Guess Who's Coming to Dinner: COVID-19 in a COVID-free Unit

Analysis of patient outcomes after urological surgery during the second and third waves of SARS-CoV-2 pandemic in a high incidence area

OBJECTIVE

To analyze surgical safety through postoperative COVID-19 incidence and mortality at the urology department of a tertiary hospital located in Madrid (Spain).

METHODS

Observational, prospective study including all patients undergoing urological surgery from 1st March 2020 to 28th February 2021. According to the hospital organization and local epidemiological situation we delimitate three epidemic waves. A set of screening and protective measures was applied from 4th May onwards. Demographic, baseline, surgical and perioperative variables, as well as postoperative outcomes, were collected. Telephone follow-up was performed at least 3 weeks after hospital discharge.

RESULTS

940 urological surgeries were performed, 12 of them had to be rescheduled due to active or recent SARS-CoV-2 infection identified by the screening protocol. Thirty-one patients developed COVID-19 (3.3% incidence) and 7 died (22.6% mortality). The average time to onset of symptoms was 62.6 days after discharge, being 25 cases attributable to community transmission. The remaining 6 cases, due to in-hospital transmission, had worse outcomes. Five of them were identified during the first wave, especially when no preoperative PCR was obtained. In contrast, during the second and third waves, fewer and milder cases were diagnosed, with just 1 in-hospital transmission among 857 urological patients.

CONCLUSIONS

After implementing complete protective measures, postoperative in-hospital COVID-19 cases almost disappeared, even during the second and third waves. Most of the cases were due to community transmission and thus driven by the general epidemiological situation. While hospitals follow recommendations to avoid COVID-19 infection, urological surgery remains safe and can be maintained.

Phytotherapy for male luts: What happens then? 10-year research

INTRODUCTION AND OBJECTIVES

Our objective is to assess the long-term results of phytotherapy, focusing on the interval between phytotherapy and pharmacological treatment and the predisposing risk factors to such switch on a 10-year follow-up.

MATERIAL AND METHODS

The data of patients taking phytotherapy for mild to moderate male lower urinary tract symptoms (LUTS) from January to December 2010 were retrospectively reviewed from a prospectively maintained database. Patients were followed for 10 years through medical visits and telephone consultations.

RESULTS

102 patients underwent at least one cycle of phytotherapy for LUTS. Twenty (19.6%) patients resolved their symptoms after one phytotherapy cycle and stopped any treatment, 27 (26.4%) continued phytotherapy, and 52 (51%) switched to alpha-blockers and/or 5a-reductase inhibitors after a median interval of 24 months. The reasons for treatment switch were symptoms (n = 45) or clinical progression (increased residual volume n = 15; urinary retention, n = 5). Patients switching to synthetic drugs had median higher age (60 vs 49), prostate volume (40 vs 26 cc), prostate specific antigen (PSA) (1.9 vs 0.9 ng/ml), residual volume (40 vs 0 cc), and a lower maximum flow rate (Qmax) (12 vs 15 ml/s) at presentation.

CONCLUSIONS

46% patients with mild to moderate LUTS undergoing phytotherapy will be either free of treatment or still on phytotherapy at 10 years from disease presentation. Older patients with larger prostates, increased residual volume and PSA, should be informed regarding their higher risk of symptomatic or clinical progression: the risk of a treatment switch to alpha-blockers or 5a-reductase inhibitors becomes an actual fact after an average span of 2 years.

