Where do urologists stand in the era of novel coronavirus-2019 disease

Ureteroscopy under conscious sedation: A proof-of-concept study

INTRODUCTION

Ureteroscopy (URS) is commonly performed under general anesthesia (GA) to maximize patient tolerability and minimize surgical complications; however, given the improvements in endoscopic technology and risks associated with GA, alternate forms of anesthesia have been postulated. We aimed to evaluate the outcomes of URS under conscious sedation.

METHODS

We completed a retrospective cohort study from November 2019 to June 2020 at a tertiary-level hospital. All URSs that were performed under urologist-directed conscious sedation were included. Our primary outcome was the ability to complete URS, defined as success rate. Secondary outcomes included: stone-free rate, intraoperative complication rate, hospital admission rate, and sedation requirement. Univariate- and multivariate-adjusted logistic regression analyses were employed.

RESULTS

Ninety-nine URSs were included. Most (73/99, 73.7%) were performed for urolithiasis. The overall success rate was 83.8% (83/99), with 81.0% (34/42) intra-renal and 70.0% (16/23) proximal ureter success rates. The stone-free rate was 80.8% (59/73). No intraoperative complications nor hospital admissions were reported. The mean amount of sedation required was 3 mg (interquartile range [IQR] 2-4] of midazolam and 100 μg (100-150) of fentanyl. On multivariate analysis, midazolam was significantly associated with increased success (odds ratio 2.496, 95% confidence interval 1.057-5.892, p=0.037).

CONCLUSIONS

We have shown that proximal and intrarenal URS under conscious sedation is safe and effective. We were limited by our lack of followup, small sample size, selection bias to chose healthy patients, and lack of patient tolerability data. Patients and healthcare systems may benefit from implementing this innovation more broadly.

[Pedagogical impact of a MOOC on surgical technique of kidney transplantation]

OBJECTIVE

To evaluate the educational impact of a pilot MOOC (Massive Open Online Course), validated by the French College of Urology Teachers (FCUT), on the surgical technique of kidney transplantation.

MATERIALS AND METHODS

We developed a MOOC on the surgical technique of kidney transplantation, based on a video of a surgical procedure, performed by an expert surgeon. The MOOC has been validated by the FCUT. We have created 2 student groups: 1) MOOC-pre-QCM group: visualization of the MOOC then answer to the MCQs and satisfaction questions; 2) MOOC-post-QCM group: answer to the MCQs then visualization of the MOOC then answers to the satisfaction questions. In total, 20 MCQs on the kidney transplantation technique were completed by the 2 groups. The answers were anonymous.

RESULTS

A total of 142 people answered the MCQs (MOOC-pre-QCM group (n=66) and MOOC-post-QCM group (n=76)). Twenty-nine percent (41/142) of the participants were fellows and 71 % (101/142) were residents. The proportion of fellows and residents was identical between the 2 groups. The rate of correct answers to the 20 MCQs was statistically higher in the MOOC-pre-QCM group, compared to the MOOC-post-QCM group (88.6 % versus 73.3 %, P<0.0001). Ninety-one percent of students found the MOOC "Very Useful" or "Useful". The median MOOC rating, given by students, was 8/10.

CONCLUSION

This study showed a positive impact of the MOOC on theoretical knowledge of kidney transplantation surgical technique. This MOOC could serve as a pilot project for the development of other MOOCs on urological surgery.

LEVEL

3.

COVID-19: The impact on urolithiasis treatment in Brazil

Introduction:

It has been more than a year since the first case of Covid-19 was diagnosed in Brazil, and its most problematic feature is the oversaturation of the healthcare system capacity. Urolithiasis is a disease that requires timely and appropriate management. The present study aimed to evaluate the impact of the pandemic in hospital admissions for urolithiasis in the Brazilian public healthcare system.

Materials and Methods:

In this cross-sectional study, hospital admissions were obtained from the Brazilian Public Health Information system. All hospital admissions associated with urolithiasis diagnosis (ICD-10 N20) between March 2017 and February 2021 were analyzed.

Results:

During the COVID-19 outbreak, there was a significant decrease in hospital admissions (p<0.0001). More than 20.000 patients probably did not have the opportunity to undergo their surgeries. The impact of the COVID-19 outbreak on women's admissions was significantly more intense than for men, reducing from 48.91% to 48.36% of the total (p=0.0281). The extremes of age seemed to be more affected, with patients younger than 20 years and older than 60 years having a significant reduction in access to hospital services (p=0.033).

