Clinical and surgical consequences of the COVID-19 pandemic for patients with pediatric urological problems: Statement of the EAU guidelines panel for paediatric urology, March 30 2020

Delayed Care Seeking and Outcomes of Testicular Torsion among Children during the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

INTRODUCTION

 Since the onset of coronavirus disease 2019 (COVID-19), stay-at-home orders and fear caused by the pandemic have had a significant effect on the timing and outcomes of testicular torsion. However, the evidence was limited since the study results were inconsistent. This study aims to examine the hospitalization rates, timing, and outcomes of testicular torsion in children before and during the pandemic.

MATERIALS AND METHODS

 Using PubMed, Embase, and Google Scholar databases, we conducted a systematic search and meta-analysis of studies reporting the timing and outcomes of children admitted with testicular torsion before and during the COVID-19 pandemic. Subgroup analyses were conducted to explore possible sources of heterogeneity.

RESULT

 The outcomes of 899 testicular torsion patients from eight studies were evaluated. Our study found an increased hospitalization rate for patients with testicular torsion (incidence rate ratio = 1.60, 95% confidence interval [CI]: 1.27-2.03; p = 0.001). Despite a significant increase in the duration of symptoms during the COVID-19 pandemic (weighted mean difference = 11.04, 95% CI: 2.75-19.33; p = 0.009), orchiectomy rates did not increase (odds ratio = 1.33, 95% CI: 0.85-2.10; p = 0.147).

CONCLUSION

 During the COVID-19 pandemic, hospitalization rates for testicular torsion and the duration of symptoms among children increased significantly. Moreover, the rate of orchiectomy did not increase during the pandemic, indicating that pediatric emergency services have remained efficient and have prevented an increase in the number of orchiectomies performed despite pandemic-related closures and delays in transporting patients to medical care.

Impact of the COVID-19 pandemic on bladder cancer patients: a multicenter real-world study

OBJECTIVE

Hospital management and medical treatment changed during the coronavirus disease 2019 (COVID-19) pandemic. This study investigated the impact of the COVID-19 pandemic on patients with bladder cancer.

METHODS

In this multicenter retrospective study, we collected information from the electronic medical records of outpatients who underwent cystoscopy and inpatients with confirmed bladder cancer in three hospitals in Nanjing (two province-level and one county-level hospitals) in 2019 and 2020. Patients' home addresses, treatment methods, length of stay, and pathology were compared between the periods.

RESULTS

In total, 4048 outpatients and 1242 inpatients were included. The average number of cystoscopies decreased significantly during the lockdown. In province-level hospitals, the number of cystoscopies increased gradually as the pandemic was brought under control but remained lower than that in 2019, whereas the number grew in 2020 in county-level hospitals. The rates of recurrence and radical cystectomy were higher in 2020 than in 2019. No significant difference in the pathological grade was observed. More patients who underwent radical cystectomy were diagnosed with muscle-invasive bladder cancer during the 2020 lockdown.

CONCLUSION

The pandemic severely affected patients with bladder cancer, mainly in their choice of institution and treatment.

The kidney in COVID-19: protagonist or figurant?

The etiology of injury in COVID-19 patients is diverse and multifactorial. Autopsy and biopsy studies reveal, alongside podocyte and tubular cell anomalies, the presence of virion within the cells. Evidence suggests that, in addition to the direct cytopathic effect of SARS-CoV-2 on the glomeruli and renal tubules, there is also the indirect effect of cell-mediated immunity, the cytokines storm and the cross-talk between organs with possible systemic effects of the disease. These mechanisms are interconnected and have profound therapeutic implications involving extracorporeal removal of inflammatory cytokines. Dialysis patients, and children, in particular, should be classified as "at high risk" of contracting the disease. Infections are one of the most frequent causes of death in children with chronic renal failure who undergo dialysis. The reasons for this particular susceptibility are to be found in the compromised immune system, secondary to chronic malnutrition, immunosuppressive therapy, and uremia, frequent contact with healthcare personnel and other patients attending the dialysis unit and in need of the presence of other family members during treatment.

Clinical characteristics, socioeconomic factors and COVID-19 were associated with delayed surgery in children with hypospadias: a retrospective study of 4439 cases in a single center

BACKGROUND

Hypospadias is one of the most common congenital diseases of the genitourinary system in children. The European Association of Urology (EAU) Guidelines recommend that children undergoing hypospadias surgery should be between 6 and 18 months. In China, where many children have hypospadias, it remains unknown whether clinical characteristics, socioeconomic factors and COVID-19 were associated with delayed surgery in children with hypospadias.

METHODS

We retrospectively analyzed children with hypospadias who underwent primary surgery at the Department of Pediatric Urology in Guangzhou Women and Children's Medical Center between January 2010 and October 2021. Patients who had two-stage surgery or a second round of surgery due to complications were excluded to eliminate data duplication. The clinical characteristics and demographic information were collected. We defined delayed surgery as primary surgery performed after 18 months following the EAU Guidelines.