A Novel Nomogram Based on Initial Features to Predict BPH Progression

Objectives: The aim of this study was to establish a tool to identify patients at risk for pharmaceutical and surgical interventions for benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTS) over a 10 year follow-up. Methods: The data of patients with mild to moderate male LUTS undergoing phytotherapy from January to December 2010 were reviewed. Patients were followed for 10 years through medical visits and telephone consultations. The outcomes were (1) treatment switch from phytotherapy or no therapy to alpha-blockers or 5α-reductase inhibitors (5-ARI), and (2) clinical progression (acute urinary retention or need for surgery). Two calibrated nomograms (one for each outcome) were constructed on significant predictors at multivariate analysis. Results: A total of 107 patients with a median age of 55 years at presentation were included; 47% stopped or continued phytotherapy, while 53% switched to alpha-blockers and/or 5-ARI after a median time of 24 months. One-third in the second group experienced clinical progression after a median time of 54 months. Age, symptom score, peak flow rate (Qmax), prostate-specific antigen (PSA), and post-void residual volume were significantly associated with the outcomes. According to our nomograms, patients switching therapy or progressing clinically had average scores of 75% and 40% in the dedicated nomograms, respectively, as compared to 25% and <5% in patients who did not reach any outcome. Conclusions: We developed a nomogram to predict the risk of pharmaceutical or surgical interventions for BPH-related LUTS at 10 years from presentation. On the basis of our models, thresholds of >75% and >40% for high risk and <25% and <5% for low risk of pharmaceutical or surgical interventions, respectively, can be proposed.

The Impact of the SARS-CoV-2 Pandemic on Healthcare Provision in Italy to non-COVID Patients: a Systematic Review

BACKGROUND

Italy has been one of the countries most affected by the SARS-CoV-2 pandemic, and the regional healthcare system has had to quickly adapt its organization to meet the needs of infected patients. This has led to a drastic change in the routine management of non-communicable diseases with a potential long-term impact on patient health care. Therefore, we investigated the management of non-COVID-19 patients across all medical specialities in Italy.

METHODS

A PRISMA guideline-based systematic review of the literature was performed using PubMed, Embase, and Scopus, restricting the search to the main outbreak period in Italy (from February 20 to June 25 2020). We selected articles in English or Italian that detailed changes in the Italian hospital care for non-COVID-19 patients due to the pandemic. Our keywords included all medical specialities combined with our geographical focus (Italy) and COVID-19.

RESULTS

Of the 4643 potentially eligible studies identified by the search, 247 were included. A decrease in the management of emergencies in non-COVID patients was found together with an increase in mortality. Similarly, non-deferrable conditions met a tendency toward decreased diagnosis. All specialities have been affected by the re-organization of healthcare provision in the hub-and-spoke system and have benefited from telemedicine.

CONCLUSIONS

Our work highlights the changes in the Italian public healthcare system to tackle the developing health crisis due to the COVID-19 pandemic. The findings of our review may be useful to analyse future directions for the healthcare system in the case of new pandemic scenarios.

Scoping review: hotspots for COVID-19 urological research: what is being published and from where?

PURPOSE

Contemporary, original research should be utilised to inform guidelines in urology relating to the COVID-19 pandemic. This comprehensive review aimed to: identify all up-to-date original publications relating to urology and COVID-19, characterise where publications were from, and outline what topics were investigated.

METHODS

This review utilised a search strategy that assessed five electronic databases, additional grey literature, and global trial registries. All current published, in-press, and pre-print manuscripts were included. Eligible studies were required to be original research articles of any study design, reporting on COVID-19 or urology, in any of study population, intervention, comparison, or outcomes. Included studies were reported in a narrative synthesis format. Data were summarised according to primary reported outcome topic. A world heatmap was generated to represent where included studies originated from.

RESULTS

Of the 6617 search results, 48 studies met final inclusion criteria, including 8 pre-prints and 7 ongoing studies from online registries. These studies originated from ten countries according to first author affiliation. Most studies originated from China (n = 13), followed by Italy (n = 12) and USA (n = 11). Topics of the study included pathophysiological, administrative, and clinical fields: translational (n = 14), COVID-19-related outcomes (n = 5), urology training (n = 4), telemedicine (n = 7), equipment and safety (n = 2), urology in general (n = 4), uro-oncology (n = 3), urolithiasis (n = 1), and kidney transplantation (n = 8).

CONCLUSION

This review has outlined available original research relevant to COVID-19 and urology from the international community. This summary may serve as a guide for future research priorities in this area.

