External factors, such as the coronavirus disease 2019 (COVID-19), can lead to cancellations and backlogs of cancer surgeries. The effects of these delays are unclear. This study summarised the evidence surrounding expectant management, delay radical prostatectomy (RP), and neoadjuvant hormone therapy (NHT) compared to immediate RP. MEDLINE and EMBASE was searched for randomised controlled trials (RCTs) and non-randomised controlled studies pertaining to the review question. Risks of biases (RoB) were evaluated using the RoB 2.0 tool and the Newcastle-Ottawa Scale. A total of 57 studies were included. Meta-analysis of four RCTs found overall survival and cancer-specific survival were significantly worsened amongst intermediate-risk patients undergoing active monitoring, observation, or watchful waiting but not in low- and high-risk patients. Evidence from 33 observational studies comparing delayed RP and immediate RP is contradictory. However, conservative estimates of delays over 5 months, 4 months, and 30 days for low-risk, intermediate-risk, and high-risk patients, respectively, have been associated with significantly worse pathological and oncological outcomes in individual studies. In 11 RCTs, a 3-month course of NHT has been shown to improve pathological outcomes in most patients, but its effect on oncological outcomes is apparently limited.

Department of Urology Charles University 116 36 Prague Czech Republic

Department of Urology Comarcal Hospital 17300 Monforte Spain

Department of Urology Hertfordshire and Bedfordshire Urological Cancer Centre Lister Hospital Stevenage School of Medicine and Life Sciences University of Hertfordshire Hatfield AL10 9AB UK

Department of Urology Ipswich Hospital Ipswich IP4 5PD UK

Department of Urology Medical University of Vienna 1090 Vienna Austria

Department of Urology Northwick Park Hospital London HA1 3UJ UK

Department of Urology Royal Free Hospital London NW3 2QG UK

Department of Urology Tan Tock Seng Hospital Singapore 308433 Singapore

Department of Urology University of Texas Southwestern Dallas TX 75390 USA

Department of Urology Weill Cornell Medical College New York NY 10065 USA

Division of Surgery and Interventional Science University College London London W1W 7TS UK

Institute for Urology and Reproductive Health Sechenov University 119991 Moscow Russia

Leicester Medical School University of Leicester Leicester LE1 7RH UK

S H Ho Urology Centre Department of Surgery Prince of Wales Hospital The Chinese University of Hong Kong Hong Kong China

School of Medicine Faculty of Medicine and Health University of Leeds Leeds LS2 9JT UK

UCL Medical School University College London London WC1E 6DE UK

Urology Unit Santa Maria della Misericordia University Hospital 33100 Udine Italy

Warwick Medical School University of Warwick Coventry CV4 7AL UK

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A systematic review and meta-analysis on delaying surgery for urothelial carcinoma of bladder and upper tract urothelial carcinoma: Implications for the COVID19 pandemic and beyond