key: cord-0841902-dsx2kkzp authors: Boehm, Katharina; Thomas, Anita; Bex, Axel; Black, Peter C.; Coburn, Michael; Haferkamp, Axel; Hamdy, Freddie; Kaufman, Ronald P.; Klotz, Laurence; Lerner, Seth P.; Pushkar, Dmitry; Ramon, Jacob; Rosenzweig, Barak; Tsaur, Igor title: Outreach and influence of surgical societies` recommendations on minimally invasive surgery during the COVID-19 pandemic – an anonymized international urologic expert inquiry date: 2020-08-08 journal: Urology DOI: 10.1016/j.urology.2020.07.043 sha: cb281fbe01f8aa2fc1ec56acb0e9e9faba0d4d89 doc_id: 841902 cord_uid: dsx2kkzp OBJECTIVE: To assess the outreach and influence of the main recommendations of surgical governing bodies on adaptation of minimally invasive laparoscopic surgery (MIS) procedures during the COVID-19 pandemic in an anonymized multi-institutional survey. MATERIALS AND METHODS: International experts performing MIS were selected on the basis of the contact database of the speakers of the Friends of Israel Urology Symposium. A 24-item questionnaire was built using main recommendations of surgical societies. Total cases/1 Mio residents as well as absolute number of total cases were utilized as surrogates for the national disease burden. Statistics and plots were performed using RStudio v0.98.953. RESULTS: 62 complete questionnaires from individual centers performing MIS were received. The study demonstrated that most centers were aware of and adapted their MIS management to the COVID-19 pandemic in accordance to surgical bodies` recommendations. Hospitals from the countries with a high disease burden put these adoptions more often into practice than the others particularly regarding swabs as well as CO2 insufflation and specimen extraction procedures. 12 respondents reported on presumed SARS-CoV-2 transmission during MIS generating hypothesis for further research. CONCLUSIONS: Guidelines of surgical governing bodies on adaptation of MIS during the COVID-19 pandemic demonstrate significant outreach and implementation, whereas centers from the countries with a high disease burden are more often poised to modify their practice. Rapid publication and distribution of such recommendation is crucial during future epidemic threats. The World Health Organization (WHO) has recently declared the outbreak of coronavirus disease 2019 caused by the newly discovered severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) a pandemic, with more than 4 million infected individuals and more than 295,000 deaths to date 1 . Meanwhile, the risk of infection for healthcare professionals (HCP) rapidly grows in many countries. Tragically, in the United States more than 9,200 HCP have been infected with COVID-19 and at least 27 have died as of April 9 2 . Currently, a challenging task for national healthcare systems is to provide maximal protection of HCP on the one hand and secure necessary medical services for non-COVID-19 patients on the other. In this context, dissemination and implementation of evidence-based recommendations for a rapid reaction of health care systems to this emergency is ultimately warranted. Possible transmission of SARS-CoV-2 during minimally invasive conventional and/or robotassisted laparoscopic surgery (MIS) is a matter of current expert debate. Evidence has been presented that SARS-CoV-2 RNA is detectable in the blood, urine, stool and gastrointestinal mucosa of infected patients raising the question whether active virus particles can be released and transmitted during laparoscopic urologic surgery on urinary tract and bowel segments [3] [4] [5] . In addition, CO2 insufflation together with cautery may foster aerosolization of the virus during MIS 4, 6 . Subsequently, it is assumed that exchange of instruments or venting of trocars may further facilitate viral transmission due to sudden bursts of CO2 and surgical smoke. However, there is no immediate evidence for transmissibility of respiratory viruses from the gastrointestinal tract and/or by the CO2-related abdominal route. The aforementioned concerns about MIS and associated risk of viral transmission to HCP led to safety recommendations published by a number of major surgical societies such as the ERUS (EAU Robotic Urology Section), SAGES (Society of American Gastrointestinal and Endoscopic Surgeons), Royal College of Surgeons (RCS) and most recently SRS (Society of Robotic Surgery) 4, 7-9 . For instance, ERUS Guidelines offer recommendations for general health and COVID-19 screening prior to surgery, necessary protective measures such as wearing goggles and FFP2/3 masks and utilizing intelligent integrated flow systems to reduce intraabdominal pressure (8-10 mmHg), thus preventing aerosol dispersal 8 . Furthermore, a critical review of indications is considered in order to reduce HCP in the operating room (OR). As