RESULTS

A total of 4439 children diagnosed with hypospadias were included in the study. The median age (29.1 ± 16.7 months) of surgery for hypospadias in our study was much higher than the recommended age reported in the EAU guidelines, and 76.6% of the children underwent surgery after the age of 18 months. Children without comorbidities including cryptorchidism (odds ratio [OR] = 1.562; 95% confidence interval [CI] 1.199-2.034; p = 0.001), prostatic cyst (OR = 2.613; 95% CI 1.579-4.324; p < 0.001), penile hypoplasia (OR = 1.778; 95% CI 1.225-2.580; p = 0.002), inguinal hernia (OR = 2.070; 95% CI 1.394-3.075; p < 0.001), and penoscrotal transposition (OR = 4.125; 95% CI 1.250-13.619; p = 0.020) were more likely to receive delayed surgery. Living in a low economic area (OR = 1.731; 95% CI 1.068-2.806; p = 0.026) or not close to a main medical center (OR = 1.580; 95% CI 1.370-1.824; p < 0.001) was highly associated with delayed surgery. The proportion of children undergoing delayed surgery and the median age of surgery during the COVID-19 pandemic were significantly higher than those before the COVID-19 pandemic (p = 0.004 and < 0.001, respectively).

CONCLUSIONS

Most children with hypospadias received delayed surgery (surgical age > 18 months). Comorbidities, living in a low economic area, too far from a main medical center and the COVID-19 pandemic were highly associated with delayed surgery. It is vital to improve the public awareness of hypospadias and strengthen the re-education of primary community doctors to reduce delayed surgery.

The ISO 26000's labor environmental issues during COVID-19: does corporate social responsibility help? Evidence from the Egyptian small and medium enterprises

Based on both the "stakeholder" and "cognitive" theories, this study shed light on the optimistic side of the COVID-19 pandemic, as it also brings the concepts of corporate social responsibility (CSR) and sustainability back into the light, which helps in solving the labor environmental issues. Our research aims to profoundly investigate the correlation between CSR and labor environmental issues based on the International Organization for Standardization's standard 26,000 (ISO 26000) during COVID-19 and to also examine how CSR practices help solve labor environmental issues in the Egyptian small and medium enterprises (SMEs). Partial least squares structural equation modeling (PLS-SEM) was adopted, for data analysis and hypotheses testing, on a sample of 307 manager-level employees in the Egyptian SMEs. Results indicate that CSR positively impacts labor practices dimensions (employment relationships, human development and training, social dialog, and health and safety at work). However, CSR has an insignificant effect on social protection and work conditions. This study is scientifically valuable since it helps better understand the pandemic's effects on environmental labor issues in the Egyptian SMEs and shows how CSR helps solve those issues. Also, it discussed the theoretical contributions and practical implications and showed the limitations and future research for this study area.

Severe acute respiratory syndrome coronavirus 2 pandemic related morbidity and mortality in patients with pediatric surgical diseases: A concerning challenge

The global spread of the novel severe acute respiratory syndrome coronavirus 2 has had serious consequences in terms of patient morbidity and mortality and overburdened health care systems as well as the socioeconomic implications. In the absence of effective therapies and vaccinations during the viral outbreak, the major and most concise means to control viral spread is spread prevention. Although information concerning the impact of severe acute respiratory syndrome coronavirus 2 on pediatric surgical patients has greatly expanded, relevant comprehensive studies are scarce. However, pandemic related morbidity has increased, while under normal circumstances mortality could have been minimized.

Pediatric urology surgical practice in the time of COVID-19: Results from tertiary Saudi Arabia hospitals

Purpose:

Our study aimed to evaluate the effect of COVID-19 on pediatric urology practice in the Kingdom of Saudi Arabia (KSA).

Methods:

Data of 10 tertiary hospitals in KSA were retrospectively analyzed. Data of outpatient department (OPD) visits and pediatric urology surgical procedures from January 1, 2019, to April 30, 2019, and from January 1, 2020, to April 30, 2020, were extracted. The primary outcome was to compare OPD visits and pediatric urology workload in the first third of 2020 versus 2019, where there was no curfew. The secondary outcome was to compare the same variables during the full curfew time, i.e., April 2020 versus April 2019.

Results:

The number of OPD visits was lower in the first third of 2020 (7390 vs. 10,379 in 2019 P < 0.001). OPD visits in April 2020 were 78.6% lower than in April 2019, and teleclinics represented 850 (94.3%). Elective procedures in the first third of 2020 were 688, with a reduction rate of 34.3% compared to the same period of 2019 (P < 0.001). In April 2020, there were 18 elective surgeries, with a 91.4% decrease than in April 2019. Ureteric reimplantation, hypospadias, cryptorchidism, and circumcision stopped, while pyeloplasty (n = 14) and urolithiasis (n = 4) procedures had declined by 50% and 76.5%, respectively. Most of the procedures (71.8%) were day surgery. Emergency procedures were similar in the first third of 2020 (65 vs. 64 in 2019, P = 0.994) and declined in April 2020 by 6.7% versus April 2019. During the full curfew, the most common emergency intervention were cases with obstructive uropathy (42.8%), followed by torsion testis (28.6%), posterior urethral valve (14.3%), and urological trauma (14.3%).

Conclusions:

In KSA, the number of elective pediatric surgical procedures were reduced by >90%, while the number of emergency pediatric surgical procdures were similar during COVID-19 pandemic compared with non-COVID-19 time. Ureteric reimplantation, hypospadias repair, cryptorchidism, and circumcision procedures were postponed. Pyeloplasty and urolithiasis-related procedures were performed to prevent irreversible disease progression or organ damage. There was an increase in rate of teleclinic and day surgery to reduce the risk of COVID-19 infection.

