Tag: #Covid-19

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Coming out of lockdown safely – A view from Italy

May 22, 2020/by Riccardo Campi

How our lives have changed. Over two months ago we published a popular blog on the effect of COVID-19 on our surgical practice (https://www.bjuinternational.com/bjui-blog/covid-19-and-urology/). In many ways it informed us as to what to do during challenging times to keep our patients safe.

As we gradually take careful steps out of lockdown, our minds are focused on the most important of all words – SAFETY.

While every nation will have differences and nuances, the principles of learning from each other, remain the same as they did when lockdowns started.

I am not surprised by new and ever changing information about the disease almost every day and see international collaboration as a powerful and positive tool in this situation.

With this in mind I requested our friends from Italy, China, Germany and New Zealand for their own perspectives.

Here are their thoughts for your reading pleasure.

Please feel free to insert your comments under the blog and share on social media.

Yours in friendship,
Prokar Dasgupta
Editor in Chief, BJUI

I am grateful to BJU International for having had the opportunity, around 2 months ago, to share my perspective on the impact of the COVID-19 pandemic on urological practice at Careggi University Hospital in Florence, Italy. I hope that information, coming from an Italian Centre that had to timely re-organize its logistics and surgical schedule in light of the rapid spread of the epidemic across the Country, might have provided some insights for urologists in the UK and worldwide to adapt their own activity during the acute phase of the COVID-19 outbreak.

Herein I am honored to share with you my perspective on how we may safely come out of lockdown, and on what we may learn as a Community from the COVID-19 pandemic to optimize the future organization of urological services.

First of all, I entirely endorse Prof. Dasgupta’s view that, while the way Urology Centres around the world are coping with the challenges raised by the COVID-19 pandemic, as well as the way they are trying to rebuild new “standards” during the “second phase” of the emergency, will certainly vary within Countries, Regions and Hospitals, we as urologists should be open-minded and strive to share and learn as much as possible from each other. As such, in the highly complex scenario we are all living in, every perspective and viewpoint should be leveraged to set new tiles in the “mosaic” of evidence on Urology practice in the post-COVID era.

The status of the COVID-19 epidemic in Italy has significantly changed through the last two months. As of 15^th March 2020, the number of laboratory-confirmed cases in Italy was 24 747, with 1809 deaths. As of 14^th May 2020, these numbers were 223 096 and 31 368, respectively (making Italy the fifth Country in the world with the higher number of infections, https://lab24.ilsole24ore.com/coronavirus/).

Fortunately, the measures undertaken by the Italian Government so far, including the lockdown, have led to a drastic reduction in the number of daily infections and deaths due to COVID-19, with a progressive parallel decrease in the burden of severely ill patients admitted in ICUs.

However, there is no doubt that this unprecedented pandemic has had a dramatic impact on Italy from all possible standpoints, including the healthcare system. In particular, urology practice has been truly revolutionized during the past two months. Indeed, not only virtually all Centres worldwide have been forced to follow strict schemes for the triage of urological procedures that should have been prioritized in light of the scarcity of resources [1-3], but also Urology training programs have suffered a significant slowdown with potential meaningful consequences on residents’ learning curve [4,5]. As such, while we are now facing the new challenge of dealing with the “adaptation” and forthcoming “chronic” phases of the pandemic (during which all urological services will be progressively reopened to patients) we should keep the focus on preventing nosocomial infection and on cost-effective use of available resources.

In this scenario, the Department of Urology of Careggi University Hospital, directed by Prof. Carini and Prof. Serni, located in Tuscany – one of the five Italian Regions that have been hit most by COVID-19 – has already planned a series of measures aiming to safely restart all Urology services in the coming weeks, ensuring patients and healthcare workers’ safety.

