COVID-19, caused by the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2),
is the ongoing pandemic which has been unprecedented.[1] We are witnessing some extraordinary
times which were unimaginable even a few months ago. These desperate times have called
for certain desperate measures which include worldwide lockdowns. In the past 20 years,
we have witnessed two major epidemics caused by coronaviruses: SARS-COV in 2002 and
Middle East respiratory syndrome (MERS)-COV in 2012. The number of people infected
due to these two viruses were minuscule (8000 by SARS-COV and 800 by MERS-COV) in
comparison to the current COVID 19 pandemic (confirmed cases – 4,013,728 and deaths
– 278,993 on May 12, 2020).[2] This has been attributed to the difference in R0 values
(3–6 for SARS-COV-2), high viral loads in the upper respiratory tract, and the potential
for infected persons with SARS-CoV-2 to shed and transmit the virus even while being
asymptomatic.[3
4] R0 (R naught), also known as reproduction number, indicates how contagious an infectious
disease is. An R0 of 3–6 in simple terms means that a person suffering from the infection
will transmit it to an average of 3–6 people. The rising number of current pandemic
mirrors those of the Spanish flu of 1918. Similarly, it might not be surprising that
the COVID 19 pandemic may last for a long time.[5] The worst affected countries such
as the USA, Italy, and Spain have mobilized the entire health resources from all specialties
to the COVID teams for managing these cases. So much so that in New York, each doctor
has been labeled a COVID doctor.[6]
In a resource-limited country like ours, we have to gear up to tackle the surge. At
the time of this writing, we in India are in our third extension of the lockdown period.
Around 96,000 cases have been diagnosed countrywide and more than 3000 deaths have
been reported so far.[7] Fighting the COVID pandemic and at the same time, balancing
the collateral damage is the target. The collateral damage includes morbidity and
deaths due to socioeconomic impact of lockdowns and due to nonCOVID illnesses.
Being a tertiary care center as well as a COVID-dedicated facility, our institution
is involved in formulating and implementing strategies for optimizing health-care
outcomes. The dynamism of the current situation can be gauged by the fact that repeated
attempts of reinstating elective services have been deferred. This is causing a delay
in the treatment of urological illnesses. As soon as the lockdown is eased, the rush
of patients who were simply “managing” their illnesses will flock the outpatient departments
(OPDs). Hence, we should be ready with an action plan to prioritize and triage these
patients to manage this damage. Through this document, we wish to provide a framework
for performing elective and emergency urological procedures and discuss the changing
paradigm of urological practice in this COVID era.
SCREENING FOR COVID
During the initial phase of the lockdown, patients visiting the emergency department
in our hospital were being screened using a symptom-based questionnaire [Figure 1]
and were initially stratified as COVID suspect or not. Those who were suspected to
have COVID underwent reverse transcriptase–polymerase chain reaction (RT-PCR) test.
Based on this method after the screening, we admitted 62 patients during this lockdown
period. With increasing COVID-positive cases in the community and planned resumption
of elective services, we believe that this screening method based on symptom-based
questionnaire alone will not be sufficient., Considering the high infectivity and
perioperative mortality (20%) in COVID 19 carriers/patients, every attempt should
be made to diagnose carriers of SARS-CoV-2 before surgery.[8]
Figure 1
Symptom-based questionnaire for screening of patients
Upper airway secretions collected by oropharyngeal and nasopharyngeal swabs are most
commonly used for doing RT-PCR testing. Studies have shown that the detection rate
of RT-PCR in samples collected from the upper respiratory tract for SARS-CoV-2 was
38%–63% only.[9
10] Hence, screening with only oral and nasal swabs can miss out a large proportion
of SARS-CoV-2 carriers. Li et al. have shown that serological testing using combined
immunoglobulin M (IgM) and IgG rapid enzyme-linked immunosorbent assay (ELISA) kits
can detect SARS-CoV-2 with a sensitivity and specificity of 88.66% and 90.63%, respectively.[11]
They recommended that a combination of nucleic acid RT-PCR and IgM/IgG antibody test
can provide the accurate diagnosis of SARS-CoV-2 infection. Hence, any patient who
is tested negative on RT-PCR should also undergo serological testing with IgM and
IgG ELISA for detecting carriers.[12
13] However, the availability of serological test kits and their questionable reliability
(based on the recent report from the Indian Council for Medical Research showing the
sensitivity of rapid ELISA kits is around 6%–71%) pose serious problems in incorporating
these tests in the treatment algorithm.[14] Hence, we advocate continued use of symptom-based
screening and addition of RT-PCR before embarking on the elective procedure to save
the treating team from cross-infection.[13]
Based on the above protocol, we operated 44 patients during this lockdown period,
and none of these patients developed symptoms of COVID following surgery [Table 1].
In case the patient is deemed a confirmed/suspected COVID case, they should be referred
to a dedicated health facility for treating COVID cases in accordance with the 3-tier
classification of health facility by the government of India.[15] Our institution
has a separate dedicated COVID hospital block with operation theaters (OTs), intensive
care units, wards, in-house investigation laboratories, and imaging facilities.
