Shiv Charan Navriya1, Satish Kumar Ranjan2*, Sunil Kumar1, Ashwani Kumar Kandari1, Tushar Aditya Narain1 and Kim Jacob Mammen3
Received: July 04, 2020; Published: August 25, 2020
Corresponding author: Satish Kumar RanjanSenior Resident, Department of Urology, All India Institute of Medical Sciences, Rishikesh (AIIMS), India
COVID-19 disease was first reported in Wuhan city of China, since then this is spreading with alarming speed and had already affected more than 213 countries around the world. The COVID-19 pandemic has had a global impact on all sectors of public health and hospital services. Naturally, urology services have been affected too with several patients, suffering from urological malignancies and renal stone disease, left to their fate. Present records hint towards this pandemic continuing at least till the end of this year and it is only prudent that we come up with strategies to re-initiate urological services in a phased and a safe manner to tackle both, the urological diseases and the COVID-19 infection. This review aims at providing recommendations for resumption of urological services in a phased manner, based on the available evidences in literature.
Keywords: COVID-19, Pandemic; Urological services; Resumption, Strategies
The Corona Virus Disease 2019 (COVID-19), caused by Severe
Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) was
first reported in Wuhan City, Hubei Province in China on the
31st December 2019. With the concern of the alarming spread of
infection and severity of disease, World Health Organization (WHO)
declared COVID-19 as a Public Health Emergency of International
Concern (PHEIC) on 30th January and as a pandemic on 11th
March 2020 . This pandemic has already affected more than
213 countries around the world, with an approximate burden of
8.40 million cases and 0.45 million deaths. The United States of
America (USA), Russia, Spain, United Kingdom (UK), Italy, France
and Germany have been the worst affected countries despite
having a world-class health care system, with the USA heading
the list with 1.5 million cases and more than 93 thousand death
 Although affected countries have been in a state of complete
lockdown for many weeks, no measures stopped the spread of this
virus, and transmission reached at a stage of community-level and
have resulted in havoc on healthcare system . The COVID-19
pandemic has had a global impact on all sectors of public health and
hospital services. Naturally, urology services have been affected too
with several patients, suffering from urological malignancies and
renal stone disease, left to their fate. Present records hint towards
this pandemic continuing at least till the end of this year and it is
only prudent that we come up with policies to re-initiate urological
services in a phased and a safe manner to tackle both, the urological
diseases and the COVID-19 infection.
A risk-benefit assessment for each patient requiring a urological intervention should be done during this COVID-19 pandemic based on the nature of the disease (benign vs malignant), risk of disease progression, impact on life if left untreated, postponed or managed medically and the risk of viral illness and transmission. Taking clues from the previous pandemic, COVID-19 too may continue for years, and we cannot afford to leave our patients untreated all this while. This review aims at providing recommendations for resumption of urological services in a phased manner, based on the available evidences in literature.
Every patient visiting the hospital should undergo a general symptomatic screening for COVID-19, including history of travel, before referring to a specialty clinic. At this stage, health care workers must have a N95/triple layer surgical mask and must use disposable gloves for the examination of the patients considering the potential source of infection from an asymptomatic case. Hospitals can be divided into COVID and Non- COVIDs block and all patients who require admission to the hospital can be admitted in COVID block in different rooms/areas and shifted to the Non-COVID area, once COVID-19 test report comes negative. Manpower should be divided into three pools and at a time, only one team should be working keeping others in reserve to minimize exposure. Specific testing of COVID-19 by Reverse Transcription Polymerase Chain Reaction (RT-PCR) should be done in all patients who are symptomatic, have a contact history, require admission in the hospital or are planned for a surgical intervention and may be done in all old age patients with multiple comorbidities, because of high mortality in this group of patients . The various Royal Colleges of United Kingdom jointly issued a statement, the “Intercollegiate General Surgery Guidance on COVID-19”. Adequate personal protective equipment (PPE) and N95 Mask for the surgical team is essential to protect healthcare workers and ensure an adequate workforce available to treat patients. A negative pressure room is strongly recommended for intubation/extubating with an experienced anesthesiologist to minimize exposure in a COVID-19 suspected or proven case. All standard precautions should be maintained in the operating room (OR), including minimal personnel to be present inside the OR, mandatory PPE to be worn by all, even if the patient is negative for the COVID-19 test. If possible, a dedicated OR should be available with a trained team of healthcare workers including experienced surgeons, anesthesiologists, OR technicians, nursing officers, and ground staff. A complete record of manpower used in different areas should be maintained .
The usual urological diseases did not cease to cause morbidity and mortality while the SARS-CoV-2 virus was creating havoc worldwide. Urological malignancies and chronic kidney diseases continued to kill all this while. We need to strike a balance between providing urological services and conserving resources to face the biggest menace of all times. In order to combat increasing number of COVID-19 cases, reallocation of resources with redistribution of health care workers is the need of the hour as there will be an ever increasing demand for beds and ventilators.6 The decision to go ahead with a particular surgery should be based on meticulous risk-benefit analysis, considering the available healthcare resources and the deleterious effects of delaying a particular surgery  (Figure 1).
Figure 1: Showing key considerations and risk-benefit analysis before starting elective surgery [8,9].
