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.

Impact on patients of the coronovirus disease 2019 pandemic and postponement of cochlear implant surgery: a qualitative study.

OBJECTIVE: This study aimed to explore the impact of the coronavirus disease 2019 pandemic and postponement of elective surgical procedures for profoundly deaf patients awaiting cochlear implantation. METHOD: Open-ended questionnaires were sent to all adult patients awaiting cochlear implantation surgery. Qualitative analysis was performed using a grounded theory approach. RESULTS: Participants described a primarily negative impact on wellbeing from the surgery delay, expressing feelings of isolation or loneliness. Low mood, depression or hopelessness were commonly expressed by elderly participants; frustration and anxiety were described by young adults. Participants described a negative impact on their general daily life, describing difficulties communicating with facemasks and struggles with reliance on telephone communication because of social distancing. Despite these significant psychosocial challenges, only a minority described adaptive coping strategies. DISCUSSION: Profoundly deaf patients may be at greater psychosocial risk because of unique challenges from their hearing disability. Our findings can be used to develop evidence-driven strategies to improve communication, wellbeing and quality of life.

Safety of emergency, elective and day case operating during the winter period at East Suffolk and North Essex NHS Foundation Trust: lessons from the outcomes of 4,254 surgical patients from the first COVID-19 wave.

BACKGROUND: There is limited evidence on perioperative outcomes of surgical patients during the COVID-19 pandemic to inform continued operating into the winter period. METHODS: We retrospectively analysed the rate of 30-day COVID-19 transmission and mortality of all surgical patients in the three hospitals in our trust in the East of England during the first lockdown in March 2020. All patients who underwent a swab were swabbed on or 24 hours prior to admission. RESULTS: There were 4,254 patients and an overall 30-day mortality of 0.99%. The excess surgical mortality in our region was 0.29%. There were 39 patients who were COVID-19 positive within 30 days of admission, 12 of whom died. All 12 were emergency admissions with a length of stay longer than 24 hours. There were three deaths among those who underwent day case surgery, one of whom was COVID-19 negative, and the other two were not swabbed but not suspected to have COVID-19. There were two COVID-19 positive elective cases and none in day case elective or emergency surgery. There were no COVID-19 positive deaths in elective or day case surgery. CONCLUSIONS: There was a low rate of COVID-19 transmission and mortality in elective and day case operations. Our data have allowed us to guide patients in the consent process and provided the evidence base to restart elective and day case operating with precautions and regular review. A number of regions will be similarly affected and should perform a review of their data for the winter period and beyond.

Safety and feasibility of resuming bariatric surgery under the cloud of COVID-19.

INTRODUCTION: Because of the COVID-19 pandemic, numerous bariatric surgical units globally have halted weight loss surgery. Obesity itself has been shown to be a predictor of poor outcome in people infected with the virus. The aim of this study was to report our experience as a high-volume bariatric institution resuming elective weight loss surgery safely amidst emergency admissions of COVID-19-positive patients. METHODS: A standard operating procedure based on national guidance and altered to accommodate local considerations was initiated across the hospital. Data were collected prospectively for 50 consecutive patients undergoing bariatric surgery following recommencement of elective surgery after the first national lockdown in the UK. RESULTS: Between 28 June and 5 August 2020, a total of 50 patients underwent bariatric surgery of whom 94% were female. Median age was 41 years and median body mass index was 43.8 (interquartile range 40.0-48.8)kg/m2. Half of the patients (n = 25/50) underwent laparoscopic sleeve gastrectomy and half underwent Roux-en-Y gastric bypass (RYGB). Of these 50 patients, 9 (18%) had revisional bariatric surgery. Overall median length of hospital stay was 1 day, with 96% of the study population being discharged within 24h of surgery. The overall rate of readmission was 6% and one patient (2%) returned to theatre with an obstruction proximal to jejuno-jejunal anastomosis. None of the patients exhibited symptoms or tested positive for COVID-19. CONCLUSION: With appropriately implemented measures and precautions, resumption of bariatric surgery during the COVID-19 pandemic appears feasible and safe with no increased risk to patients.

Plastic Surgery amidst the Pandemic: The New York University Experience at the Epicenter of the COVID-19 Crisis.

