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Table of Contents
SHORT REVIEW
Year : 2020  |  Volume : 17  |  Issue : 3  |  Page : 180-184

Urology practice in COVID-19 era, Indian perspective


Urology and Robotic Surgery, Indraprastha Apollo hospitals, New Delhi, India

Date of Submission28-Jun-2020
Date of Acceptance30-Jun-2020
Date of Web Publication05-Aug-2020

Correspondence Address:
Rajesh Taneja
Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi - 110 070
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_67_20

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  Abstract 


COVID-19 has hit the world as an unforeseeable calamity leading to unprecedented difficulties faced by the medical fraternity on the whole. A review of published literature pertaining to global experiences in the field of urology, in the backdrop of this disease has been carried out. The common problems faced by urologists world over have been difficulty in the stratification and advising surgical intervention, while conforming to the principles of medical ethics. This has been compounded by rationing of resources, diversion of trained workforce, and increased financial burden on hospitals and patients alike. There has been a reduction in the outpatient department (OPD) attendance, OPD procedures, and major surgical procedures in the past 3 months. Benign diseases have been deferred much more than malignant conditions. A guide for stratification of urological illness according to deferability has been proposed. The psychological burden of the patients, who have been categorized low in priority after the diagnosis has been made, may be immeasurable. Working with personal protective gear along with lead apron has been pointed out as physical stress, which may affect the surgeons' performance. The training of residents has been a collateral damage, which may have far reaching implications. The consequences of this may manifest in some years to come. Telemedicine may be the new normal in the coming times.

Keywords: COVID-19, telemedicine, urooncology, urology services, urology training


How to cite this article:
Taneja R. Urology practice in COVID-19 era, Indian perspective. Apollo Med 2020;17:180-4

How to cite this URL:
Taneja R. Urology practice in COVID-19 era, Indian perspective. Apollo Med [serial online] 2020 [cited 2020 Sep 24];17:180-4. Available from: http://www.apollomedicine.org/text.asp?2020/17/3/180/291469


  Introduction Top


COVID-19, caused by a novel coronavirus, was declared to be a pandemic by the WHO on March 11, 2020. The magnitude of disease and the disaster it was potentially capable of causing was not immediately discernible by the part of globe that hadn't witnessed it in true reality. The disease has come to engulf the planet as a deluge and since the scientific community knows very little about the biology of this virus, at the present time, it is difficult to predict the exact duration that this pandemic may last, if at all it chooses to be controlled by mankind or terminate itself.

All spheres of life have been affected, and medical field has been rattled. All surgical specialties have been put up against unprecedented challenges of a different dimension. Urology care has been affected as much, with challenging times for both, urologists and their patients. In the following passages, an attempt has been made to sum up the various facets ultimately affecting the urology care globally.

For the purpose of this manuscript, literature search using the key words such as “COVID-19,” “Urology care,” and “Urological services” were used to search the PUBMED. A total of 30 articles were short-listed and their full text accessed.


  Factors Affecting Decision-Making in Urology during Covid Era Top


Biology of virus

This little known virus is intriguing because it does not conform to the usual organism having a natural habitat. The survival of this organism in wide ranges of temperature, humidity, and other physical factors, beyond those occurring in natural climate on earth, pose a challenge to the epidemiologists. The rapid mutations as documented by the prevalence of multiple strains are another dimension.[1] Its presence in body fluids is a matter of direct concern to the surgeons. Even though other viruses such as severe acute respiratory syndrome 1 were found in abundance in peritoneal fluid, this virus has not been detected as much in the peritoneal carbon dioxide generated during minimally invasive surgery.[2],[3],[4] There were few reports suggesting the presence of this virus in significant concentrations in urine, which were refuted by other studies. However, its presence in cerebrospinal fluid and stools in addition to blood and respiratory secretions poses a risk of transmission. Urologists have a threat of exposure to the blood mixed urine, which could indeed be a potentially very high dose exposure.