Prominence of urinary biomarkers for bladder cancer in the COVID-19 era: From the commercially available to new prospective candidates

Molecular markers detected in urine may improve our understanding of the evolution of bladder cancer (BCa) and its micro- and macroenvironment. Detection of such markers will identify disease earlier, allow stratification of patients according to risk, and improve prognostication and prediction of outcomes, thereby facilitating targeted therapy. However, current guidelines have yet to embrace such markers for routine management of BCa, and most research studies have focused on urine-based tumor markers. In this review, we summarize known urinary biomarkers for BCa and highlight newly identified molecules. We then discuss the challenges that must be overcome to incorporate these markers into clinical care.

Intraoperative Measures to Reduce the Risk of COVID-19 Transmission During Minimally Invasive Procedures: A Systematic Review and Critical Appraisal of Societies' Recommendations

BACKGROUND

The coronavirus 2019 pandemic and the hypothetical risk of virus transmission through aerosolized CO2 or surgical smoke produced during minimally invasive surgery (MIS) procedures have prompted societies to issue recommendations on measures to reduce this risk. The aim of this systematic review is to identify, summarize and critically appraise recommendations from surgical societies on intraoperative measures to reduce the risk of severe acute respiratory syndrome coronavirus 2 transmission to the operative room (OR) staff during MIS.

METHODS

Medline, Embase, and Google Scholar databases were searched using a search strategy or free terms. The search was supplemented with searches of additional relevant records on coronavirus 2019 resource websites from Surgical Associations and Societies. Recommendations published by surgical societies that reported on the intraoperative methods to reduce the risk of severe acute respiratory syndrome coronavirus 2 transmission to the OR staff during MIS were also reviewed for inclusion. Expert opinion articles were excluded. A preliminary synthesis was performed of the extracted data to categorize and itemize the different types of recommendations. The results were then summarized in a narrative synthesis.

RESULTS

Thirty-three recommendation were included in the study. Most recommendations were targeted to general surgery (13) and gynecology (8). Areas covered by the documents were recommendations on performance of laparoscopic/robotic surgery versus open approach (28 documents), selection of surgical staff (13), management of pneumoperitoneum (33), use of energy devices (20), and management of surgical smoke and pneumoperitoneum desufflation (33) with varying degree of consensus on the specific recommendations among the documents.

CONCLUSIONS

While some of the early recommendations advised against the use of MIS, they were not strictly based on the available scientific evidence. After further consideration of the literature and of the well-known benefits of laparoscopy to the patient, later recommendations shifted to encouraging the use of MIS as long as adequate precautions could be taken to protect the safety of the OR staff. The release and implementation of recommendations should be based on evidence-based practices that allows health care systems to provide safe surgical and medical assistance.

Survey on what COVID-19 pandemic changed in pediatric urology

OBJECTIVE

We aimed to conduct a survey to see how the patient management of pediatric urologists has changed during the COVID-19 pandemic in daily practice and its compliance with the guidelines that aim to minimize the harm to the patient and healthcare professionals.

MATERIAL AND METHODS

A questionnaire was prepared to be asked to physicians via Microsoft Forms dealing with pediatric urology for this purpose, and a link was shared in social media groups of doctors managing pediatric urology patients.

RESULTS

A total of 58 (46 males and 12 females) doctors participated in the survey. Participants stated that they made a very high rate of change in their clinical routine; the most preferred approach for the prevention in the operating room was reducing the number of the working staff, and the second most frequent was performing a preoperative COVID-19 screening. Elective surgeries (ie, inguinoscrotal pathologies) were delayed by the majority. However, the majority of the surgeons did not delay surgeries for ureteropelvic junction obstruction or urinary stones. Ninety-five percent of the participants stated that the number of patients was decreased in the outpatient clinics, which was mainly due to the hospital and government policies. The most used method to communicate with patients during the pandemic was phone calls, and there was a 52% increase in the WhatsApp messenger application before the pandemic.

CONCLUSION

Our survey provided us with an opinion about how our colleagues' lives changed during the pandemic and showed us the importance of a well-established telemedicine system.

Risk-based stratification triaging system in pediatric urology: what COVID-19 pandemic has taught us

INTRODUCTION AND OBJECTIVE

SARS-COV-2 pandemic has affected the population worldwide requiring social distancing, quarantine and isolation as strategies to control virus propagation. Initial measures to reduce the burden to the health care system during the pandemic included deferring elective surgery. These damage control measures did not take into account the mid- and long-term implications. Management of congenital anomalies can be time sensitive with delays resulting in permanent disability, morbidity and increased costs to the healthcare system. This study reports the results of using a novel scoring system that enables triage of time sensitive congenital anomalies and pediatric surgical conditions and how implementation of Enhanced Recovery After Surgery (ERAS®) principles allowed optimization of resources and reduced the burden to the system while allowing for appropriate care of pediatric patients with urgent urologic surgical conditions.