Conclusions:

In conclusion, we have noticed a considerable reduction in overall admissions for the treatment of urolithiasis in the Brazilian public healthcare system during the first year of the Covid-19 pandemic. Women and individuals older than 60 years were especially affected. In contrast, we noted a rise in urgent procedures, comparing with the average of the corresponding period of the three previous years. Recovery plans will be needed while returning to activities to handle the impounded surgical volume.

The role of telemedicine in gynecologic healthcare: A narrative review

ABSTRACT

This article offers a comprehensive narrative literature review on telemedicine use in gynecologic healthcare analyzing current telemedicine integration in the field and outlining innovative and best practices. Telemedicine use in contraceptive care, sexually transmitted infections, acute and chronic gynecologic conditions, and education are discussed. NPs are in a unique position to offer these services to patients in need of women's healthcare services. Barriers, facilitators, clinical implications, and future research are addressed.

Outcomes of loco-regional anaesthesia in ureteroscopy for stone disease: a systematic review

PURPOSE OF REVIEW

Routine ureteroscopy (URS) for stone disease is performed under a general anaesthesia. However, controversy exists on the role of loco-regional anaesthesia and the outcomes associated with it. Here we review the challenges, outcomes and complications of loco-regional anaesthesia for URS. A Cochrane style review was performed in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines to evaluate the outcomes of loco-reginal anaesthesia for URS in stone disease, including all English language articles from January 1980 and December 2019.

RECENT FINDINGS

Twenty-one studies (1843 procedures) with a mean age of 46 years and a male : female ratio of 1.2 : 1 underwent URS under loco-regional anaesthesia. The mean stone size was 9 mm (range:4-21 mm) and except five papers, all other papers included stones in the ureter of which the majority were in the distal ureter. The conversion to general anaesthesia was needed in 2.7% patients (range 1-21%) across studies, with a stone free rate of 48-100%. The complication rate varied from 1.4 to 36%. Although the intraoperative complications included ureteric injury (n = 21) or perforation (n = 4), the postoperative complications included fever (n = 37), urinary tract infection (n = 20), haematuria (n = 4), urosepsis (n = 4) and others (n = 7).

SUMMARY

The present systematic review shows that local anaesthetic URS is a potential alternative to general anaesthetic URS in carefully selected patients. Randomised controlled trials with subgroup analysis are required to further assess whether loco-regional anaesthesia URS is noninferior to general anaesthesia URS and might help determine if the former approach should become more widespread.

Consensus of multiple national guidelines: agreed strategies for initial stone management during COVID-19

PURPOSE

To review the existing available information regarding urolithiasis management and the impact of COVID-19 on this, and propose recommendations for management of emergency urolithiasis presentations in the COVID-19 era.

METHODS

Review of published guidelines produced by Urological Governing Bodies, followed by the literature review regarding urolithiasis management during the COVID-19 pandemic.

RESULTS

Consistent recommendations across guidelines and literature were that urolithiasis with concurrent sepsis or renal failure remains a urological emergency warranting urgent intervention within the pandemic environment. Ureteric stenting and percutaneous nephrostomy are considered equivalent for decompression in this setting, with both ideally to be performed under local anaesthesia where possible to spare ventilators and reduce aerosol-generating procedures. Greater utilization of medical expulsive therapy and dissolution chemolysis may occur during the pandemic, and longer indwelling stent times may be accepted while definite stone clearance is deferred.

CONCLUSIONS

Urolithiasis will continue to be a source of emergency presentations requiring urgent intervention during the COVID-19 pandemic. However, it is possible to limit these interventions to decompression of the collecting system in the setting of concurrent obstruction or infection, performed under local anaesthesia to limit use of resources and minimise aerosol-generating procedures, with deferral of definitive management.

A prospective study on the incidence of postponed time-sensitive urological procedures during the SARS-CoV-2 pandemic due to patient preference

Background

The risk of acquiring perioperative SARS-CoV-2 infection is concerning for surgeons and patients.

Aims

In this study, we investigate the incidence of postponed, medically necessary, time-sensitive urological procedures due to a patient’s unwillingness to proceed to a recommended surgical intervention during the first phase of the SARS-CoV-2 pandemic.