Strict adherence to COVID-19 safety guidelines, social distancing, entrance screening, waiting room policy, a visitor’s policy and separate staff to treat non-COVID19 patients are required. Considering the reported increased incidence of postoperative morbidity and mortality, it is advised to get pre-operative COVID-19 screening test in all patients and a mandate for patients with clinical symptoms or close contacts of COVID-19 patient or belonging to a hotspot area. Further decision of scheduling a case for surgery should be based on a prioritization strategy prepared for that institute. Time to time review of COVID-19 metrics and statics in local area are required frequently to reassess and reconsider a change in policy. Any plan in this crisis should be dynamic and should change as the situation unfolds [7-9].
Although the initial thoughts behind promoting telemedicine services were to provide health services to remote rural and sequestered areas , but this pandemic has unearthed the undiscovered potentials of distant telemedicine services and virtual OPDs. Telemedicine can be accessible anywhere and avoids a hospital visit, thus keeping both patient and health care providers safe. The ways of communication in telemedicine can be text message, voice calls or audio-video using social media platforms, telephonic calls or special telehealth applications  The discipline of urology has immense potential of using telemedicine services by providing prescription to non-operative patients, to triage a patient for hospital visit, for preoperative assessment and to follow-up in post-operative period allowing them to stay away from the hospital environment 
The rationale for prioritization is to provide surgical care timely to needy patient while preserving resources including PPE, beds, ventilators and sparing health care workers to provide alternate services related to COVID-19 pandemic  Determining which urology procedures can be safely delayed, should be based on the severity of disease, risk from delaying surgery, probable length of hospital stay, local healthcare resources and COVID-19 statics in that particular geographical region  Approaches to urological conditions should be tailored to individual settings, and preferably should have a shared decision making of both patient and treating urologist. Ample evidences are available in literature to guide us regarding the effects of delay of the particular procedure. Compiling these available evidences, we have tried to simplify the recommendations, pertinent to a given area with its burden of the COVID-19 disease. (Table 1) The first scenario is a state of exponential rise of COVID-19 cases and exhausted health care resources; in such a situation, only emergency lifesaving procedures should be performed. Second scenario includes availability of adequate health resources and stable rate of rise in COVID-19 cases; high priority cases can be catered to besides the emergency surgeries. Third scenario is a stage of decline of cases and re-established supply chain of resources; this is a phase of capacity building and backlog of cases should be identified and elective cases should be resumed. [14,15] (Figure 2).
All the health care workers must have graded step wise training
of donning and doffing [16-18] The personal protection kit must
be government [19-34]authorized and shall be pre-available in OR
(operating rooms) . Powered air purifying respirators if possible,
should be made available with PPE kits. A detailed surveillance
must be done of all the OR staff followed by a simulation course
incorporating all the precautionary steps relating to COVID-19 
Staff should be divided into teams and the team members should
not come in contact with members of the other. All surgeries should
be performed by experienced surgeon with established standard
techniques. Senior surgeons above 60 years may play the role of
coordinators and make way for their younger colleagues as senior
citizens have been most susceptible for the disease .
OTs must be divided into COVID and non COVID OTs. All precautions must be taken to keep COVID OT away from regular elective OTs as far as possible. There are plenty of reports in literature suggesting risk of infection by evaporated smoke during surgery so attempts should be made to minimize the smoke and aerosol generation. Electro cautery devices should be used minimum and minimal invasive surgery with laparoscopy and robotics should have minimum intra-abdominal pressure with closed evacuation system for gas [37,38]. The US center for disease control and prevention recommends a negative pressure airborne infection isolation room for patients undergoing aerosol generating procedures. All the OTs must remain closed for 10 minutes before intubation and after extubating. There shall be minimum and restricted movement from the OR. Prior to a surgery all necessary items must be brought to OR. The main anaesthesia trolley should remain outside the OR with minimum drugs to be prepared and taken into OR. The drugs taken inside the OR room must be preprepared into disposable syringes and labelled. In case of difficult airway video-laryngoscope may be used with disposable blades because it becomes difficult to intubate a patient with impaired vision due to PPE/goggles 
Current statics predicts a long war with COVID-19, and it would be wise to resume routine urological services in a prioritized graded manner to avoid accumulation of large number of cases requiring intervention. Timely and appropriate urological care should be made available while at the same time, resources and manpower should be conserved so as to be in a position to fight both, the urological diseases and the SARS-CoV-2 virus, and emerge triumphant.
Bio chemistryUniversity of Texas Medical Branch, USA
Department of Criminal JusticeLiberty University, USA
Department of PsychiatryUniversity of Kentucky, USA
Department of MedicineGally International Biomedical Research & Consulting LLC, USA
Department of Urbanisation and AgriculturalMontreal university, USA
Oral & Maxillofacial PathologyNew York University, USA
Gastroenterology and HepatologyUniversity of Alabama, UK
Department of MedicineUniversities of Bradford, UK
OncologyCirculogene Theranostics, England
Radiation ChemistryNational University of Mexico, USA
Analytical ChemistryWentworth Institute of Technology, USA
Minimally Invasive SurgeryMercer University school of Medicine, USA
Pediatric DentistryUniversity of Athens , Greece
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