METHODS

We present a prospective case series of patients with congenital urological conditions scheduled and taken to surgery during COVID-19 pandemic. All pediatric urology cases that were pending and or scheduled for surgery at the moment the pandemic struck as well as all cases that presented to the emergency department with urological conditions were triaged and included for analysis using a modified Medically Necessary, Time-Sensitive Procedures: Scoring System (MeNTS). A modified MeNTS was implemented for pediatric patients, giving more priority to the impact of deferring surgical intervention on patient's prognosis. An individualized evaluation using this scoring system was applied to each patient. Intra- and postoperative ERAS^® principles were applied to all cases operated during the pandemic between March 20th and April 24th to reduce the burden to the healthcare system.

RESULTS

A total of 49 patients were triaged and included for analysis with a mean age of 6.47 years of age. Adjusted MeNTS showed that all clinically emergent cases had a score of 12 or less. Cases that could be postponed for 2 weeks but no longer had a score between 13 and 15. The ones that could wait 6 weeks or longer had scores higher than 16. Score results were not the same for similar procedures and individualized assessments resulted in scores based on an individual patient's conditions. From the total cases, implementation of ERAS^® principles increased outpatient procedures from 68 to 90.4%.

CONCLUSION

Our results provide a novel triaging method to rank pediatric urological surgical management based on individualized patient's clinical conditions. Cutoff values of 12 and 16 allowed appropriate triage preventing the postponement of urgent urologic cases during the COVID-19 pandemic. Implementation of ERAS^® principles allowed for these procedures to be done in the outpatient setting, preserving valuable healthcare resources.

TYPE OF STUDY

Prospective cohort study.

LEVEL OF EVIDENCE

IV.

Pediatric urology in the era of COVID-19

Introduction

The coronavirus disease 2019 (COVID-19) has mandated the pediatric urologists to adapt to the changing dynamics and adopt the strategy to minimise the collateral damage. The purpose of this study is to compile all the available literature and published guideline to facilitate the patient management.

Materials and methods

PubMed, Scopus, and Google scholar database were systematically searched using the search terms “COVID-19” AND “pediatric” AND “urology”. All published papers retrieved from this search were considered for this review based on PRISMA guidelines. In addition to this, World Wide Web search was conducted for guidelines, and recommendations published by scientific societies and their websites were searched for the desired information.

Results

Total eight articles and society recommendations met the inclusion criteria and included in the study. The general level of agreement was found on need to postpone the elective cases and ensuring the safety of hospital staff. The organ and life-threatening conditions like acute and symptomatic obstructive uropathy and testicular torsion should be treated on an emergent basis irrespective of COVID status. There is no evidence that any modality either open or laparoscopic has any advantage over the other. The protocols need to be modified based on stage of pandemic, availability of resources, and local guidelines. The restart of work once the pandemic is over should also be prioritised.

Conclusion

There are very few articles and society guidelines on pediatric urology care in the COVID era, but all the available guidelines stress on prioritisation, protocol-based management, and improvisation as per the circumstances.

Level of evidence

V.

Human resource management and the COVID-19 crisis: implications, challenges, opportunities, and future organizational directions

The COVID-19 has grandly shaken all organizations, creating a complex and challenging environment for managers and human resource management (HRM) practitioners, who need to find ingenious solutions to ensure the continuity of their companies and to help their employees to cope with this extraordinary crisis. Studies addressing the impact of this crisis on HRM are sparse. This paper is a general literature review, which aims at broadening the scope of management research, by exploring the impact of the COVID-19 on HRM. It identifies the main challenges and opportunities that have arisen from this new pandemic and it offers insights for managers and HRM practitioners into possible future organizational directions that might arise from these opportunities.

Adaptations and Safety Modifications to Perform Safe Minimal Access Surgery (MIS: Laparoscopy and Robotic) During the COVID-19 Pandemic: Practice Modifications Expert Panel Consensus Guidelines from Academia of Minimal Access Surgical Oncology (AMASO)

The pandemic of COVID-19 across the globe triggered national lockdowns hampering normal working for all the essential services including healthcare. In order to reduce transmission and safety of patients and healthcare workers, the elective surgeries have been differed. The visits to the hospitals for follow-ups and consultations received temporary halt. However, we cannot halt the treatment for cancer patients who may or may not be COVID-19 positives. These are emergencies and should be treated ASAP. Conducting emergency surgeries during pandemic like COVID-19 is challenge for surgeons and the entire hospital infrastructure. The available information about COVID-19 and its propensity of contamination through droplets and aerosol need some modifications for conducting surgeries successfully without contaminating the hospital buildings, protecting healthcare teams and the patient. With these objectives, some modifications in the operating theater including surgical techniques for minimal access, laparoscopy, and robotic surgery are proposed in this review article. This review article also discusses the safety measures to be followed for the suspected or confirmed COVID-19 patient and the guidelines and recommendations for healthcare teams while treating these patients. Although there is little evidence of viral transmission through laparoscopic or open approaches, modifications to surgical practice such as the use of safe smoke evacuation and minimizing energy device used to reduce the risk of exposure to aerosolized particles to healthcare team are proposed in this review article.

Methodology for triage of urologic surgical cases in the setting of a pandemic

Background

The first wave of the COVID-19 pandemic in March 2020 forced our healthcare system in the Bronx, New York to cancel nearly all scheduled surgeries. We developed a framework for prioritizing postponed urologic surgeries that was utilized once cases were permitted to be rescheduled. As many parts of our country experience first and second waves of this pandemic, our framework may serve as a resource for other centers experiencing restrictions on the scheduling of elective urologic surgeries.