Table 1
Urological surgical burden before and after lockdown over comparable time duration
at our tertiary care center
Surgical procedure (emergency)
Cases performed just before lockdown (over 45 days)
Cases performed during lockdown (March 25, 2020-May 10, 2020)
TURBT
42
31
Radical cystectomy and ileal conduit
0
4
Nephrectomy
11
1
Debridement for Fournier’s gangrene
2
4
Open clot evacuation
1
1
High inguinal orchiectomy
4
1
Radical nephroureterectomy
0
1
Bladder repair
1
1
Total Emergency surgeries
61
44
Surgical procedure (elective)
Endourologic surgeries
141
0
Laparoscopic surgeries
39
0
Robot assisted surgeries
46
0
Open surgeries
37
0
Total elective surgeries
263
0
Overall surgeries
324
44
TURBT=Transurethral resection of bladder tumor
EMERGENCY UROLOGICAL SURGERIES
Since the beginning of lockdown, all elective outpatient clinics and elective inpatient
admissions have been suspended at our institution and as recommended by all guidelines,
only emergency procedures are being done.[16
17] The rationale for this is to conserve the already strained health-care resources.
We have been catering to emergency services which primarily involve malignancies with
active hematuria, urosepsis, and urological trauma [Table 1]. Cases of obstructive
uropathy with or without sepsis secondary to stones/stricture in the urinary tract
are being managed by urgent diversion using percutaneous nephrostomy (n = 16) or double-J
stent placement (n = 3). Cases of acute or impeding urinary retention secondary to
benign prostatic hyperplasia or urethral stricture are being managed by per-urethral
catheterization or suprapubic catheter placement (n = 26). Neoadjuvant chemotherapy
was administered to fit patients to defer elective surgery (n = 3). As elective procedures
have come to a standstill, emergency procedures are expected to rise further. There
is a 86% fall in urological surgeries during the lockdown period at our center.
ELECTIVE UROLOGICAL SURGERIES
Telemedicine instead of physical OPD visit should be used for consultation and planning
elective surgeries. This will help in minimizing visits at the OPDs. Recently, the
Ministry of Health and Family Welfare has provided guidelines for carrying out telemedicine
services.[18] All hospitals should create their own Standard Operating Procedures
(SOPs) for conducting telemedicine services. Elective surgeries should be planned
only when the number of COVID positive cases poses a low burden on the health-care
resources of the hospital. Therefore, continuous audit of the bed occupancy status,
amount of hospital staff, and equipment available should be done before considering
elective surgeries. Needless to say, malignancies should get top priority. Patients
with other benign conditions should also be prioritized according to the disease.
For example, patients with obstructing renal or ureteric stones already on double-J
stent or percutaneous nephrostomy should also be given priority.[19] After prioritizing
the cases, they should be planned for operation only after screening for SARS-CoV-2.
Both the European association of Urology (EAU) and Urological Society of India (USI)
have released their advisories regarding stratification of various urological procedures.[16
17]
ANESTHESIA CONSIDERATIONS
General anesthesia (GA) leads to aerosol generation as it involves close manipulation
of the oral cavity and upper airway tract. It therefore poses the highest chance of
transmission to OT team. Hence, avoiding GA would significantly reduce exposure to
patients’ respiratory secretions. It will also protect the anesthesia machine and
its accessory equipment's from getting into contact with the respiratory secretions.
Hence, wherever feasible, regional anesthesia (RA) should be considered. Patients
undergoing surgery under RA should always wear a filtering facepiece 2/3 mask.
RA has lower postoperative cardiopulmonary and thromboembolic complications due to
continued postoperative analgesia and early ambulation. There have been concerns regarding
the presence of virus in cerebrospinal fluid and consequential transmission to the
anesthetic team during the administration of RA.[20] Zhong et al. have suggested that
anesthetists should use level 3 personal protective equipment (PPE) while giving spinal
anesthesia.[21] All our endoscopic cases were performed under spinal anesthesia.
Patients who are considered for GA should be induced by an experienced anesthesiologist.
High-efficiency hydrophobic filters should be used between the face mask and breathing
circuit. 100% preoxygenation with rapid sequence intubation should be preferred.[22]
Awake fiberoptic intubation should be avoided at any cost. Tracheal intubation should
be always be preferred over laryngeal mask airway.[22] In addition to RA, an obturator
block may be used during resection of bladder tumors.[23] Although most urologists
prefer GA for endoscopic renal surgery, RA has equivalent efficacy and safety outcomes
with possibly reduced operative time, hospitalization stay, blood transfusion rates,
and postoperative pain without compromising stone clearance rates.[24
25
26
27]
GENERAL SURGICAL CONSIDERATIONS
Minimum staff should be posted in the OT and should wear PPE, as suggested by the
hospital policy. PPE in the form of N95 masks, goggles or face shield, impervious
gowns, and gloves should be used. Hand hygiene should be strictly followed. Donning
and doffing procedures should be strictly adhered to. OTs should be adequately ventilated
with preferably negative pressure ventilation and High-efficiency particulate air
(HEPA) filters should be mandatory.
