key: cord-0689226-0l1vdjnj
authors: Merino-Mateo, L.; Tordable Ojeda, C.; Cabezalí Barbancho, D.; Gómez Fraile, A.
title: Impact of the COVID-19 pandemic on the surgical activity of Pediatric Urology: analysis of postoperative complications according to the Clavien-Dindo classification
date: 2020-11-20
journal: nan
DOI: 10.1016/j.acuroe.2020.11.005
sha: bbe3aa90692a5fa762961955777de8fad1b620bf
doc_id: 689226
cord_uid: 0l1vdjnj

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.

ARTÍCULO ORIGINAL Repercusión de la pandemia COVID-19 sobre la actividad quirúrgica de Urología Pediátrica: análisis de las complicaciones posquirúrgicas según la clasificación de Clavien-Dindo Impact 

Introducción y objetivo El "Coronavirus Disease 2019" (COVID-19) ha ocasionado una pandemia de repercusión mundial que obligó a tomar medidas social-políticas como la declaración del estado de alarma en España. Paralelamente se llevo a cabo la restructuración de las actividades e infraestructuras medico-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 (8 previos a la implantación de las fases de desescalada). La patología con prioridad alta fue la más Introduction J o u r n a l P r e -p r o o f Since December 2019, the outbreak of infectious pneumonia known as coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, has spread, causing a pandemic with global repercussions 1 . In Spain, which is among European worst affected countries by COVID-19 2 , the diagnosed cases increased over five hundred confirmed cases 3 , causing the declaration of a state of alarm for the management of the health crisis situation (Royal Decree 463/2020 of March 14th.). The affected population included children, who presented less severe clinical pictures, with the most frequent symptoms being fever, cough and rhinorrhea, in the context of upper respiratory infections and pneumonia 3, 4 .

In parallel to the socio-political measures taken with the declaration of the state of alarm, the need to dedicate economic and healthcare resources to adult COVID-19 patients, who were more affected by this pathology than pediatric patients, led to the restructuring of medical-related activities and pediatric surgical procedures, suspending Pediatric Urology non-urgent or elective surgical activity 5 . In this scenario, the European Association of Urology (EAU) and the European Society of Pediatric Urology The objective of this study was to analyze the impact of the COVID-19 pandemic on the surgical activity of the Pediatric Urology section in a Spanish tertiary hospital since the declaration of the state of alarm, by evaluating the pathologies treated and the prioritization criteria. In the same way, the aim is to study the surgical complications recorded in these patients based on the Clavien-Dindo classification.

We conducted a retrospective observational study recording the surgical activity Table 2 Table 2 . No patients were excluded for being SARS-CoV-2 positive on PCR, despite the fact that five were considered as such, and the appropriate personal safety measures were taken, given the urgency of surgical intervention (testicular torsion).

A larger percentage of high priority surgical interventions was seen across the first three phases of de-escalation analyzed (pre-de-escalation, phase 0 and phase 0.5), which J o u r n a l P r e -p r o o f decreased gradually. Conversely, the rate of low priority interventions increased as the de-escalation phases progressed. The phases with the highest proportion of urgent interventions were 1 and 2, with three urgent interventions in each of them (Table 3,   Table 3 , and Figure 2 , Figure 2 ).

The pathology requiring surgical treatment with more frequency during the time period (Table 4 Table 4 ). When analyzing the priority of the pathologies requiring surgical intervention, and taking into account that we have followed the EAU recommendations regarding delay of pathologies based on the potential clinical harm that it would entail in the patient, it is not surprising that the period with a larger percentage of high priority procedures was the first one, or the pre-de-escalation phase. There are certain surgical interventions of lower priority that stand out in earlier phases; this can be due to the fact that these procedures had shorter operative time and could be incorporated to the daily surgical activity, prioritizing waiting times for inclusion on the waiting list.

It also interesting that pathologies with high priority (emergency), although without analyzing its statistical significance, were more prevalent in later stages. In this sense, we wanted to highlight the adverse outcome suffered by two thirds of the patients who underwent orchiectomy due to poor appearance of the affected testicle. This is consistent with previous studies that describe more advanced clinical conditions in pediatric patients, probably related to delayed consultation due to fear of COVID-19 10 infection. The importance of prompt visits to ER departments in case of diseases of high prevalence and clinical repercussions, such as testicular torsion, should be highlighted, and social awareness in this regard must be increased.

After analyzing the complications, the results show a rate of 8.8%, but no type III or IV complications were registered. These would include those conditions that require surgical intervention or admission to the ICU and, therefore, could be considered as major or very serious complications. Complications of respiratory origin have not been J o u r n a l P r e -p r o o f described in our patients; but there were complications of an infectious origin that affected only the urinary tract, with no apparent relationship with the pandemic.

The COVID-19 infection has implied changes in the pediatric surgical activity in many aspects, having had to adapt the physical, human and material resources to the emergency situation. In Pediatric Urology, the recommendations of the EAU/ESPU for the readjustment of surgical activity have allowed a correct and gradual transition to recovering the department's usual pace.

The Clavien-Dindo classification of surgical complications is useful and valid for application in Pediatric Urology. No respiratory complications, whether infectious or not, have been described in the pediatric population treated during the period of study, without this necessarily showing a null rate of infection.

The authors declare that they have no conflicts of interest. Figura 1 Distribución de los pacientes en función de los subgrupos de fase de desescalada a la que fueron asignados. Dos pacientes fueron reintervenidos para retirada de catéter doble J, siendo excluidos del análisis comparativo. gr1 = Figure 1 Distribution of patients according to the subgroups of the de-escalation phase to which they were assigned. Two patients underwent reoperation for removal of the double J catheter and were excluded from the comparative analysis. gr1 If the patient suffers from a complication at the time of discharge, the suffix "d" (for "disability") is added to the respective grade of complication. This label indicates the need for a follow-up to fully evaluate the complication. Table 3 Descriptive analysis of the sample in relation to each subgroup of the deescalation phase. Data are described as absolute frequencies and percentage, respectively. Pre (n = 8)

Phase 0 (n = 5) 

COVID-19 and urology: a comprehensive review of the literature

From the editors: The COVID-19 crisis and its implications for pediatric surgeons

Actualización de la situación epidemiológica de la infección por SARS-CoV-2 en España. Comentarios a las recomendaciones de manejo de la infección en pediatría

SARS-CoV-2 infection in ambulatory and hospitalised Spanish children

Paediatric urology practice during COVID-19 pandemic

Clinical and surgical consequences of the COVID-19 pandemic for patients with pediatric urological problems

El impacto del COVID-19 en la epoca de transición o "desescalada" en la urología pediátrica [ Impact of COVID-19 during de-escalation in pediatric urology

Classification of Surgical Complications : a new proposal with evaluation in a cohort of 6336 patients and results of a survey

Influencia de la pandemia por coronavirus 2 (SARS-Cov-2) en la apendicitis aguda

Additional material to this article can be consulted in the electronic version available at doi: 10.1016 / j.acuro.2020.09.003.

J o u r n a l P r e -p r o o f