Methods

As the COVID-19 pandemic started and peaked in New York, almost all of our scheduled urologic surgeries were cancelled. Each Urologist was asked to rank his/her cancelled surgeries by priority (Level 1—least urgent; Level 2—moderately urgent; Level 3—most urgent). A committee of Urologists assigned a subclass to Level 3 and 2 cases (3a—least urgent; 3b—moderately urgent; 3c—most urgent; 2a—lower priority; 2b—higher priority). The committee then reviewed cases by urgency to derive a final priority ranking.

Results

A total of 478 total urologic surgeries were canceled and categorized: 250 Level 1, 130 Level 2, 98 Level 3 (73 adult, 25 pediatric). Level 3c involved renal cell carcinoma ≥ T2b, high-grade bladder urothelial carcinoma, adrenal mass/cancer > 6 cm, testicular cancer requiring radical orchiectomy, and penile cancer. Level 3b involved T2a renal masses requiring nephrectomy, while high-risk prostate cancer and symptomatic nephrolithiasis were classified as 3a. Level 2 included testicular cancer requiring retroperitoneal lymph node dissection and complicated benign prostatic hyperplasia. Surgeries for urologic reconstruction, non-complicated nephrolithiasis, erectile dysfunction, and urinary incontinence were considered Level 1.

Conclusions

Our disease-specific approach to surgical rescheduling offers appropriate guidance for triaging urologic surgeries. Our system can provide guidance to other institutions as COVID-19 cases surge in different regions and with the growing second wave.

Adaptations and Safety Modifications to Perform Safe Minimal Access Surgery (Minimally Invasive Surgery: Laparoscopy and Robotic) during the COVID-19 Pandemic

It is inevitable that some patients with suspected or confirmed COVID-19 may require urgent surgical procedures. The objective of this review was to discuss the modifications required in the operating room during COVID-19 times for minimal access, laparoscopy, and robotic surgery, especially with regard to minimally invasive surgical instruments, buffalo filter, trocars with smoke evacuator, and special personal protection equipment. We have discussed the safety measures to be followed for the suspected or confirmed COVID-19 patient. In addition to surgical patients, health care workers should also protect themselves by following the guidelines and recommendations while treating these patients. Although there is little evidence of viral transmission through laparoscopic or open approaches, we recommend modifications to surgical practice such as the use of safe smoke evacuation and minimizing energy device use to reduce the risk of exposure to aerosolized particles to the health care team. Therefore, hospitals must follow specific protocols and arrange suitable training of the health care workers. Following well-established plans to accomplish un-deferrable surgeries in COVID-19-positive patients is strongly recommended.

Urology during COVID-19 Pandemic Crisis: A Systematic Review

Background  Coronavirus disease 2019 (COVID-19) has evolved as a pandemic of unimaginable magnitude. The health care system is facing a tremendous challenge to provide ethical and quality care. The transformation of the patient-based care to population-based care during the COVID-19 pandemic has raised ethical dilemma among urologists. Our objective is to explore the consensus in modified standard urology care, that can be adopted and applied during COVID-19 and similar pandemic.

Methods  We adopted an exploratory study design using secondary data. The data were extracted from a web-based medical library using keywords “COVID-19,” “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2),” and “urology.” We identify and extrapolate (screening, eligibility, and inclusion) the data using PRISMA protocol, and summarize pandemic standard urology care under four main themes: (1) general urology care, (2) choice of surgical modality, (3) triage, and (4) urology training.

Result  We identified 63 academic papers related to our research question. The majority are expert opinions and perspectives on urology care. The common consensus is triage-based urology care and surgeries. Life or organ threatening conditions need immediate attention. Universal protective measures (personal protective equipment, safe operative environment) and protocol-based patient care are necessary to prevent and control SARS-CoV-2 infection. Conservation of the resources and its rational distribution provide an ethical basis for population-based health care during a pandemic. Informed decision making serves best to patients, families, and society during the public health crisis.

Conclusion  COVID-19 pandemic tends to transform standard urology practice into crisis standard population-based care. The consensus in crisis is drawn from evolving pieces of medical evidence and public health ethics. The provision of urology care during a pandemic is based on the availability of resources; severity of the disease, consequences of deferment of service, and dynamics of the pandemic.

Role of Mini-Percutaneous Nephrolithotomy in the Management of Pediatric Stone Disease: A Systematic Review of Literature

