Following on from our blog and recent podcasts on how the coronavirus (Covid-19) is affecting urological operations in three countries: Italy, China and South Korea, we have put together a collection of the latest BJUI-published articles on the topic.
The first article by Connor and coworkers from Imperial Prostate discusses the potential costs to cancer patients if outpatient activity is cancelled by NHS trusts in order to free up resources for Covid-19 patients. They recommend that a virtual clinic consultation takes place in the first instance. So, what is life like in Isreal under COVID-19? Mostly quiet and a little surreal. In other words, very much like it is here. Israel was very aggressive in its early efforts to combat the spread of the virus, taking immediate measures to limit public gatherings, closing all non-essential businesses, and cancelling almost every major event in the country. Extreme yes, but also very safe.
The second article is by Ahmed, Hayat and Dasgupta from King’s Health Partners, London UK and discusses the national situation as of the end of March 2020: all non-urgent elective surgical procedures have been put on hold for three months to free up hospital beds and theatre staff; the discharge process for surgical inpatients has been accelerated and staff are being redeployed from non-essential services. But what impact will this have on the mental health of those patients missing out on treatment for their infertility or incontinence? And how are conditions categorized? The Cleveland Clinic Urology department has developed a five-point scale to aid in risk-stratifying patients – the following table is a more general version.
|Surgical Procedure||Summary of Impact of COVID-19 on selected Urological procedures|
|Endoscopic/Outpatient procedures||Diagnostic work should be avoided where possible, only emergency procedures under local anesthetic ideally. Only urgent outpatient procedures should be carried out, these include biopsies of the prostate, cystoscopies for suspected bladder malignancy or hematuria.|
|Open/Laparoscopic||-Only urgent procedures, assessment for COVID-19 should be carried out, reduce chances of the need for post-surgery critical care. Full personal protection equipment should be worn. Urgent procedures may include trauma, ureteric stones, torsion and high-risk cancer patients
-The safety of carrying out laparoscopic work remains undetermined
-The merits of local versus general anesthetic should be considered on a case by case basis if applicable
|Selected points on general theatre safety||-The number of staff in theatre should be minimised and all must wear personal protective equipment in full with visors
-Positive pressurisation should be put on hold in theatre during a procedure and only 20 minutes after the patient has left the theatre, should it be restarted
– Need for COVID 19 testing of the patients and the clinical team prior to the procedure
Table 1. Adapted from RCS Intercollegiate General Surgery Guidance on COVID-19 (https://www.rcseng.ac.uk/coronavirus/joint-guidance-for-surgeons-v2/) and BJUI “COVID-19 and Urology” blog.
Again, the idea of virtual clinics is raised as is the future training of medical and surgical students to enable them to be quickly deployed in the case of another pandemic, and a suggestion for parallel healthcare systems.
Testing, of course, is also of paramount importance.
In a comprehensive review of the situation as of the end of March 2020, Bernardo Rocco and co-workers describe what we know about the SARS-CoV-2 virus so far and what has been done, at least within Europe, to cope with the pandemic.
It is thought that kidney cells are particularly prone to invasion by the virus, as evidenced by the numbers of kidney dysfunction in COVID-19 patients, and this may be due to the presence of angiotensin-converting 2 enzyme receptors on a small percentage (2-4%) of these cells to which the SARS-CoV-2 virus has an affinity.
The article further discusses the situation for medical students, transplant clinics and oncology, focussing on China, Italy and the UK. It also outlines extra precautions to take to limit virus transmission given the unknowns about its presence in blood, urine and faeces.
Returning to the subject of medical students, in particular in Italy, this paper by Porpiglia and coworkers explains that residents are unable to practise as the areas in which they usually work have been suspended (benign pathologies, lower urinary tract surgery and andrology), as have case meetings and outpatient clinics, and major surgery is being carried out by senior colleagues. Alternative teaching methods, via video link, are being introduced, e.g. surgeryinmotion-school.org, a well-established website showing recorded and live surgeries. The use of webinars for presentation of cases and social media, such as Twitter’s Journal Club, allow discussions to take place. Daily staff meetings can also take place via the web.
A further article on the use of virtual technology solutions by Karim et al. highlights the forward thinking of urologists generally with their early uptake of robotic technologies; the next step could be championing teleproctoring and telementoring using augmented reality platforms such as Proximie (https://www.proximie.com/), allowing surgeons to communicate with each other and their patients in a timely yet safe way during the pandemic.