Introduction
The WHO declared COVID‐19 as a pandemic on 11th of March 2020. Since then, COVID-19 pandemic has obliged urologists to conform to the guidelines that appear on a daily basis formulated by multidisciplinary surgical groups to manage urological emergencies. Consequently, in this time of health crisis, Urologists have to adapt to the resources available, implementing all biosecurity measures to protect patients and all health personnel who are in charge of patient management.
So far the COVID-19 is the biggest global health threat. There have been major changes of priorities. All elective outpatient visits are postponed. Priorities go to surgical procedures to save facilities and resources for urgent cases and patients with COVID-19 patients. Health authorities and governments have taken unprecedented measures to contain the spread of SARS‐CoV‐2.
All non‐urgent elective operations are postponed and limitations have to be made on the inpatient and outpatient services to critically ill patients,at the same time increasing the critical care capacity. Nobody can estimate the impact of Covid on economic, social, and medical sequelae. On top of that, current pandemic has also jeopardised clinical research, as several ongoing clinical trials are facing obstacles, which may impact their final outcomes.
Effect on the Urinary Tract
Covid-19 virus has a specific spike protein three‐dimensional structure that is characterised by its strong binding affinity to angiotensin‐converting enzyme 2 (ACE2) receptors. Human cells that express ACE2 may act as target cells for the SARS‐CoV‐2. A threshold of 1% ACE2‐positive cells (based on the ACE2 expression in type II alveolar cells in the lung in eight individuals) is used to determine organs at high risk of viral invasion and reported that the heart, ileum, oesophagus, urinary bladder (ACE2‐positive cells in bladder urothelium (2.4%) and the kidneys (ACE2 positive cells at the proximal convoluted tubules is 4%) may be at high risk of viral invasion. This may explain the acute kidney injuries occurring in 0.1–29% of the patients with COVID‐19.
On top of that, acute kidney disease in patients with COVID‐19 may be explained by the sepsis or septic shock resulting in cytokine storm syndrome or by the immune‐mediated kidney damage. What is to be noted is that patients with COVID‐19 with acute kidney injury have high mortality rates (60–90%) Interestingly, Ling et al. demonstrated in their study of 66 patients who had recovered from COVID‐19 that the viral RNA was identified in the urine samples of 6.9% of the patients. It has been reported that the urine samples remained positive even after the throat swab returned a negative result.
Impact of Covid-19 on Urological care and Urological operations
All elective urological operations have to be postponed. The reduction of undergraduate clinical rounds, and decrease in post- graduate activities will potentially have a stressful impact.Rocco and group raised the concern that some urologists may have to deal with patients with COVID‐19 presenting only with fever as they may be mistaken as having urosepsis, thus awareness of the symptoms and their prevalence is important for all medical personnel even those with surgical backgrounds.
Uro-Oncology
Malignant patients are characterised by their greater susceptibility to infectious disease compared to the general population, with a 3.5‐fold increased risk of COVID‐19‐related serious events (39% vs 8%, P < 0.001) in the form of intensive care admission, requirement for mechanical ventilation, or death due to their immunocompromised state related to the nature of their malignancy and the anti‐cancer management (chemotherapy, radiotherapy, or surgery). It is recommended to delay all elective cancer surgeries or adjuvant chemotherapy in patients with stable cancer, increase the protective measures for patients,with cancer or cancer survivors, and comprehensive surveillance and/or treatment is advised in patients with cancer with COVID‐19. However, the delay of onco‐urological surgeries may have an impact on short‐term progression and/or mortality rates, as a result of the limited availability of ventilators and anaesthesiologists.
Residency Training and Undergraduate Students
Almost all undergraduate clinical rounds were cancelled and all the teaching activities (for residents and undergraduates) were switched to the online platforms. Similarly, medical training programmes in the UK are likely to be cancelled or disrupted in response to the COVID‐19 pandemic; however, efforts are ongoing to ensure that these actions will not compromise the long‐term needs.
Kidney Transplantation
ESRD Patients (end‐stage kidney disease patients) are at greater risk of developing infectious disease compared to the general population, as a result of their intrinsic fragility caused by their defective immune system. Despite the absence of any evidence of COVID‐19 transmission by organ donation, it cannot be neglected, as the virus has been isolated in the blood in ~15% of patients. In these settings, the Italian Transplant Authority released donor management guidelines recommending nasopharyngeal swabbing or broncho alveolar lavage for identifying donors with COVID‐19 in highly epidemic regions, with exclusion of COVID‐19‐positive donors. Similarly, the Transplantation Society recommended testing for SARS‐CoV‐2 in donors suspected of COVID‐19 in endemic areas or those with history of travel to an endemic area. Furthermore, they stated that more elective transplant patients can be deferred in an area with widespread disease. Similarly, the USA Food and Drug Administration recommended that the donor’s travel history to endemic areas, previous contact with patients with COVID‐19, and confirmed or suspicion of COVID‐19 within 28 days prior to the organ donation, should be considered .
Laparoscopic and Robot‐Assisted operations
Aerosol transmission of SARS‐CoV‐2 should not be neglected, as it is capable of being viable in aerosols for 3 h. In this setting, it is recommended to use the lowest acceptable intra‐abdominal pressure for pneumoperitoneum during robot‐assisted or laparoscopic surgeries to reduce the risk of aerosol infection for healthcare workers. Furthermore, the recent the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines recommend the use of devices that are capable of filtering the aerosolised particles from the CO2 produced during laparoscopic surgeries; however, these guidelines were updated to ensure that currently there is no evidence for the aerosol presence of SARS‐CoV‐2 in the surgical smoke of laparoscopic surgeries, but the guidelines were based on the assumptions that this novel virus may share the properties of other detected viruses (Hepatitis B, papilloma virus, or HIV). Furthermore, Zheng et al. , recommended using a lower power setting for electrocautery, as ultrasonic scalpels or electrical devices may produce large amount of surgical smoke. Additionally, adequate and complete desufflation of the pneumoperitoneum may reduce the risk.
Endoscopic Procedures
There is only one published report which has reported the presence of SARS‐CoV‐2 in the urine specimen of 6.9% of patients, and there is no available evidence on urine transmission. It is recommended that endoscopic procedures and urethral catheterisation should be performed with caution and surgeons should be completely protected against infection if the patients are suspected of having or are confirmed to have COVID‐19.
Conclusion
So far, COVID‐19 pandemic is the biggest challenge facing healthcare systems worldwide. In urological fields, all elective operations should be deferred in regions with high COVID‐19 caseloads, as a result of the limited availability of ventilators, manpower, and hospital beds. Nevertheless, surgical intervention should be considered for urological emergencies, e.g., high‐grade malignancies and unstable trauma patients. All healthcare workers including urologists should adopt sufficient protection strategies to guard against infection when dealing with patients with COVID‐19.
References
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