Introduction: Kidney stone disease in the pediatric setting is rare, but the incidence is rising. Mini-percutaneous nephrolithotomy (mPCNL) is one of the newer surgical interventions to have been developed in recent decades. The aim of this study was to carry out a systematic review (SR) to formally evaluate the safety and efficacy of pediatric mPCNL, which was defined as PCNLs using tract size between 15F and 20F. Methods: An SR was carried out in accordance with Cochrane guidelines and A MeaSurement Tool to Assess systematic Reviews (AMSTAR) checklist. Original studies reporting on outcomes of mPCNL with 20 or more patients (aged ≤18 years) were included. Results: Eight studies were finally identified, which satisfied our predefined criteria. This included two randomized trials and six cohort studies. A total of 384 patients with a weighted mean age of 7.5 years (range: 0.5-18 years) and a male:female ratio of 3:2 underwent mPCNL. The weighted mean stone size was 1.2 cm (range: 0.8-3.5 cm). The weighted mean operative time and length of hospital stay were 76.8 minutes (range: 20-120 minutes) and 4.6 days (range: 1-33 days), respectively. The most common location(s) of stones were lower pole (57%) and renal pelvis (24.3%). The weighted mean initial and overall stone-free rates were 87.9% (range: 76%-97.5%) and 97% (range: 91.3%-100%), respectively. None of the cases required intraoperative conversion to standard PCNL. Complications occurred in 19% (n = 73) of patients. The weighted mean transfusion rate reported across studies was 3.3% (range: 0%-10.3%). Conclusions: mPCNL is safe and effective in the pediatric population. Further randomized studies will help determine its formal role in pediatric endourology and help guideline recommendations accordingly.

Impact of the COVID-19 pandemic on the surgical activity of Pediatric Urology: analysis of postoperative complications according to the Clavien-Dindo classification

Introducción y objetivo

La coronavirus disease 2019 (COVID-19) ha ocasionado una pandemia de repercusión mundial que obligó a tomar medidas sociopolíticas, como la declaración del estado de alarma en España. Paralelamente se llevó a cabo la reestructuración de las actividades e infraestructuras médico-quirúrgicas pediátricas, con la consecuente suspensión de la actividad quirúrgica no urgente de Urología Pediátrica. Analizamos la repercusión de la pandemia COVID-19 sobre la actividad quirúrgica en una sección de Urología Pediátrica, así como las complicaciones quirúrgicas, según la clasificación de Clavien-Dindo.

Materiales y métodos

Se procedió a la revisión sistemática de los datos epidemiológicos, clínicos y quirúrgicos, incluyendo las complicaciones y reingresos de todos los pacientes intervenidos en la sección de Urología Pediátrica desde la declaración del estado de alarma hasta el levantamiento del mismo. Para su estudio se procedió a la división en cinco bloques temporales acorde a las fases de desescalada.

Resultados

Se realizaron 49 intervenciones quirúrgicas en 45 pacientes (ocho previos a la implantación de las fases de desescalada). La patología con prioridad alta fue la más frecuente en las primeras fases, siendo la estenosis de la unión pieloureteral (EPU) la más prevalente. Se registraron cuatro complicaciones (8,8%), ninguna de ellas de origen respiratorio.

Conclusiones

Las recomendaciones de la EAU para la reanudación de la actividad quirúrgica han permitido una correcta, segura y gradual transición al ritmo quirúrgico habitual en Urología Pediátrica. La clasificación de Clavien-Dindo es útil y válida para su aplicación en esta sección. No se han registrados complicaciones respiratorias que pudiesen ser atribuibles a la situación pandémica.

Benefits and barriers to pediatric tele-urology during the COVID-19 pandemic

INTRODUCTION

Telemedicine video visits are an under-utilized form of delivering health care. However due to the COVID-19 pandemic, practices are rapidly adapting telemedicine for patient care. We describe our experience in rapidly introducing video visits in a tertiary academic pediatric urology practice, serving primarily rural patients during the COVID-19 pandemic.

OBJECTIVE

The primary aim of this study was to assess visit success rate and identify barriers to completing video visits. The secondary aim identified types of pathologies feasible for video visits and travel time saved. We hypothesize socioeconomic status is a predictor of a successful visit.

MATERIALS AND METHODS

Data was prospectively collected and analyzed on video visits focusing on visit success, defined by satisfactory completion of the visit as assessed by the provider. Other variables collected included duration, video platform and technical problems. Retrospective data was collected via chart review and analyzed including demographics, insurance, and distance to care. Socioeconomic status was estimated using the Distressed Communities Index generated for patient zip code.

RESULTS/DISCUSSION

Out of 116 attempted visits, 81% were successful. The top two reasons for failure were "no-show" (64%) and inability to connect (14%). Success versus failure of visit was similar for patient age (p = 0.23), sex (p = 0.42), type of visit (initial vs. established) (p = 0.51), and socioeconomic status (p = 0.39). After adjusting for race, socioeconomic status, and type of provider, having public insurance remained a significant predictor of failure (p = 0.017). Successful visits were conducted on multiple common pediatric urologic problems (excluding visits requiring palpation on exam), and video was sufficient for physical exams in most cases (Summary Table). A median of 2.25 h of travel time was saved.

CONCLUSIONS

While socioeconomic status, estimated using the Distressed Communities Index, did not predict success of video visits, patients with public insurance were more likely to have a failed video visit. There is compelling evidence that effective video visits for certain pathologies can be rapidly achieved in a pediatric urology practice with minimal preparation time.

Impact of the COVID-19 pandemic on the surgical activity of Pediatric Urology: analysis of postoperative complications according to the Clavien-Dindo classification

Introduction and objective

The "Coronavirus Disease 2019" (COVID-19) has caused a pandemic of global impact that forced social-political measures to be taken, such as the declaration of the state of alarm in Spain. At the same time, the reorganization of the pediatric medical-surgical activities and infrastructures was carried out, with the consequent suspension of the non-urgent surgical activity of Pediatric Urology. We analyzed the impact of the COVID-19 pandemic on surgical activity in a Pediatric Urology division, as well as surgical complications according to the Clavien-Dindo classification.