such, interventions with urgent indications should be performed during the pandemic and those with limited risk should be postponed 8 . In addition, it was recommended that MIS be performed by experienced surgeons in order to reduce complications and operative time. Alterations in the existing policies around MIS cause considerable burden on surgical facilities requiring profound restructuring steps in order to adapt to the COVID-19 pandemic. Thus, the aim of this study was to shed light on the outreach and implementation of the main recommendations for MIS by international senior urologic-oncology surgeons during the current COVID-19 crisis. We built a 24-item questionnaire based on the recommendations of ERUS, SAGES and RCS concerning the management of MIS during the COVID-19 pandemic. Speakers of the international Friends of Israel Urology (FOI) Symposium were invited to participate 10 . Only one member of any given hospital was contacted in order to exclude repetition of the same data. The contact took place via email containing the link to the questionnaire. (Table S1 ), patient related management (e.g. swabs, surgery on COVID 19 positive patients, surgery on patients suspicious of being COVID-19 carrier), management in the OR (e.g. CO2 insufflation, specimen extraction, electrocautery), and staff-related management (e.g. reduction of staff in the OR, use of FFP2 masks and protective goggles). To better depict different risk-adapted strategies among geographical areas, survey results were stratified according to countries with low/intermediate versus high risk COVID19 case burden (Table 1) . Descriptive statistic and plots were performed using RStudio v0.98.953 (R Project for Statistical Computing, www.R-project.org). Overall, 80 physicians answered our questionnaire. Of these 16 do not perform MIS and 2 did not answer the entire questionnaire, allowing for 62 complete questionnaires. Most participants are members of the AUA (25%), EAU (28.7%) or both (37.5%) and employed in an academic hospital (82.5%) (Table S1 ). Additionally, most work in Europe (51.6%) and North America (37.1%), followed by Asia (6.5%), Australia (3.2%) and South America (1.6%). Daily practice has been changed by 90.3% of the respondents during the pandemic, with a nonsignificant difference between countries with low/intermediate case load versus high case load (85.4 vs 100%, p=0.1). Three participants did not find the proposed modification helpful. The stated reasons were 1x time exposure, 1x associated expenditures and 2x others. Most participants have heard about the recommendations of the EAU and SAGES on MIS (90.3%). In countries with a high case load significantly more swabs were taken from patients preoperatively (p=0.004; Figure 2A) Virtually the same results were reported when stratifying according to total deaths per million inhabitants (data not shown). The COVID-19 pandemic represents a social challenge like none other than we have experienced since World War 2, inflicting long-term consequences on many areas of human life. Since HCP are at the forefront of the combat against this dangerous disease with multiple potential opportunities for exposure from infected patients each day, health protection measures for HCP are of utmost importance in managing the pandemic 11 . Even if the risk of COVID-19 transmission in the primary care setting was recently estimated to be low for HCP, 12 it might significantly increase for OR staff particularly in close proximity to the patient 13 . These concerns have led to a number of safety measures being recommended by surgical societies to prevent infection with SARS-CoV-2 in the OR 13 . Notably, most of these recommendations are based on a very low level of evidence and have been predominantly extrapolated from the findings derived from other epidemics. Reliable risk quantification is not possible 4, 13 . The main concern related to MIS is that besides anesthesiologic personnel exposed to respiratory tract aerosol during anesthetic procedures, surgeons and nurses may also be endangered by exposure to CO2 deflation mixed with surgical plume potentially transferring infectious aerosolized SARS-CoV-2 particles released by electrocautery, laser surgery or ultrasonic devices 4, 14 . However, there is not yet any data that demonstrates that CO2 aerosol can transport virions or induce an active infection with SARS-CoV-2. A contemporary review yielded no convincing data that surgical smoke emerging from the treatment of human papillomavirus (HPV)related lesions results in a higher incidence of HPV-related diseases in OR staff even though the HPV DNA could contaminate their upper airways 15 . Of note, HPV virion size is similar to that of SARS-CoV-2 (55 vs. 60-140 nm) 16, 17 . In concert with this data, hepatitis B virus was detectable