Guidelines for Urological Surgeries in the COVID-19 Pandemic: Is it Time for Revision?

In this correspondence the authors try to show that guidelines and recommendations including what was published by EAU rapid reaction group must be further updated and tailored according to different epidemiologic data in different countries. The authors assign the countries worldwide in three categories. First category comprises countries that experience the secondary surges smoother than the first one. The second category include countries with stronger or -merging and rising-secondary surges and the third category encompasses countries with successful initial response and secondary stronger but still more controllable surges. Authors proclaim that after passing the first baffling impact we find out that postponement strategies preached in many of these scout treatises are no more suitable at least for the countries delineated in the second category and can culminate in performance of procedures in worse. The authors proffer Iranian Urology Association COVID-19 Taskforce Pamphlet(IUA-CTP) as a paragonic document mentioning it's the time we must recognise the wide variability of the situation in different regions and any advisory position must consider this huge variance in epidemiologic profile.

Death following pulmonary complications of surgery before and during the SARS-CoV-2 pandemic.

BACKGROUND: This study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. METHODS: This was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January-October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection. RESULTS: This study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery before and 4371 (59.1 per cent) during the pandemic. Overall, 4.3 per cent (187 of 4371) developed postoperative SARS-CoV-2 in the pandemic cohort. The pulmonary complication rate was similar (7.1 per cent (216 of 3031) versus 6.3 per cent (274 of 4371); P = 0.158) but the mortality rate was significantly higher (0.7 per cent (20 of 3031) versus 2.0 per cent (87 of 4371); P < 0.001) among patients who had surgery during the pandemic. The adjusted odds of death were higher during than before the pandemic (odds ratio (OR) 2.72, 95 per cent c.i. 1.58 to 4.67; P < 0.001). In mediation analysis, 54.8 per cent of excess postoperative deaths during the pandemic were estimated to be attributable to SARS-CoV-2 (OR 1.73, 1.40 to 2.13; P < 0.001). CONCLUSION: Although providers may have selected patients with a lower risk profile for surgery during the pandemic, this did not mitigate the likelihood of death through SARS-CoV-2 infection. Care providers must act urgently to protect surgical patients from SARS-CoV-2 infection.

This study compared death rates in patients who developed pulmonary complications of surgery before and during the pandemic in two large, international studies. Patients who underwent surgery during the pandemic tended to be younger and fitter. Overall, 4.3 per cent were diagnosed with SARS-CoV-2 infection after surgery in the pandemic cohort. Deaths within 30 days after surgery tripled during the first wave of the pandemic (from 0.7 to 2.0 per cent), whereas the rate of pulmonary complications remained the similar (7.1 to 6.3 per cent). Over half of these excess deaths (54.8 per cent) were estimated to be related to SARS-CoV-2 infection.

Reducing last-minute cancellations of elective urological surgery-effectiveness of specialist nurse preoperative assessment.

Last-minute cancellations in urological surgery are a global issue, resulting in the wastage of resources and delays to patient care. In addition to non-cessation of anticoagulants and inadequately treated medical comorbidities, untreated urinary tract infections are a significant cause of last-minute cancellations. This study aimed to ascertain whether the introduction of a specialist nurse clinic resulted in a reduction of last-minute cancellations of elective urological surgery as part of our elective recovery plan following the Coronavirus disease 2019, the contagious disease caused by severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2 pandemic. A specialist urology nurse-led clinic was introduced to review urine culture results preoperatively. Specialist nurses contacted patients with positive urine cultures and their general practitioners by telephone and email to ensure a minimum of 2 days of 'lead-in' antibiotics were given prior to surgery. Patients unfit for surgery were postponed and optimized, and vacant slots were backfilled. A new guideline was created to improve the timing and structure of the generic preassessment. Between 1 January 2021 and 30 June 2021, a mean of 40 cases was booked each month, with average cancellations rates of 9.57/40 (23.92%). After implementing changes on 1 July 2021, cancellations fell to 4/124 (3%) for the month. On re-audit, there was a sustained and statistically significant reduction in cancellation rates: between 1 July 2021 and 31 December 2021 cancellations averaged 4.2/97.5 (4.3%, P < .001). Two to nine (2%-16%) patients were started on antibiotics each month, while another zero to two (0%-2%) were contacted for other reasons. The implementation of a specialist urology nurse-led preassessment clinic resulted in a sustained reduction in cancellations of last-minute elective urological procedures.

Covid-19 (Sars-Cov-2 Infection) Information for Patients with Predialytic Chronic Kidney Disease.