Materials and methods

A systematic review of epidemiological, clinical and surgical data was carried out, including complications and readmissions of all patients operated on in the division of Pediatric Urology within the duration of the state of alarm. Five time periods have been created according to the de-escalation phases.

Results

Forty-nine surgical procedures were carried out on 45 patients (8 prior to the implementation of the de-escalation phases). High priority pathologies were the most frequent in the first phases, being the ureteropelvic junction (UPJ) obstruction the most prevalent. Four complications were recorded (8.8%), none of them were respiratory.

Conclusions

The EAU recommendations for the resumption of surgical activity have allowed a correct, safe and gradual transition to the routine surgical activity in Pediatric Urology. The Clavien-Dindo classification is useful and valid for application in this division. No respiratory complications have been reported that could be attributable to the pandemic situation.

Virtual consultations: delivering outpatient clinics in paediatric surgery during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has resulted in many changes to clinical practice, including the introduction of remote clinics. Those familiar with remote clinics have reported benefits to their use, such as patient satisfaction and cost benefits; however, ongoing challenges exist, including delivering optimal patient-centred care. As a tertiary paediatric surgery unit in the UK, completing remote clinics was a new experience for most of our surgical team. We completed a service evaluation early into the COVID-19 pandemic aiming to define and address issues when delivering remote clinics in paediatric surgery. Remote clinics were observed (telephone and video), with follow-up calls to families following the consultations.

RESULTS

Eight paediatric surgeons were observed during their remote clinics (telephone n = 6, video n = 2). Surgeons new to remote clinics felt their consultations took longer and were reluctant to discharge patients. The calls did not always occur at the appointed time, causing some upset by parents. Prescription provision and outpatient investigations led to some uncertainty within the surgical team. Families (n = 11) were called following their child's appointment to determine how our remote clinics could be optimised. The parents all liked remote clinics, either as an intermediate until a face-to-face consultation or for continued care if appropriate.Our findings, combined by discussions with relevant managers and departments, led to the introduction of recommendations for the surgical team. An information sheet was introduced for the families attending remote clinics, which encouraged them to take notes before and during their consultations.

CONCLUSIONS

There must be strong support from management and appropriate departments for successful integration of remote clinics. Surgical trainees and their training should be considered when implementing remote clinics. Our learning from the pandemic may support those considering integrating remote clinics in the future.

Impact of the COVID-19 pandemic on the surgical activity of Pediatric Urology: analysis of postoperative complications according to the Clavien-Dindo classification

INTRODUCTION AND OBJECTIVE

The coronavirus disease 2019 (COVID-19) has caused a pandemic of global impact that forced social-political measures to be taken, such as the declaration of the state of alarm in Spain. At the same time, the reorganization of the pediatric medical-surgical activities and infrastructures was carried out, with the consequent suspension of the non-urgent surgical activity of Pediatric Urology. We analyzed the impact of the COVID-19 pandemic on surgical activity in a Pediatric Urology division, as well as surgical complications according to the Clavien-Dindo classification.

MATERIALS AND METHODS

A systematic review of epidemiological, clinical and surgical data was carried out, including complications and readmissions of all patients operated on in the division of Pediatric Urology within the duration of the state of alarm. Five time periods have been created according to the de-escalation phases.

RESULTS

Forty-nine surgical procedures were carried out on 45 patients (8 prior to the implementation of the de-escalation phases). High priority pathologies were the most frequent in the first phases, being the ureteropelvic junction (UPJ) obstruction the most prevalent. Four complications were recorded (8.8%), none of them were respiratory.

CONCLUSIONS

The EAU recommendations for the resumption of surgical activity have allowed a correct, safe and gradual transition to the routine surgical activity in Pediatric Urology. The Clavien-Dindo classification is useful and valid for application in this division. No respiratory complications have been reported that could be attributable to the pandemic situation.

Pediatric surgery during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has had a major impact on pediatric surgery. The infection is often asymptomatic and atypical in children, while overlapping presentations with other infectious diseases generate additional diagnostic challenges. The high probability of missed pediatric cases and the invasive nature of surgery generate great concern for widespread transmission in this setting. Current guidelines suggest that triage of cases should be made on a case-by-case basis by a multidisciplinary team of experts. Decision-making can be assisted by classifying cases as elective, urgent, or an emergency according to the risks of delaying their surgical management. A workflow diagram should ideally guide the management of all cases from admission to discharge. When surgery is necessary, all staff should use appropriate personal protective equipment, and high-risk practices, such as aerosol-generating tools or procedures, should be avoided if possible. Furthermore, carefully designed organizational protocols should be established to minimize transmission while ensuring the uninterrupted operation of pediatric surgery units. For example, surgical teams can be divided into small weekly rotating groups, and healthcare workers should be continuously monitored for COVID-19 symptoms. Additionally, team protocols in the operating room can optimize communication and improve adherence to personal protective equipment use. Isolated operating rooms, pediatric intensive care units, and surgical wards should be specifically designed for suspected or confirmed COVID-19 cases. Finally, transportation of patients should be minimal and follow designated short routes. All these measures can help mitigate the effects of the COVID-19 pandemic on pediatric surgery units.