Endourological procedures
There is a high chance of contacting the patient's urine while doing these procedures.
Evidence for virus presence in urine is not robust. While viral RNA has been identified
in the urine samples of 6.9% patients who had recovered from COVID-19, others have
reported that virus shedding in urine is absent.[10
28] However, to decrease the chance of contamination, the entire operating team should
take necessary precautions such as the use of fluid impervious drapes, disposable
equipment, and closed drainage of returning irrigation fluid.
Laparoscopic/robot-assisted procedures
There are concerns regarding laparoscopic surgeries due to risk of transmission of
virus from aerosol created by CO2 gas used for pneumoperitoneum or smoke plume generated
from electrocautery.[29] These are based on studies on hepatitis B virus, HIV, and
human papilloma virus in surgical smoke.[30
31
32] As of now, there has been no report of transmission of SARS-CoV-2 to the operative
personnel following laparoscopy. All the surgical societies currently hold that there
is insufficient evidence to recommend for or against an open versus laparoscopic approach
in COVID era.[16
17
33
34] However, the Royal College of Surgeons and EAU Robotic Urology Section stated
that laparoscopy should be considered only in select individual cases.[33
34] The USI has also issued advisory to avoid laparoscopic and robotic procedures.[17]
The generation of aerosol/pneumoperitoneum leak can occur at various points during
laparoscopy: during exchange/insertion of instruments and trocars; practice of intermittent
venting of the abdomen off smoke through stopcock of the trocar; and while decompressing
the abdomen at the end of the procedure or for retrieval of specimen or for conversion
to open surgery. To minimize the risk of transmission, we recommend the following
precautionary measures.
Port incisions should be of appropriate size and ribbed or ballooned ports should
be used to prevent air leak. The use of integrated intelligent flow system such as
AirSeal system (Conmed, NY, USA), etc., is recommended. Operating pressures should
be kept to minimum (8–10 mmHg).[30
31
32] Ultrasonic device and electrocautery should be activated for a minimum time at
minimum energy settings to decrease smoke plume formation. Instrument change should
be kept to minimum. Suction device or wet gauze pieces/sponges should be used to prevent
aerosol transmission. Smoke evacuation should be minimized using stopcock and it should
be done through a dependent port attached to a vacuum suction unit. Before placing
an incision for specimen retrieval, the abdomen should be deflated completely using
suction and release of gas by the filtered port with the use of vacuum.
In case dedicated air seal systems are not available, filters used in mechanical ventilator
circuits may be borrowed from the anesthetist. For robot-assisted surgeries, the majority
of the precautions apply. In addition, the use of reducers should be minimized and
if used, they should be snugly fit to avoid leak. However, we recommend that in COVID
era, the use of laparoscopy should be minimized wherever possible. We have resorted
to open surgical approach even for patients who were surgically fit candidates for
laparoscopy.
Open procedures
Adequate measures to minimize the generation of aerosol like minimal use of electrocautery
and harmonic shears, minimal energy settings, and the use of smoke evacuation devices
intraoperatively should be followed. The majority of oncological procedures have been
performed under RA with equivalent outcomes.[35
36] In pelvic surgeries, Combined Epidural Spinal Anasthesia (CESA) offers the advantages
of reduced volume need, decreased perioperative blood loss, and maintaining postoperative
analgesia.[37] For pelvic surgeries, Trendelenburg position should be minimized to
avoid pulmonary congestion, respiratory compromise, and aerosol production. Substitution
urethroplasty using buccal mucosal graft (BMG) needs a special mention here.[38] It
is the only urological procedure where a urosurgeon comes in close contact with the
oral cavity. In the era of COVID-19, harvesting BMG could pose a potential risk of
cross infection between the patient and health-care workers. In our opinion, avoiding
BMG and the use of inner preputial graft (IPG) for substitution urethroplasty may
be safer with equivalent outcomes.[39] We feel that open procedures are likely to
increase across specialties in the current era.
SURGERY IN CONFIRMED COVID-19 CASES
COVID 19-confirmed cases should be evaluated by a multidisciplinary team, and the
treatment of the viral illness takes precedence over the underlying urological disease,
unless emergent. All the SOPs related to surgery in a COVID positive case should be
followed as recommended by the WHO.[40] A flowchart depicting the management of urological
cases in the current COVID era is given in Figure 2.
Figure 2
Algorithm for management of urological patients during COVID era
In summary, SARS-CoV-2 is here to stay and major modifications loom over surgical
practices. Resource allocation in the management of COVID-19 and emergency services
will take precedence over elective procedures. Screening for COVID-19 should be the
norm. Universal precautions and use of PPE should be strictly adhered to. RA should
be considered over GA, wherever feasible. Open surgical approach should be preferred
over minimally invasive approach till further evidence is available. Limiting the
casualties due to COVID-19 and addressing the collateral damage by non-COVID illnesses
are the need of the hour.
Financial support and sponsorship:
Nil.
Conflicts of interest:
There are no conflicts of interest.