An Italian multicenter analysis of emergency admissions and treatment of upper tract urolithiasis during the lockdown and reopening phases of the COVID-19 pandemic: Are we ready for a second wave of the outbreak?

OBJECTIVES

To assess if the lockdown period (March-April 2020) during the coronavirus disease-19 outbreak in Italy influenced the number, presentation, and treatment of urgent admissions to the emergency department for ureteral lithiasis, and to evaluate the same variables during the reopening phase (May-June 2020).

METHODS

We performed a retrospective analysis of patients admitted to the emergency department of three different hospitals (two coronavirus disease-19 hubs). Demographics and data on acute pyelonephritis, acute kidney injury, urinoma, hematuria, inpatient admission/discharge home, and type of treatment were gathered and compared with the same periods in 2019.

RESULTS

A total of 516 patients were admitted during the study period, of whom 62.4% were male. Their mean age was 58.86 ± 16.24 years. The number of admissions decreased significantly, by 51.25% (P = 0.003), during lockdown compared to 2019 (78 vs 160 admissions). The number of admissions in the reopening phase (May-June 2020) was in line with that in 2019 (n = 138). The number of hospitalizations (P = 0.005), acute obstructive pyelonephritis (P = 0.019), and complications (P = 0.02) was statistically significantly higher during lockdown compared to 2019. The increase in the rate of surgical procedures nearly reached significance (P = 0.059). The odds of having complications and being hospitalized were almost fivefold (odds ratio 4.68, 95% confidence interval 1.98-11.07) and twofold greater (odds ratio 2.39, 95% confidence interval 1.29-4.43) compared to the same period in 2019. No difference was noted between May-June 2020 and 2019.

CONCLUSION

The coronavirus disease-19 lockdown period provoked a meaningful reduction in symptomatic ureteral lithiasis admission. Most patients presented with complicated disease, which required an increased rate of interventional procedures compared to the equivalent period in 2019. Admissions reverted to normal levels during the reopening phase.

Rallying All Resources: A Multidisciplinary Innovation to Plan for the Projected COVID-19 Inpatient Surge

BACKGROUND

The COVID-19 pandemic resulted in the need for hospitals to plan for a potential "surge" of COVID-19 patients.

PROBLEM

Prior to the onset of the COVID-19 pandemic, our hospital adult acute care capacity ranged 90% to 100%, and a potential hospital surge was projected for Oregon that would exceed existing capacity.

APPROACH

A multidisciplinary team with stakeholders from nursing leadership, nursing units, nurse-led case management, and physicians from hospital medicine was convened to explore the conversion of an ambulatory surgical center to overflow patient acute care capacity.

OUTCOMES

A protocol was rapidly created and implemented, ultimately transferring 12 patients to an ambulatory surgery unit.

CONCLUSIONS

This project highlighted the ability for stakeholders and innovators to work together in an interprofessional, multidisciplinary way to rapidly create an overflow unit. While this innovation was designed to address COVID-19, the lessons learned can be applied to any other emerging infectious disease or acute care capacity crisis.

Decision making and treatment options in endourology post-coronavirus disease 2019 - adapting to the future

PURPOSE OF REVIEW

To describe and critically discuss the most recent evidence regarding stone management during the coronavirus disease 2019 (COVID-19) and post-COVID-19 era.

RECENT FINDINGS

There is a need to plan for resuming the normal elective stone surgery in the post-COVID era, keeping a clear record of all surgeries that are being deferred and identifying subgroups of surgical priorities, for the de-escalation phase. Telehealth is very useful because it contributes to reduce virus dissemination guaranteeing at the same time an adequate response to patients' care needs. Once the pandemic is over, teleurology will continue to be utilized to offer cost-effective care to urological patients and it will be totally integrated in our clinical practice.