Natural history of urologic diseases

When evaluating a patient with urological ailment, it is very important to stratify the patients according to the risk the natural history of disease poses to the individual. One such stratification has been developed by Heldwein et al.[5] This is a five-category risk stratification, which gives a fairly good idea when planning a treatment of urological patients in the backdrop of COVID-19. [Table 1], [Table 2], [Table 3], [Table 4], [Table 5] summarize the practical guidelines of this categorization when applied to common urological conditions and can serve as a quick reference.
Table 1: Proposed stratification of deferrability

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Table 2: Deferrability in urolithiasis

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Table 3: Deferability of uro oncology

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Table 4: Deferability of urological conditions needing urgent care

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Table 5: Deferability in benign urological conditions

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It is important to understand that this classification has been done keeping in consideration the disease progression, serious implications to life or organ, and the perceived risks accompanied by the treatment itself in this special phase of time. However, from the patients' perspective, things might be very different.

Psychological impact of ailments

A psychological impact of an impending danger can play upon the mind of the patient due to a so called “Lower risk disease” listed as a low priority disease during these testing times. This is especially compounded by lockdown situation, plenty of time to think, the atmosphere of fear around, and knowledge of someone in close circles suffering from apparently “similar” disease. So while we have stratified an ailment according to its natural history, its psychological impact on the individual has been left out to a large extent. For example, a patient with stress incontinence may be anxious about how the outcome is going to be if at all a surgical procedure is finally performed at a later, more suitable time.[6] The anxiety of slowly rising prostate specific antigen (PSA) or a newly diagnosed low risk cancer of prostate are other such examples. The psychological impact varies depending upon the education and financial status of individual, thus forcing to break guidelines.

Safety of patient

While planning the treatment, safety of patients as well as their caregivers has to be kept in mind. The definite risk of exposure of attendants/caregivers along with patient when they are out of their homes, travelling to the hospital, and visiting pharmacies cannot be entirely negated. It is important for the discussions to include the risks of serious COVID disease manifesting in the immediate postoperative period jeopardizing the results of treatment, apart from addition of anxiety, financial burden and risk of infection to family members. This may happen despite the preoperative reverse transcriptase polymerase chain reaction test being negative in immediate preoperative period.[7],[8] Any decision thus must involve these facets and in the presence of responsible attendants of the patient.

Safety of staff

In all urological procedures, splashes from blood-stained urine can occur, generating aerosols and causing exposure of a high volume viral load to the assistants and scrub nurse, who are very close to the operating field, actually much closer than one may imagine. The use of personal-protective equipment (PPE) including waterproof shields and goggles becomes cumbersome over the heavy lead aprons and soon enough, the vision of surgeon is jeopardized by condensed humidity. At that time, a tired, struggling surgeon may do more harm to the patient than good. There is certainly an urgent need to invent methods of reducing fogging of vision or means of cleansing during the procedure.

It is very important to periodically test and rotate the staff as per the quarantine norms of the hospital.[9] During the period March 2020– June 25, 2020, four out of six residents at the Urology Department at Indraprastha Apollo Hospital tested positive for coronavirus infection. Two had to be quarantined due to accidental exposure to undiagnosed COVID cases during the early period of this phase. Evacuation and handling of outflow irrigant resulting from the endourological procedure needs to be maintained in a closed circuit with additional precautions, which need to be taught and emphasized to the handlers of such work. Physiotherapists are at a great risk as they supervise respiration of patents very closely.

Conservation of resources

In large hospitals, the residents are a part of overall common pool. In a crisis like COVID, residents may be required to be shifted to more demanding sections of the hospital. This has the inherent double problem of depleting a specialty-trained department of the trained resource and suboptimal output from such personnel when deployed in other specialties.

Treatment of urological ailments, which can be deferred, should be deferred also because of unforeseeable need for intensive monitoring of a proportion of these patients may end up straining such resources.[10],[11],[12] Rationing of overall hospital resources to various departments has to be kept in mind and all heads of departments need to be coordinating, congruent, and cohesive on the same plane.