Patients with Chronic Kidney Disease are among those individuals at increased risk for developing more serious forms of Covid-19. This increased risk starts in the pre-dialysis phase of the disease. Providing useful information for these patients, in language that facilitates the understanding of the disease, can help nephrologists and other healthcare professionals to establish a more effective communication with these patients and help minimize contagion and the risks of serious illness in this population.

Battling against the great disruption to surgical care in a pandemic: experiences of 11 South and Southeast Asian countries.

OBJECTIVES: The majority of the cancelled elective surgeries caused by the COVID-19 pandemic globally were estimated to occur in low- and middle-income countries (LMICs), where surgical services had long been in short supply even before the pandemic. Therefore, minimising disruption to existing surgical care in LMICs is of crucial importance during a pandemic. This study aimed to explore contributory factors to the continuity of surgical care in LMICs in the face of a pandemic. DESIGN: Semistructured interviews were conducted over zoom with surgical leaders of 25 tertiary hospitals from 11 LMICs in South and Southeast Asia in September to October 2020. Key themes were subsequently identified from the interview transcripts using the Braun and Clarke's method of thematic analysis. RESULTS: The COVID-19 pandemic affected all surgical services of participating institutions to varying degrees. Overall, elective surgeries suffered the gravest disruption, followed by outpatient surgical care, and finally emergency surgeries. Keeping healthcare workers safe and striving for continuity of essential surgical care emerged as notable response strategies observed across all participating institutions. CONCLUSION: This study suggested that four factors are important for the resilience of surgical care against COVID-19: adequate COVID-19 testing capacity and effective institutional infection control measures, designated COVID-19 treatment facilities, whole-system approach to balancing pandemic response and meeting essential surgical needs, and active community engagement. These findings can inform healthcare institutions in other countries, especially LMICs, in their effort to tread a fine line between preserving healthcare capacity for pandemic response and protecting surgical services against pandemic disruption.

Performing elective cardiac invasive procedures during the COVID-19 outbreak: a position statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI).

The rearrangement of healthcare services required to face the coronavirus disease 2019 (COVID-19) pandemic led to a drastic reduction in elective cardiac invasive procedures. We are already facing a "second wave" of infections and we might be dealing during the next months with a "third wave" and subsequently new waves. Therefore, during the different waves of the COVID-19 pandemic we have to face the problems of how to perform elective cardiac invasive procedures in non-COVID patients and which patients/procedures should be prioritised. In this context, the interplay between the pandemic stage, the availability of healthcare resources and the priority of specific cardiac disorders is crucial. Clear pathways for "hot" or presumed "hot" patients and "cold" patients are mandatory in each hospital. Depending on the local testing capacity and intensity of transmission in the area, healthcare facilities may test patients for SARS-CoV-2 infection before the interventional procedure, regardless of risk assessment for COVID-19. Pre-hospital testing should always be conducted in the presence of symptoms suggestive of SARS-CoV-2 infection. In cases of confirmed or suspected COVID-19 positive patients, full personal protective equipment using FFP 2/N95 masks, eye protection, gowning and gloves is indicated during cardiac interventions for healthcare workers. When patients have tested negative for COVID-19, medical masks may be sufficient. Indeed, individual patients should themselves wear medical masks during cardiac interventions and outpatient visits.

Pre-anaesthetic assessment and related outcome measures in adults undergoing elective surgery-Scoping review protocol.

BACKGROUND: Pre-anaesthesia assessment is crucial to ensure the quality and safety of anaesthesia and surgery. However, despite being very common and essential for many patients undergoing elective surgery, little is known about the different pre-anaesthesia assessment approaches. Hence, this article outlines a study protocol for a scoping review aiming to, systematically, map the literature on pre-anaesthetic assessment approaches and outcomes, synthesise existing evidence, and identify knowledge gaps for future research. METHODS: We will conduct a scoping review of all study designs following the Preferred Reporting Items for Systematic and Meta-Analyses (PRISMA) statement. Moreover, the five steps set forth by Arksey and O'Malley and refined by Levac will guide the review process. Studies with adults (≥18 years) scheduled for elective surgery are included. Data regarding trial characteristics, patients, clinicians performing the pre-anaesthetic assessment, interventions and outcomes are included using a combination of Covidence and Excel. Quantitative data are summarised using descriptive statistics, and qualitative data are presented through a descriptive synthesis. CONCLUSION: The outlined scoping review will provide a synthesis of the literature, which can support the development of new evidence-based practices for safe perioperative management of adult patients undergoing elective surgery.

Strategies for recovery of a surgical service in the COVID-19 era.