SUMMARY: The coronavirus disease of 2019 pandemic became a global threat in a matter of weeks, with its future implications yet to be defined. New York City was swiftly declared the epicenter of the pandemic in the United States as case numbers grew exponentially in a matter of days, quickly threatening to overwhelm the capacity of the health care system. This burgeoning crisis led practitioners across specialties to adapt and mobilize rapidly. Plastic surgeons and trainees within the New York University Langone Health system faced uncertainty in terms of future practice, in addition to immediate and long-term effects on undergraduate and graduate medical education. The administration remained vigilant and adaptive, enacting departmental policies prioritizing safety and productivity, with early deployment of faculty for clinical support at the front lines. The authors anticipate that this pandemic will have far-reaching effects on the future of plastic surgery education, trends in the pursuit of elective surgical procedures, and considerable consequences for certain research endeavors. Undoubtedly, there will be substantial impact on the physical and mental well-being of health care practitioners across specialties. Coordinated efforts and clear lines of communication between the Department of Plastic Surgery and its faculty and trainees allowed a concerted effort toward the immediate challenge of tempering the spread of coronavirus disease of 2019 and preserving structure and throughput for education and research. Adaptation and creativity have ultimately allowed for early rebooting of in-person clinical and surgical practice. The authors present their coordinated efforts and lessons gleaned from their experience to inform their community's preparedness as this formidable challenge evolves.

Modelling the impact of changes to abdominal aortic aneurysm screening and treatment services in England during the COVID-19 pandemic.

BACKGROUND: The National Health Service (NHS) abdominal aortic aneurysm (AAA) screening programme (NAAASP) in England screens 65-year-old men. The programme monitors those with an aneurysm, and early intervention for large aneurysms reduces ruptures and AAA-related mortality. AAA screening services have been disrupted following COVID-19 but it is not known how this may impact AAA-related mortality, or where efforts should be focussed as services resume. METHODS: We repurposed a previously validated discrete event simulation model to investigate the impact of COVID-19-related service disruption on key outcomes. This model was used to explore the impact of delayed invitation and reduced attendance in men invited to screening. Additionally, we investigated the impact of temporarily suspending scans, increasing the threshold for elective surgery to 7cm and increasing drop-out in the AAA cohort under surveillance, using data from NAAASP to inform the population. FINDINGS: Delaying invitation to primary screening up to two years had little impact on key outcomes whereas a 10% reduction in attendance could lead to a 2% lifetime increase in AAA-related deaths. In surveillance patients, a 1-year suspension of surveillance or increase in the elective threshold resulted in a 0.4% increase in excess AAA-related deaths (8% in those 5-5.4cm at the start). Longer suspensions or a doubling of drop-out from surveillance would have a pronounced impact on outcomes. INTERPRETATION: Efforts should be directed towards encouraging men to attend AAA screening service appointments post-COVID-19. Those with AAAs on surveillance should be prioritised as the screening programme resumes, as changes to these services beyond one year are likely to have a larger impact on surgical burden and AAA-related mortality.

Surgical Infection Society Guidance for Restoration of Surgical Services during the Coronavirus Disease-2019 Pandemic.

Background: As the coronavirus disease-2019 (COVID-19) pandemic continues globally, high numbers of new infections are developing nationwide, particularly in the U.S. Midwest and along both the Atlantic and Pacific coasts. The need to accommodate growing numbers of hospitalized patients has led facilities in affected areas to suspend anew or curtail normal hospital activities, including elective surgery, even as earlier-affected areas normalized surgical services. Backlogged surgical cases now number in the tens of millions globally. Facilities will be hard-pressed to address these backlogs, even absent the recrudescence of COVID-19. This document provides guidance for the safe and effective resumption of surgical services as circumstances permit. Methods: Review and synthesis of pertinent international peer-reviewed literature, with integration of expert opinion. Results: The "second-wave" of serious infections is placing the healthcare system under renewed stress. Surgical teams likely will encounter persons harboring the virus, whether symptomatic or not. Continued vigilance and protection of patients and staff remain paramount. Reviewed are the impact of COVID-19 on the surgical workforce, considerations for operating on a COVID-19 patient and the outcomes of such operations, the size and nature of the surgical backlog, and the logistics of resumption, including organizational considerations, patient and staff safety, preparation of the surgical candidate, and the role of enhanced recovery programs to reduce morbidity, length of stay, and cost by rational, equitable resource utilization. Conclusions: Resumption of surgical services requires institutional commitment (including teams of surgeons, anesthesiologists, nurses, pharmacists, therapists, dieticians, and administrators). Structured protocols and equitable implementation programs, and iterative audit, planning, and integration will improve outcomes, enhance safety, preserve resources, and reduce cost, all of which will contribute to safe and successful reduction of the surgical backlog.