Medical ethics

During a pandemic, sticking to medical ethics may be sometimes more difficult than treating urological ailment. The four pillars of medical ethics, namely ”Beneficence,””Nonmaleficence,””Autonomy,” and ”Justice” need to be balanced which is not always easy during an ongoing pandemic with strained resources. However, “surgeon-patient relationship” without these pillars can be disastrous and these must be adhered to as much strictly as possible. The problem comes when one needs to choose between treating an individual or community. Rationing of resources can really skew the decision-making while deciding to save “years of life” or “year of lives.”[13],[14]


  Effect of Covid on Urology Training Top


The rationale of reducing the strain on the resources of hospital and financial burden to the patients makes it imperative to reduce the number of disposable protection gear for the surgical team, considerably reducing the number of residents scrubbing with the consultants. In addition, the possibility of exposure to potentially infectious aerosol and irrigant outflow fluid indicates restricting the number of assistants in the operation theatre. The residents are at the age when they have elderly parents and small children/pregnant women at home. It is therefore a difficult decision, both for the residents and the consultants alike, as to how many the residents be allowed inside the theatre during a surgical procedure. Some of the procedures can be allowed to be done by residents while the consultants can watch through the monitor from a distance, sometimes from a place outside the actual operating room. However, if there is a borderline case, which may require the consultant to take over, it is in the interest of the hospital and patient that the consultant performs the procedure himself from the beginning itself. However, this takes away the already thinned out the opportunity of hands on training from the residents. The number of urological cases in Indraprastha Apollo hospitals in the last 3 months has fallen drastically by almost three fourths. Any examiner would be hesitant to award a degree to residents with this limited kind of surgical exposure.

The trainees, looking forward to enroll patients for their thesis, are at a great disadvantage. The COVID era seems to go on, and the residents are running out of their opportunity for training. In a survey of Italian urology trainee residents, a severe reduction (>40%) or complete suppression (>80%) of training exposure ranged between 41.1% and 81.2% for “clinical” activities while between 44.2% and 62.1% for “surgical” activities during COVID period.[15] This happens to be a very important but much less talked about, long-term effect of this era.

The silver lining of all this is the opportunity to attend various online webinars, case based discussions, surgical tips and tricks, and online teaching sessions as has been instituted by the Urological Society of India under the aegis of Indian School of Urology. This has also provided opportunity to attend various online major international conferences like American Urology Association and European Association of Urology, which were almost out of reach for a large majority of residents.


  Global Impact on Urological Services during Covid Period Top


A whooping number of research papers have been published during the COVID era globally, and urology is no exception. The various major international and national societies have published their local guidelines. The major medical centers in the worst hit cities of the world have come out with their perception, experience, and recommendations specific to practicing urology in the COVID era.[16],[17],[18],[19],[20],[21]

A web-based cross-sectional survey containing 55 item questionnaire, conducted during March and April 2020, addressed to practicing urologists, urology trainees, and urology nurses that attracted a total of 1004 responses, was published in European Urology.[22] A significant number (47%) reported fear to go to work, while 41% reported a colleague getting infected with coronavirus. A quarter of all respondents were diverted to other department as backup force. A varying degree of reduction was noted in outpatient services, outpatient investigations, and surgical procedures. Treatment of benign conditions was affected more than the malignant ones. A significant 50% of the respondents believed that postponement of urological treatment would significantly affect the outcomes adversely. In another survey of 27 urology centers in Italy during March and April 2020, there was decrease in attendance of outpatient and emergency from 956/week to 291/week.[6] What is perplexing is that during this period, the emergencies such as hematuria, colic, scrotal pain retention all seem to have reduced in an unexplainable manner.[23]

Review of various guidelines issued in urology societies during the COVID period revealed almost congruent recommendations.[5] There was the consensus in postponing robotic radical prostatectomy in low-grade tumors, low-grade bladder tumors, small renal masses up to T2, and even Stage 1 seminoma. All guidelines consistently advised relief of obstructed infected kidneys and those causing renal impairment or imminent loss of glomerular filtration rate if treatment was differed. Only European Association of Urology guidelines provided evidence-based (mostly level 3 evidence) procedures followed during their formulation.