SUMMARY

This COVID-19 pandemic represents a real challenge for all national health providers: on the one hand, every effort should be made to assist COVID patients, while on the other hand we must remember that all other diseases have not disappeared in the meanwhile and they will urgently need to be treated as soon as the pandemic is more under control. A correct prioritization of cases when surgical activity will progressively return back to normality is of paramount importance.

Deferring Elective Urologic Surgery During the COVID-19 Pandemic: The Patients' Perspective

OBJECTIVES

To explore the perspective of urological patients on the possibility to defer elective surgery due to the fear of contracting COVID-19.

METHODS

All patients scheduled for elective urological procedures for malignant or benign diseases at 2 high-volume centers were administered a questionnaire, through structured telephone interviews, between April 24 and 27, 2020. The questionnaire included 3 questions: (1) In light of the COVID-19 pandemic, would you defer the planned surgical intervention? (2) If yes, when would you be willing to undergo surgery? (3) What do you consider potentially more harmful for your health: the risk of contracting COVID-19 during hospitalization or the potential consequences of delaying surgical treatment?

RESULTS

Overall, 332 patients were included (51.5% and 48.5% in the oncology and benign groups, respectively). Of these, 47.9% patients would have deferred the planned intervention (33.3% vs 63.4%; P < .001), while the proportion of patients who would have preferred to delay surgery for more than 6 months was comparable between the groups (87% vs 80%). These answers were influenced by patient age and American Society of Anesthesiologists score (in the Oncology group) and by the underlying urological condition (in the benign group). Finally, 182 (54.8%) patients considered the risk of COVID-19 potentially more harmful than the risk of delaying surgery (37% vs 73%; P < .001). This answer was driven by patient age and the underlying disease in both groups.

CONCLUSIONS

Our findings reinforce the importance of shared decision-making before urological surgery, leveraging patients' values and expectations to refine the paradigm of evidence-based medicine during the COVID-19 pandemic and beyond.

Risk Assessment and Prevention of Severe Acute Respiratory Syndrome Coronavirus 2 Transmission for Hospitalized Urological Patients After the COVID-19 Pandemic in Wuhan, China

Background

Emerging asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections were detected and multiple cases were found to be SARS-CoV-2 positive again, which raised an alarm for the patients hospitalized after the coronavirus disease 2019 (COVID-19) pandemic.

Objective

We investigated the risk and prevention of hospital transmission of SARS-CoV-2 to hospitalized urological patients.

Design, setting, and participants

This is a retrospective study of 319 hospitalized urological patients enrolled between April 20, 2020 and May 11, 2020 from two tertiary hospitals in Wuhan, China.

Intervention

Chest computed tomography (CT) images, nucleic acid tests (NATs), and serum antibody were examined at the outpatient department and 1 wk after admission for all patients.

Outcome measurements and statistical analysis

The chest CT images, NATs, serum antibody results, and clinical data were collected and analyzed.

Results and limitations

None of the 319 patients was found to be SARS-CoV-2 NAT positive. Ten and four patients were detected to be immunoglobulin (Ig)G and IgM positive, respectively. The chest CT features of 116 patients showed abnormal lung findings. During the 1-wk isolation, one patient initially being IgG positive only was found to be IgM positive, and another initially IgM-positive patient had a rising IgG level. Through risk assessment, we identified seven patients with very high and high risk for hospital transmission, and delayed the surgery while maintaining close follow-up. Five intermediate-risk patients were operated on successfully under paravertebral block or epidural anesthesia to avoid opening the airway with endotracheal intubation. The remaining 104 low-risk and 203 normal patients underwent normal surgery.

Conclusions

Of the 319 patients, seven were identified as very high and high risk, which reinforced the importance of epidemic surveillance of discharged COVID-19 patients and asymptomatic infections. Five intermediate-risk patients were operated on successfully under regional anesthesia.

Patient summary

Our experience of risk assessment and management practice may provide a strategy to prevent severe acute respiratory syndrome coronavirus 2 transmission to hospitalized urological patients after the coronavirus disease 2019 (COVID-19) pandemic.