Elective Surgical Delays Due to COVID-19: The Patient Lived Experience.

BACKGROUND: This qualitative research explored the lived experiences of patients who experienced postponement of elective cardiac and vascular surgery due to coronavirus disease 2019 (COVID-19). We know very little about patients during the novel coronavirus pandemic. Understanding the patient voice may play an important role in prioritization of postponed cases and triage moving forward. METHODS: Utilizing a hermeneutical phenomenological qualitative design, we interviewed 47 individuals who experienced a postponement of cardiac or vascular surgery due to the COVID-19 pandemic. Data were analyzed and informed by phenomenological research methods. RESULTS: Patients in our study described 3 key issues around their postponement of elective surgery. Patients described robust narratives about the meanings of their elective surgeries as the chance to "return to normal" and alleviate symptoms that impacted everyday life. Second, because of the meanings most of our patients ascribed to their surgeries, postponement often took a toll on how patients managed physical health and emotional well-being. Finally, paradoxically, many patients in our study were demonstrative that they would "rather die from a heart attack" than be exposed to the coronavirus. CONCLUSIONS: We identified several components of the patient experience, encompassing quality of life and other desired benefits of surgery, the risks of COVID, and difficulty reconciling the 2. Our study provides significant qualitative evidence to inform providers of important considerations when rescheduling the backlog of patients. The emotional and psychological distress that patients experienced due to postponement may also require additional considerations in postoperative recovery.

Surgical site infections: guidance for elective surgery during the SARS-CoV-2 pandemic - international recommendations and clinical experience.

BACKGROUND: The COVID-19 pandemic not only had an impact on public life and healthcare facilities in general, but also affected established surgical workflows for elective procedures. The strategy to protect patients and healthcare workers from infection by SARS-CoV-2 in surgical departments has needed step-by-step development. Based on the evaluation of international recommendations and guidelines, as well as personal experiences in a clinical 'hot spot' and in a 450-bed surgical clinic, an adapted surgical site infection (SSI) prevention checklist was needed to develop concise instructions, which described roles and responsibilities of healthcare professionals that could be used for wider guidance in pandemic conditions. METHOD: Publications of COVID-19-related recommendations and guidelines, produced by health authorities and organizations, such as WHO, US-CDC, ECDC, the American College of Surgery and the Robert Koch Institute, were retrieved, assessed and referenced up to 31st January 2020. Additionally, clinical personal experiences in Germany were evaluated and considered. RESULTS: Part 1 of this guidance summarizes the experience of a tertiary care, surgical centre which utilized redundant hospital buildings for immediate spatial separation in a 'hot spot' COVID-19 area. Part 2 outlines the successful screening and isolation strategy in a surgical clinic in a region of Germany with outbreaks in surrounding medical centres. Part 3 provides the synopsis of personal experiences and international recommendations suggested for implementation during the COVID-19 pandemic. CONCLUSION: Understanding of COVID-19, and SARS-CoV-2-related epidemiology, is constantly and rapidly changing, requiring continuous adaptation and re-evaluation of recommendations. Established national and local guidelines for continuation of surgical services and prevention of SSI require ongoing scrutiny and focused implementation. This manuscript presents a core facility checklist to support medical institutions to continue their clinical and surgical work during the COVID-19 pandemic.

COVID-19 Impact on Surgical Resident Education and Coping.

BACKGROUND: Healthcare systems and surgical residency training programs have been significantly affected by the novel coronavirus disease 2019 (COVID-19) pandemic. A shelter-in-place and social distancing mandate went into effect in our county on March 16, 2020, considerably altering clinical and educational operations. Along with the suspension of elective procedures, resident academic curricula transitioned to an entirely virtual platform. We aimed to evaluate the impact of these modifications on surgical training and resident concerns about COVID-19. MATERIALS AND METHODS: We surveyed residents and fellows from all eight surgical specialties at our institution regarding their COVID-19 experiences from March to May 2020. Residents completed the survey via a secure Qualtrics link. A total of 38 questions addressed demographic information and perspectives regarding the impact of the COVID-19 pandemic on surgical training, education, and general coping during the pandemic. RESULTS: Of 256 eligible participants across surgical specialties, 146 completed the survey (57.0%). Junior residents comprised 43.6% (n = 61), compared to seniors 37.1% (n = 52) and fellows 19.3% (n = 27). Most participants, 97.9% (n = 138), anticipated being able to complete their academic year on time, and 75.2% (n = 100) perceived virtual learning to be the same as or better than in-person didactic sessions. Participants were most concerned about their ability to have sufficient knowledge and skills to care for patients with COVID-19, and the possibility of exposure to COVID-19. CONCLUSIONS: Although COVID-19 impacted residents' overall teaching and clinical volume, residency programs may identify novel virtual opportunities to meet their educational and research milestones during these challenging times.