Methods

We prospectively monitored all patients undergoing elective urological surgery during the initial phase of the SARS-CoV-2 pandemic. The primary outcome measurement was incidence of postponed, medically necessary, urological procedures due to the patient’s decision not to proceed to a recommended urological intervention (16th of March–5th of June 2020). The secondary outcome measurements were the type of delayed procedure and duration of postponement.

Results

During the initial 12-week period of the SARS-CoV-2 pandemic, 155 elective urgent urological procedures were scheduled after pre-operative SARS-CoV-2 screening. In total, 140 procedures were performed and 15 (10%) patients intentionally delayed their urological procedure due to the perceived risk of acquiring nosocomial perioperative SARS-CoV-2 infection. The duration for procedural delays is currently 42 ± 23 (range: 15–80) days. The most frequently postponed procedures among patients unwilling to proceed to surgery are urgent endourological procedures due to symptomatic urolithiasis (n = 7/15).

Conclusions

The incidence for patients postponing urological procedures due to the risk of acquiring nosocomial SARS-CoV-2 is 10%. Endourological procedures for urolithiasis are the most frequently postponed procedures by patients. This study demonstrates that a subset of patients will decline urgent urological surgery during the SARS-CoV-2 pandemic.

The impact of the COVID-19 pandemic on pediatric operations: a retrospective study of Chinese children

BACKGROUND

The aim of this study was to quantify the impact of coronavirus disease 2019 (COVID-19) on pediatric operations, and establish preoperative, intraoperative, and postoperative protocols to improve the pediatric operations.

METHODS

We here compare the number of patients who underwent surgery in Chongqing Medical University Affiliated Children's Hospital during the pandemic (January 23-March 11), after the pandemic (March 12-April 30), after our measures were put in place (May 1-May 21), and the equivalent period in 2019.

RESULT

During the COVID-19 pandemic, 62.68% fewer patients underwent surgery than during the homologous period of time 1 year earlier (P < 0.01). After the COVID-19 pandemic, the number of orchidopexy cases increased significantly from 175.14 to 504.57 per week (P < 0.01). The large number of patients that accrued in our hospital may have increased the risk of COVID-19 transmission. In response, hospitals and clinics have made protocols and reorganized healthcare facilities (e.g., performing nucleic acid tests (NAT), adding adequate personal protective equipment (PPE)) from May 1, 2020. After the measures were implemented, the number of operations performed remained stable and comparable to the pre-pandemic period. COVID-19 RNA detection was performed in 5104 cases and there were no new confirmed cases in our hospital.

CONCLUSION

This outbreak of COVID-19 has affected not only individuals with COVID-19 but also patients seeking surgical operations. Understanding the present situation helps clinicians provide a high level of treatment to all children.

COVID-19 and the urological practice: changes and future perspectives

Introduction

The COVID-19 pandemic has brought great challenges to the management of urological patients. Like most surgical specialties, urology has shifted towards an emergency mentality. Currently, the beginning of the de-escalation phase of the pandemic has been observed, which will certainly pose new challenges to the urological community.

Material and methods

A non-systematic search was conducted through the Medline and Web of Science databases. The main keywords used in the search were: ‘COVID-19’, ‘SARS-CoV-2’, ‘urology’. The search included articles without time and language limitation.

Results

During the peak of the COVID-19 pandemic urological services had to focus on maintaining urgent-oncological and emergency-trauma procedures. First adapted recommendations were released at the end of March 2020. Primarily, they included information regarding the prioritization of surgical procedures. Currently, the beginning of the de-escalation phase in many countries has forced the necessity of establishing new degrees of priority for surgical interventions.

During the COVID-19 pandemic, cancellations and rescheduling significantly extend the waiting time for outpatient appointments and surgical procedures. A network of expert high-volume centres, at every level of referentiality, should guarantee the continuity of oncological care, supported with telemedicine systems.

The COVID-19 pandemic has caused a substantial decrease in clinical activity of urology residents. There also is huge potential for remote technology to address and improve education and training continuation in this field.

Conclusions

Urological care has been severely impaired by the COVID-19 pandemic. Urologists must adapt to the dynamically changing reality, prioritizing the safety and well-being of their patients and their clinic workforce.