A review of three high volume urooncology centers in Italy revealed that almost two thirds of the urooncology surgeries could be categorized as deferrable.[24] This was important recommendation during the strained resources at the peak of pandemic in that country. There is an indication that during this pandemic situation, there is a shift toward nonoperative methods of treatment of cancers, thereby increasing the role of radiotherapy.[25],[26],[27] There have been instances of deferring adjuvant chemotherapy following surgery. Cancer detection activities have been put on hold worldwide and have been labeled as low priority.


  Future of Urology Services “the New Normal in Urology” Top


As on the end of June 2020 in India, it appears that the threat of coronavirus infection is going to last longer than most may anticipate. The “New Normal of Urology” is going to be different from what we all have been used to, even though it is still in the phase of evolution.

Telemedicine

Teleconsultation with patients would be utilized increasingly, having experienced its ease on both the ends, and getting familiar and “used to” using these systems.[28] Over the last 3 months, there has been a forced increase in the number of tele-consultations on all participants. The most important facet of telemedicine is the legal consent by the patient to accept a consultation and evaluation, which is actually short of physical visit and examination. There is an enhanced responsibility of the clinician, bestowed upon him due to his ability to judge the need for evaluation in person and physical examination of the patient. There are several such situations in urology such as evaluation of borderline rise in PSA or imparting opinion on incontinence without being able to feel the presence of palpable bladder. The platforms need to be secure, safe, and complete. Any shortcuts by physician can land him and his patient in an entirely avoidable difficulty. The system of telemedicine offered by Apollo 24/7 happens to be almost a complete and secure system, even though it still is in a phase of constant evolution. Of note is the imperative need of having a high-speed Internet service at both ends and the patients' ability to use the technology. It is hoped that the patient population as well as the medical personnel will increasingly become efficient in using this technology.

Surgical procedures

The urological procedures will slowly limp back to a rising trend from the nadir that they have seen. The prioritization would become less strict as the COVID curve starts to recede. The recommended standard operating procedure would be followed by all personnel as they may have gone through the unpleasant experience of seeing many colleagues getting infected. The shift toward nonoperative treatments will still persist whenever feasible. However, we may be prepared to see more number of metastatic adenocarcinoma prostate cases in years to come. Loss of renal function due to neglected obstructions, which are presently causing minimal or no symptoms would be evident in near future, perhaps earlier and more significant in number than we may anticipate at present. There would be a kind of acceptance of discomfort associated with the PPE and methods to reduce that would certainly be invented.

Functional urology

Functional urology has had a back seat during the COVID period.[29] Telemedicine can help a long way in treating these patients till they require a surgical procedure. In the era of COVID, these patients have been neglected globally and there has been an immeasurable suffering that these patients may have gone through. As urologists have started to take charge of their bearings, they should now take up the challenge to treat and follow patients suffering from functional urology ailments such as incontinence.

Training of residents

Training is going to remain tough and suboptimal as long as this pandemic stays. The residency program needs to be reorganized with an option of extending the residency period and a temporary limitation at the entrance level.


  Conclusion Top


Coronavirus-induced disease has played havoc among the masses and health-care workers alike, across the globe. Urology services have been affected for the reasons of prioritization, the fear of COVID during treatment of so-called “deferrable” surgical procedures, and rationing of resources. Training of residents has been affected adversely and needs due consideration. The lack of cancer detection programs is going to show a long-term impact in the years to come. Improvisations in the visual aids during all kinds of surgical procedures are the need of the hour to enhance the safety of patients as well as operating surgeons.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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