Experience of clinical screening for COVID-19 among patients undergoing elective orthopedic surgeries: an alternative proposal.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is the largest global event in recent times, with millions of infected people and hundreds of thousands of deaths worldwide. Colombia has also been affected by the pandemic, including by the cancellation of medically necessary surgical procedures that were categorized as nonessential. The objective of this study was to show the results of the program implemented in two institutions in Bogotá, Colombia, in April 2020 to support the performance of elective essential and nonessential low- and medium-complexity orthopedic surgeries during the mitigation phase of the COVID-19 pandemic, which involved a presurgical clinical protocol without serological or molecular testing. METHODS: This was a multicenter, observational, retrospective, descriptive study of a cohort of patients who underwent elective orthopedic surgery at two institutions in the city of Bogota, Colombia, in April 2020. We implemented a preoperative clinical protocol that did not involve serological or molecular tests; the protocol consisted of a physical examination, a survey of symptoms and contact with confirmed or suspected cases, and presurgical isolation. We recorded the types of surgeries, the patients' scores on the medically necessary, time-sensitive (MeNTs) scale, the presence of signs, symptoms, and mortality associated with COVID-19 developed after the operation. RESULTS: A total of 179 patients underwent orthopedic surgery. The average age was 47 years (Shapiro-Wilk, P = 0.021), and the range was between 18 and 81 years. There was a female predominance (61.5%). With regard to the types of surgeries, 86 (48%) were knee operations, 42 (23.5%) were hand surgeries, 34 (19%) were shoulder surgeries, and 17 (9.5%) were foot and ankle surgeries. The average MeNTs score was 44.6 points. During the 2 weeks after surgery, four patients were suspected of having COVID-19 because they developed at least two symptoms associated with the disease. The incidence of COVID-19 in the postoperative period was 2.3%. Two (1.1%) of these four patients visited an emergency department where RT-PCR tests were performed, and they tested negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). No patients died or were hospitalized for symptoms of COVID-19. CONCLUSION: Through the implementation of a presurgical clinical protocol consisting of a physical examination; a clinical survey inquiring about signs, symptoms, and epidemiological contact with suspected or confirmed cases; and presurgical isolation but not involving the performance of molecular or serological diagnostic tests, positive results were obtained with regard to the performance of low- and medium-complexity elective orthopedic surgeries in an early stage of the COVID-19 pandemic. LEVEL OF EVIDENCE: IV.

Effect of the COVID-19 pandemic first wave and public policy on elective and emergency surgery provision in Southern Queensland.

BACKGROUND: Several public health initiatives in Australia were implemented in March 2020 to contain the spread of COVID-19. The effect of these initiatives on surgical provision is unknown. The primary objective was to determine the effect of public health policies and surgical society guidelines implemented during the pandemic on elective and emergency caseload of surgical specialities operating within South East Queensland. METHODS: This observational study utilized non re-identifiable electronic data to quantify the caseload of surgical specialities across five secondary and tertiary referral hospitals in South East Queensland prior to and during the implementation of such initiatives. All patients undergoing a surgical procedure between 1 March and 24 April 2019 and the same period in 2020 were included. Participants' demographic and clinical information, such as age, the American Society of Anesthesiologists score, surgical date and location, surgical subspecialty and procedure name, was included. RESULTS: During the 2020 time period, there were 2991 elective cases compared to 4422 surgeries occurring in the same period in 2019 (32.4% reduction). Meanwhile, 2082 emergency surgeries were performed in the 2020 period compared to 2362 in 2019 (12.0% decrease). Ophthalmology and dental/ear, nose and throat/maxillofacial surgery experienced the largest reduction in elective surgeries, whereas emergency caseload increased for vascular and cardiothoracic services, and only slightly decreased for plastics and urology. CONCLUSION: The public health initiatives and guidance implemented during the COVID-19 pandemic reduced surgical specialties' elective caseload. However, emergency caseload was not affected to the same extent. This insight helps to guide resource allocation in future waves of the pandemic.