A Systematic Review on Guidelines and Recommendations for Urology Standard of Care During the COVID-19 Pandemic

CONTEXT

The first case of the new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), was identified in Wuhan, China, in late 2019. Since then, the coronavirus disease 2019 (COVID-19) outbreak was reclassified as a pandemic, and health systems around the world have faced an unprecedented challenge.

OBJECTIVE

To summarize guidelines and recommendations on the urology standard of care during the COVID-19 pandemic.

EVIDENCE ACQUISITION

Guidelines and recommendations published between November 2019 and April 17, 2020 were retrieved using MEDLINE, EMBASE, and CINAHL. This was supplemented by searching the web pages of international urology societies. Our inclusion criteria were guidelines, recommendations, or best practice statements by international urology organizations and reference centers about urological care in different phases of the COVID-19 pandemic. Our systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Of 366 titles identified, 15 guidelines met our criteria.

EVIDENCE SYNTHESIS

Of the 15 guidelines, 14 addressed emergency situations and 12 reported on assessment of elective uro-oncology procedures. There was consensus on postponing radical prostatectomy except for high-risk prostate cancer, and delaying treatment for low-grade bladder cancer, small renal masses up to T2, and stage I seminoma. According to nine guidelines that addressed endourology, obstructed or infected kidneys should be decompressed, whereas nonobstructing stones and stent removal should be rescheduled. Five guidelines/recommendations discussed laparoscopic and robotic surgery, while the remaining recommendations focused on outpatient procedures and consultations. All recommendations represented expert opinions, with three specifically endorsed by professional societies. Only the European Association of Urology guidelines provided evidence-based levels of evidence (mostly level 3 evidence).

CONCLUSIONS

To make informed decisions during the COVID-19 pandemic, there are multiple national and international guidelines and recommendations for urologists to prioritize the provision of care. Differences among the guidelines were minimal.

PATIENT SUMMARY

We performed a systematic review of published recommendations on urological practice during the coronavirus disease 2019 (COVID-19) pandemic, which provide guidance on prioritizing the timing for different types of urological care.

A survey and panel discussion of the effects of the COVID-19 pandemic on paediatric urological productivity, guideline adherence and provider stress

INTRODUCTION

The COVID-19 pandemic has led to an unprecedented need to re-organise and re-align priorities for all surgical specialties. Despite the current declining numbers globally, the direct effects of the pandemic on institutional practices and on personal stress and coping mechanisms remains unknown. The aims of this study were to assess the effect of the pandemic on daily scheduling and work balances, its effects on stress, and to determine compliance with guidelines and to assess whether quarantining has led to other areas of increased productivity.

METHODS

A trans-Atlantic convenience sample of paediatric urologists was created in which panellists (Zoom) discussed the direct effects of the COVID-19 pandemic on individual units, as well as creating a questionnaire using a mini-Delphi method to provide current semi-quantitative data regarding practice, and adherence levels to recently published risk stratification guidelines. They also filled out a Perceived Stress Scale (PSS) questionnaire to assess contemporary pandemic stress levels.

RESULTS

There was an 86% response rate from paediatric urologists. The majority of respondents reported near complete disruption to planned operations (70%), and trainee education (70%). They were also worried about the effects of altered home-lives on productivity (≤90%), as well as a lack of personal protective equipment (57%). The baseline stress rate was measured at a very high level (PSS) during the pandemic. Adherence to recent operative guidelines for urgent cases was 100%.

CONCLUSION

This study represents a panel discussion of a number of practical implications for paediatric urologists, and is one of the few papers to assess more pragmatic effects and combines opinions from both sides of the Atlantic. The impact of the pandemic has been very significant for paediatric urologists and includes a decrease in the number of patients seen and operated on, decreased salary, increased self-reported stress levels, substantially increased telemedicine usage, increased free time for various activities, and good compliance with guidelines and hospital management decisions.

The effect of the Covid-19 Pandemic on pediatric urology

Medical and surgical priorities have changed dramatically at the time of this pandemic. Scientific societies around the World have provided rapid guidance, underpinned by the best knowledge available, on the adaptation of their guidelines recommendations to the current situation. There are very limited scientific evidence especially in our subspecialty of pediatric urology. We carry out a review of the little scientific evidence based mainly on the few publications available to date and on the recommendations of the main scientific societies regarding which patients should undergo surgery, when surgery should be performed and how patient visits should be organize.

Hospital preparedness and management of pediatric population during COVID-19 outbreak

With the recent pandemic of Coronavirus disease-2019 (COVID-19), there has been a higher number of reported cases in children more than to the prior Corona Virus-related diseases, namely, severe acute respiratory syndrome and the Middle East respiratory syndrome. The rate of COVID-19 in children is lower than adults; however, due to high transmission rate, the number of reported cases in children has been increasing. With the rising numbers among children, it is imperative to develop preparedness plans for the pediatric population at the hospital level, departmental level, and patient care areas. This paper summarizes important considerations for pediatric hospital preparedness at the hospital level that includes workforce, equipment, supply; capacity planning, and infection prevention strategies, it also span over the management of COVID-19 pediatric patients in high-risk areas such as critical care areas, Emergency Department and operative rooms.