key: cord-0826000-fafqg4i3
authors: Paramore, Louise; Yang, Bob; Abdelmotagly, Yehia; Noureldin, Mohamed; McLean, Duncan; Rajkumar, Govindaraj; Adamson, Andrew; Emara, Amr; White, Christopher; Hindley, Richard; Nedas, Timothy
title: Delivering urgent urological surgery during the COVID‐19 pandemic in the United Kingdom: Outcomes from our initial 52 patients.
date: 2020-05-14
journal: BJU Int
DOI: 10.1111/bju.15110
sha: 3221d5a662ad8d97228b5a340252ca1854fe7629
doc_id: 826000
cord_uid: fafqg4i3

Since first reported in December 2019, the novel RNA betacoronavirus disease (COVID‐19) has spread rapidly across the world with, as of the 3rd May 2020, 3.3 million confirmed cases with more than 230,000 deaths worldwide and more than 200 countries affected. The most common symptoms reported include dry cough, fever and fatigue with ground‐glass opacification bilaterally in the lungs on imaging and lymphopenia on haematological analysis. In severe cases the patients can develop acute respiratory distress syndrome (ARDS) or multi organ failure which can lead to death. Transmission of the virus (SARS‐CoV‐2) is via direct contact or via droplets spread by a cough or sneeze from an infected individual. The difficulty in disease detection and containment has been the long course of COVID‐19. Current evidence shows an incubation period of up to 14 days post exposure to the virus, and on average most patients first display symptoms on day five after initial exposure. More importantly, carriers are contagious even during this preceding asymptomatic incubation phase of the disease.

cases with more than 230,000 deaths worldwide and more than 200 countries affected. 1 The most common symptoms reported include dry cough, fever and fatigue with ground-glass opacification bilaterally in the lungs on imaging and lymphopenia on haematological analysis. In severe cases the patients can develop acute respiratory distress syndrome (ARDS) or multi organ failure which can lead to death. 2 

CoV-2) is via direct contact or via droplets spread by a cough or sneeze from an infected individual. The difficulty in disease detection and containment has been the long course of COVID-19. Current evidence shows an incubation period of up to 14 days post exposure to the virus, and on average most patients first display symptoms on day five after initial exposure. More importantly, carriers are contagious even during this preceding asymptomatic incubation phase of the disease. 2, 4 In the United Kingdom (UK), a general lockdown was introduced on the 23rd March 2020 as the major public health measure to slow viral transmission. Even before then, hospitals in the National Health Service (NHS) had been preparing for a surge in demand by redeploying All patients had standard pre-COVID-19 pre-operative assessments with no COVID-19 swabs taken preceding surgery. In addition, a HHFT standardised screening consent form for COVID-19 symptoms were included as part of the pre assessment ( Figure 1 ) and patients were excluded if any symptoms were present.

A consecutive series of patients listed for operations during the first three weeks since the UK lockdown were identified for prospective follow up.

Standard operating procedures were followed as per the Public Health England (PHE) COVID-19 infection control policy. 6 During the operation, standard Personal Protective Equipment (PPE) for aerosol generating procedures were used by the anaesthetics team.

The theatre team used standard PPE for non-aerosol generating procedures.

During the postoperative period, all patients were recovered on designated "COVID-19

negative" surgical wards in multi-patient shared bays.

After 14 days, all patients were contacted via a telephone consultation to assess for any potential postoperative or COVID-19 complications.

A total of 52 consecutive patients underwent a urological operation between 23rd March and 9th April 2020. The average age was 66 (range 22 -89). 45 (86·5%) patients were male. SIx

This article is protected by copyright. All rights reserved 

This article is protected by copyright. All rights reserved However our cohort included five cases of laparoscopic radical nephrectomies which are counted as high risk major surgeries in urology. Furthermore, by the lockdown stage in the UK, the awareness of COVID-19 within the medical and general population had increased, with social distancing in the community already in place by this stage which may have decreased the incidence of infection within the community. In addition, PPE advice from PHE had already been implemented by this stage to prevent transmission both from patient to staff as well as the other way round. However as of the 3rd May 2020, there have been 2827 confirmed cases of COVID-19 in the Hampshire Upper Tier Local Authority area. 7 This is the third highest number of cases in England, with an estimated overall local population of around 1·3 million people. 8 Therefore the disease by the lockdown stage was likely already prevalent in the local community, and in particular the actual number of COVID-19 cases will be higher than the official confirmed cases as people with COVID-19 symptoms who did not require hospital admission will have neither been swabbed nor counted.

Cases were performed where possible as either a day-case or short inpatient admission in order to limit patient exposure to the clinical environment, with over 90% of cases discharged home within 48 hours. One patient stayed longer than 73 hours and had a 50 day length of stay. He was admitted with urosepsis following a collapse at home and has known advanced prostate cancer with bilateral stents in situ. An emergency stent change was performed on day 45 of admission due to bacterial colonisation and the patient was discharged on day five post-operatively after appropriate social care support was arranged.

There were two complications discovered in the postoperative period, both were of urinary tract infection symptoms post endoscopic procedure, which were treated in the community with a standard seven day course of oral antibiotics which fully resolved the symptoms. This is within the normal parameters expected post general endoscopic urological operations where the risk of infections are quoted as between 10 -50%.

Our study supports the continued delivery of appropriately triaged urgent urological surgery during the COVID-19 pandemic. A thorough assessment accounting for the risks and benefits for each case is necessary, and as the duration of the pandemic progresses, the ability to continue delivering urgent surgical care will greatly help mitigate the longer term impact on delaying treatment and meet the urgent needs of non-COVID-19 patients.

This article is protected by copyright. All rights reserved

LP and BY designed the study, collected and analysed the data. All authors participated in data collection. LP and BY drafted the manuscript. RH and TN revised the final manuscript. 

The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak

Epidemiological and initial clinical characteristics of patients with family aggregation of COVID-19

A Review of Coronavirus Disease-2019 (COVID-19)

Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection

COVID-19 personal protective equipment (PPE)

Coronavirus (COVID-19) cases in the UK -Data Dashboard