The COVID-19 pandemic has resulted in a massive backlog of elective cases. Delays in the provision of "elective" surgical care have dire consequences for the patient: progression of disease and comorbidities, higher complication rates, and lower overall survival. Delays in elective surgery also have significant consequences for the health system: added emotional strain on healthcare workers, a reduction in training opportunities, increased costs, and increased inequality in health-service provision. As the virus is likely to become endemic, the recovery of surgical services from the initial shock of the first three waves needs to be carefully planned, in order to mitigate the further loss of elective surgical services. This article presents a narrative review of the latest international guidelines and recommendations pertaining to surgical recovery strategies in the COVID-19 pandemic. To begin with, any recovery plan should be led by a local governance committee, who need to design and implement a number of strategies across the three phases of recovery. The preparation phase includes deciding on a system of case prioritisation, assessing and organising resources, and planning innovative ways to reorganise the service itself. The perioperative phase involves putting measures in place to reduce the risk of COVID-19 transmission. The post discharge phase includes the implementation of telemedicine for follow-up, as well as methods of service audit to enable continuous adjustment and improvement. Surgical service recovery presents many challenges; however, these also present a unique opportunity to reassess and improve the efficiency of surgical care delivery.

Psychological Impact of Cancellation of Elective Surgeries for Ophthalmic Patients during COVID-19 Pandemic.

The COVID-19 pandemic has disrupted routine hospital services globally. The cancellation of elective surgeries placed a psychological burden on patients. A questionnaire study was conducted to identify the psychological impact of canceling cataract operations on patients at Kowloon East Cataract Center, Tseung Kwan O Hospital, Hong Kong, from April to June 2020. In total, 99 participants aged 59 years old and above, who had their cataract surgeries postponed or as scheduled, were studied using the standardized patient health questionnaire (PHQ-9) and generalized anxiety disorder questionnaire (GAD-7). None of the patients who had their cataract surgeries rescheduled reached the cutoff score for major depression in PHQ-9, whereas, according to GAD-7, five patients had mild symptoms of anxiety, and one had severe symptoms. There was no significant psychosocial impact of the cancellation of cataract surgeries on patients.

COVID-19 pandemic and its impact on emergency surgery in colorectal cancer: A single centre experience.

INTRODUCTION: The COVID-19 pandemic has led to major changes in the provision of surgical services and also affected patients' health-seeking behaviour. This contributes to delayed presentation of many surgical conditions resulting in poorer outcomes. Colorectal cancer (CRC) patients who present with acute surgical emergencies such as complete bowel obstruction, perforation, bleeding or sepsis often require immediate intervention. This study aimed to assess the impact of COVID-19 pandemic on the proportion of emergency surgery in CRC patients. MATERIALS AND METHODS: This is a retrospective cohort study. All CRC patients who underwent elective and emergency surgery from January until December 2019 (pre-COVID era) and September 2020 until August 2021 (COVID era) were included. Patient demographics, presentation, tumour stage, surgery performed and waiting time for surgery were collected. Data were then compared. RESULTS: Seventy-seven and 76 new cases of CRC underwent surgery before and during COVID-19, respectively. The proportions of emergency surgery before and during COVID-19 are 29% vs 33% (p=0.562). Of those who required emergency surgery, the proportions of patients who required stoma formation are 59% vs 72% (p= 0.351). There was no difference in median waiting time for patients requiring elective surgery (p= 0.668). CONCLUSION: The proportion of emergency surgery for CRC patients is not statistically higher during the pandemic.

Postoperative outcomes in patients undergoing elective general surgery after recovery from Covid-19 at a tertiary care centre: A one-year case series.

Background Planned elective surgery had to be postponed for a large number of patients who tested positive for Covid-19 in the preoperative period. We aimed to assess the postoperative outcomes of patients who were operated on for elective indications, following recovery from Covid-19 infection. Methods We did a retrospective study of patients who underwent elective general surgery between 1 April 2020 and 31 March 2021, following recovery from Covid-19. The 30-day postoperative morbidity and mortality were analysed. The data relevant for the study were retrieved from the hospital's electronic medical records. Results Of the 109 patients included, 54.1% were women and the median (range) age was 49 (16-76) years; 53.2% of operations were performed for benign indications and the rest were for malignancies. Eighty-five (78%) patients underwent surgery following recovery from an asymptomatic Covid-19 infection and 23 (21.1%) patients following recovery from mild Covid-19 infection; 73.3% of the operations were performed following a planned delay of 2- 5 weeks from the diagnosis of Covid-19. The 30-day major postoperative morbidity (Clavien-Dindo grade ≥3) was 6.4%, the postoperative pulmonary morbidity was 0.9%, and there was no 30-day mortality. Conclusions Elective general surgical procedures can be done safely in patients who have recovered from asymptomatic and mild Covid-19 infection, following a minimum wait period of 2 weeks.

