is high intensity focused ultrasound (HIFU).  

HIFU, which is appropriate for patients whose prostate cancer is confined to the prostate, uses guided imagery to locate and destroy only the diseased portion of the prostate.  It is done quickly (approximately two to three hours), in a single session at the Maimonides’ ambulatory surgery center. Patients like the ability to get in and out, with minimal exposure to the health care system.  HIFU is ideal for this.

Whereas the standards of care for prostate cancer, such as radiation, requires the patient to come to the hospital five to six times a week for seven to eight weeks, or radical surgery which is done in the main hospital, exposes the patient to multiple personnel and instrumentation, and almost always requires a hospital stay. 

HIFU is different from other procedures for localized prostate cancer. That’s because there has been a shift in the way urologists conceptualize the treatment of prostate cancer. Doctors wouldn’t think of removing a woman’s entire breast for a small tumor present in one location. Likewise, removing the entire prostate for a tumor that may only be in one location has also become unnecessary. 

HIFU uses imaging technology that allows urologists to pinpoint the exact location of the tumor, direct sound waves to destroy it and spare the rest of the organ. Urologists no longer have to remove or radiate the whole prostate and have the patient risk losing control of urinary or sexual function. Urologists like to say, “kill the cancer, keep the prostate.”

HIFU appealed to Dr Silver’s prostate cancer patient, Santoro Pasquale, “because quality of life was at the top of my list.” Since having the HIFU procedure Pasquale says, “My life continues to be the same. I enjoy it and I do all the things I did before the treatment.”

HIFU is noninvasive. It’s outpatient.  It’s a one-shot procedure. It definitely has less side effects than total ablation, or surgery or radiotherapy.  And it can be repeated if necessary. And, as of January 1, 2021, HIFU now has a Category One CPT code, assigned by the American Medical Association. With this new CPT code, hospitals can now bill Medicare and private insurers for reimbursement of the procedure.  

HIFU has really increased in popularity, especially during this pandemic, and patients are asking for this because they’ve heard that they can come in the morning, have the procedure and go home before lunch.

Watch Dr Silver’s latest interview on COVID-19, Prostate Cancer and HIFU on Prostate Choices Zoomcast.