Strategies to Deliver Urology Services in the Times of COVID-19 Pandemic Based on Current Literature

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.


Introduction
The Coronavirus Disease 2019 , caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was first reported in Wuhan City, Hubei Province in China on the 31 st 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 30 th January and as a pandemic on 11 th March 2020 [1]. 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 93,000 deaths [2]. Although affected countries have been in a state of complete lockdown for many weeks, no measures stopped the spread of this virus, and transmissions reached at a stage of community-level and have resulted in havoc on healthcare system [3].
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 [4].

General Measures
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 [5]. 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/extubation 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 [4].

Adaptations to Dance with COVID-19 Pandemic
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 everincreasing demand for beds and ventilators [6]. The decision to go ahead with a particular surgery should be based on meticulous riskbenefit analysis, considering the available healthcare resources and the deleterious effects of delaying a particular surgery [7] (Figure 1).
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 post-operative 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 [8].

Encouraging Telemedicine Services
Although the initial thoughts behind promoting telemedicine services were to provide health services to remote rural and sequestered areas [10], 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 [11]. 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 [12].

Triage and Prioritization of Urology Services According to Slope of Curve
The rationale for prioritization is to provide surgical care timely to needy patient while preserving resources including PPE, beds, and ventilators and sparing health care workers to provide alternate services related to COVID-19 pandemic [6]. 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 [13]. 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).

Figure 1:
Showing key considerations and risk-benefit analysis before starting elective surgery [8,9].    [27,28] Prostate [16] Consider upfront mpMRI and if high risk and symptomatic proceed for biopsy [29] For locally advanced prostate cancer (including cN1) Consider long term ADT + EBRT 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).

Perioperative Adaptations
All the health care workers must have graded step wise training of donning and doffing [36]. The personal protection kit must be government 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 [37].
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 [37].
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. Electrocautery 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 [38,39].
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 min before intubation and after extubation. There shall be minimum and restricted movement from the OR. Prior to a surgery all necessary items must be brought to OR. The main anesthesia 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 pre-prepared into disposable syringes and labeled. In case of difficult airway video-laryngoscope may be used with disposable blades owing to the fact that it becomes difficult to intubate a patient with impaired vision due to PPE/goggles [37].

Conclusion
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.