Elective colorectal surgery service provision during SARS-CoV-2 pandemic / Atividade coloproctológica eletiva durante a pandemia de SARS-CoV-2

The SARS-Cov-2 pandemic and its immediate public health impact has caused severe disruption of regular medical care provision. The morbimortality of other diseases continues to affect people regardless of the viral infection. Indeed, it would be reasonable to assume that they have been aggravated by the period of most restrictive public health measures that were adopted against the virus. Recovery and maintenance of healthcare provision is required despite the ongoing threat. Therefore, it is critical to resume services in a structured and safe way, otherwise greater harm could come to our patients and to ourselves. The present article proposes to be a broad guide to the recovery and maintenance of elective outpatient, surgical and lower endoscopic services, aiding the colorectal surgeon in identifying risks, assessing their multiple dimensions, and implementing risk management strategies in a pragmatic and efficacious way. (AU)

A pandemia de SARS-Cov-2 e suas imediatas consequências para a saúde coletiva causaram enormes restrições ao atendimento médico-hospitalar normal. A despeito disso, os riscos de morbimortalidade relacionados a outras doenças e agravos à saúde são incessantes. E é razoável de presumi-los como aumentados pela falta de atendimento regular no período restrições mais severas decorrentes das medidas sanitárias contra a epidemia. A retomada do atendimento é necessária, ainda que o vírus permaneça uma ameaça. Portanto, é crítico que esta seja feita de forma estruturada e segura, sob pena de causar mal adicional aos nossos pacientes e a nós mesmos. O presente artigo se propõe a servir como guia para a retomada e manutenção dos atendimentos eletivos ambulatorial, cirúrgico e endoscópico baixo, auxiliando o coloproctologista a identificar os riscos, avaliar a suas dimensões e implementar medidas de controle de forma pragmática e eficaz. (AU)

Perioperative management of emergency and elective surgeries during the pandemic.

The effects of the 2019 novel coronavirus, SARS-CoV-2, and its associated pandemic are complex and widespread. It has permeated all aspects of daily life around the world. Unsurprisingly, it also had significant impacts on proceedings within hospitals around the world as well. Most notably, the multiple waves of the pandemic have each had untoward effects on surgical productivity within hospital systems. More specifically, the disruption of surgical procedures has impacted both emergent and elective cases. In the context of emergent procedures, hospital systems have had to reevaluate how they define 'emergent,' forcing them to determine which cases could not be rescheduled versus those that could. Elective procedures, on the other hand, were nearly halted altogether in the initial pandemic waves. If these were not completely stopped in some places, then they were greatly reduced. This paper will serve to describe the effect the pandemic has had on the proceedings of both elective and emergent surgeries. It will also describe how we have reevaluated and changed the way we define 'emergent' surgeries and describe the potential implications of this. We will also describe literature that speaks to the implications of the delay of elective procedures. Additionally, the cost implications of fewer surgical procedures performed will be discussed. Finally, we will describe literature that has established protocols for scheduling surgeries in waves of the pandemic, how these have evolved over time, and how they have created confusion for hospital systems navigating the pandemic.

Increased Complications of Emergent Surgical Procedures During the First Wave of COVID-19.

INTRODUCTION: Based on recommendations by CMS elective surgery was stopped during the first wave of COVID-19. Despite hospitals being open for emergent surgery, there were some studies that showed a decrease in surgical volume. METHODS: A retrospective analysis for all surgeries from 185 affiliated hospitals from the first wave of the COVID-19 pandemic (March 2020 to May 2020) and as a comparison the previous year, March 2019 to May 2019 were obtained. Five surgeries were further analyzed: appendectomies, cholecystectomies, craniotomies, exploratory laparotomies, and endoscopic retrograde cholangiopancreatographies (ERCPs). RESULTS: Between March 2019 and May 2019, 326,726 surgeries were performed, and between March 2020 and May 2020, 237,809 surgeries were performed. The highest specialty for both years was gastroenterology. In 2020, 15.7% of the patients were admitted to the ICU versus 13.7% in 2019. For appendectomies, cholecystectomies, craniotomies, exploratory laparotomies and ERCPs, there was an increase from 2019 to 2020 in acute kidney injuries rate, infection, systemic inflammatory response syndrome (SIRS), and sepsis. All the changes in surgical volumes for the five surgeries from 2019 to 2020 were significant. For appendectomy, the statistically significant complications were infection and SIRS and sepsis. CONCLUSIONS: Across the board, there was a decrease in surgical volume during the COVID-19 pandemic first wave. There was a statistically significant decrease in appendectomy, cholecystectomy, exploratory laparotomy, craniotomy, and ERCP. For all five surgeries, we did see an increase in mortality rates and several complications. The only statistically significant complications were infection and SIRS and sepsis, for appendectomy.