in surgical smoke during laparoscopic surgery, but no solid evidence exists that this can cause airborne infections 18 . In addition, active virus particles have never been isolated from the blood or urine of SARS-CoV-2 infected patients 19 . Interestingly, a recent case report showed no infection of a patient with severe aplastic anemia who received apheresis platelet transfusion from a donor subsequently diagnosed with COVID-19 20 . Nonetheless, given a still limited experience with this dangerous condition, safety measures including patient testing, personal protection equipment for HCP, adaptation of surgical technique (filters, precautions during the exsufflation of the pneumoperitoneum, instrument use or change) and organization of the operating room are essential 21 . In our study, practical management of MIS during the COVID-19 pandemic was investigated based on the data of respondents from 64 centers on 5 continents performing minimally invasive conventional and/or robot-assisted laparoscopic procedures. Given that 98.4% of participants were members of the two biggest international urologic associations and 91.2% of their national urologic associations, it can be assumed with a high degree of certainty that they were sufficiently supplied with the COVID-19 related information relevant for urologic practice. In addition, professional activity of 90.6% of the responding physicians at an academic hospital supports their up-to-date knowledge of the local COVID-19 related epidemiologic situation and respective health care measures. Importantly, 90.3% of the responding participants modified their MIS handling during the pandemic. This practice change was undertaken independently of the national disease burden emphasizing a high concern of the centers about health protection of their OR staff. Alarmingly, Tan and colleagues reported that SARS-CoV-2 nucleocapsid protein was detected in gastrointestinal epithelial cells and infectious virus particles were isolated from faeces, thus making them potentially infectious 23 . Notably, 71% of the centers utilize CO2 insufflation with a closed system and appropriate filtering of aerosolized particles as well as turning CO2 insufflation off and venting the gas through a filter prior to specimen extraction. Once again, significantly more hospitals adopted these steps in the countries with a high disease burden during the COVID-19 pandemic. On the contrary, only every fifth center lowered cautery during MIS in response to the outbreak. insufflation with a closed system with filtering of aerosolized particles?" stratified by COVID19 disease burden. C Distribution of respondent answers to the question "Are you turning CO2 insufflation off and venting the gas through a filter before specimen extraction?" stratified by COVID19 disease burden. Coronavirus disease (COVID-19) Pandemic n Characteristics of Health Care Personnel with COVID-19 -United States Evidence for Gastrointestinal Infection of SARS-CoV-2 Society of Robotic Surgery Review: Recommendations Regarding the Risk of COVID-19 Transmission During Minimally Invasive Surgery SARS-CoV-2 can be detected in urine, blood, anal swabs, and oropharyngeal swabs specimens What Is the Appropriate Use of Laparoscopy over Open Procedures in the Current COVID-19 Climate? Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic Urology Section (ERUS) guidelines during COVID-19 emergency 2020 Royal College of Surgeons. Intercollegiate General Surgery Guidance on COVID-19 Update 2020 Aafhwraucj-g-f-s-v COVID-19: protecting health-care workers Transmission risk of SARS-CoV-2 to healthcare workers -observational results of a primary care hospital contact tracing Safe management of surgical smoke in the age of COVID-19 COVID-19 and laparoscopic surgery, a scoping review of current literature and local expertise. JMIR Public Health Surveill. 2020. 15. Fox-Lewis A, Allum C, Vokes D, Roberts S. Human papillomavirus and surgical smoke: a systematic review Electrostatic Charged Nanofiber Filter for Filtering Airborne Novel Coronavirus (COVID-19) and Nano-aerosols Papillomavirus genome structure, expression, and post-transcriptional regulation Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery Virological assessment of hospitalized patients with COVID-2019 COVID-19 transmission and blood transfusion: A case report Risks of viral contamination in healthcare professionals during laparoscopy in the Covid-19 pandemic Enteric involvement of coronaviruses: is faecal-oral transmission of SARS-CoV-2 possible? Review article: gastrointestinal features in COVID-19 and the possibility of faecal transmission MIS= minimal invasive procedure EAU= European association of urology; SAGES= Society of American Gastrointestinal and Endoscopic Surgeons We thank all the participants of the survey.