First, since late March, all patients scheduled for urological procedures (as well as patients undergoing minor surgeries in the outpatient setting, ESWL and prostatic biopsies) had to be tested for Sars-CoV-2 infection (through nasopharyngeal swaps) 48 hours before surgery. Patients who resulted positive for COVID-19 were recommended to remain in quarantine until two consecutive nasopharyngeal swaps resulted negative for the infection. Then, they could have been rescheduled for surgery. In addition, starting from May 1^st 2020, all patients undergoing surgery were tested for Sars-CoV-2 infection through nasopharyngeal swaps 24-48 hours before discharge from the Hospital. Of note, patients’ relatives were not allowed to enter the Department during the whole hospitalization period; as such, the news regarding both the intervention and the postoperative course were communicated by the urologists in charge of the inpatient ward by telephone.
Second, beyond appropriate use of all PPE, all healthcare workers in our Department, including nurses, doctors and administrative staff, underwent serology testing (IgM, IgG) for Sars-CoV-2 infection during the first weeks of April. Those who resulted positive according to the serology underwent further testing with two consecutive nasopharyngeal swaps; if positive, they were recommended to remain in quarantine until two consecutive nasopharyngeal swaps resulted negative for the infection.
Regarding the Urology operating rooms, we are currently using 50% of them (two out of four) in the main Hospital pavilion, prioritizing major uro-oncological surgery (open and minimally-invasive procedures for prostate, urothelial, and kidney cancer), as well as surgery for penile and testicular cancer. Most endoscopic surgeries for bladder cancer (TURBs) were redeployed in a different Hospital pavilion (in one dedicated operating theater, active four days a week). Overall, the surgical activity of our Urology Department is currently reduced by 20-25% as compared to a “standard” period. Fortunately, we are not facing major concerns regarding the availability of ICU beds for urological patients at our Hospital.

While in the very first weeks after the spread of the epidemic, only high-priority major uro-oncological surgeries (i.e. radical cystectomy, radical prostatectomy for locally-advanced diseases, nephrectomy for cT2+ cancers, radical nephroureterectomy for high-risk upper tract urothelial carcinoma) were performed – accounting for approximately one third of all major cancer surgeries at our Centre based on a recently published study by our group [6]) – later on we progressively included in the surgical schedule also lower-priority interventions (i.e. radical prostatectomy for intermediate-risk prostate cancer, radical/partial nephrectomy for cT1b tumors, etc.).

Similarly, we progressively reintroduced into the surgical schedules also elective interventions for benign urologic conditions, prioritizing those patients who were symptomatic and/or at higher risk of adverse clinical outcomes. It is important to highlight that the management of the surgical waiting list during the acute phase of the COVID-19 pandemic and the planning of the weekly surgical schedule was performed according to a careful day-by-day evaluation of the available resources in the Hospitals’ ICUs, as well as the number of available theaters for urological procedures.
Importantly, we did not record any case of COVID-19 after elective or urgent urological procedure during the past two months (including after minimally-invasive surgery, the safety of which has been object of great debate within the Urology Community [7]).
Regarding urological emergencies, patients who were admitted to our Urology Unit from the Accident & Emergency Department had to be tested for Sars-CoV-2 infection (through nasopharyngeal swaps) before admission. If needed, surgery for urological emergencies was performed in a dedicated operating theater in the main Urology pavilion.
The kidney transplantation program from deceased donors (both donors after brain death [DBD] and donors after circulatory death [DCD]) continued without major changes at our Unit, thanks to a timely and effective reorganization of all activites related to organ procurement by the Tuscany Transplant Authority, as well as a series of logistical and clinical measures implemented early after the spread of the epidemic to prevent transmission of the disease to KT recipients. On the contrary, kidney transplantation from living donors was (and is still) suspended since the end of February 2020.
Most urological procedures in the outpatient setting (ESWL, minor surgeries, prostatic biopsies) were canceled during the first weeks of the COVID-19 epidemic, being the only exception cystoscopies for suspected bladder cancer. Thereafter, they were progressively re-started (especially during the last 2 weeks), provided that patients had been tested negative for Sars-CoV-2 infection and anyway after a comprehensive triage by telephone outlining the priority of such procedure.
Finally, while during the “acute phase” of the pandemic the vast majority of urological consultations in the outpatient setting were canceled (and replaced by telemedicine strategies, except for those visits deemed urgent by urological staff after a careful screening by telephone interview and those for medications after elective surgery). In the coming weeks most of them will be re-started, provided adequate logistics (i.e. distancing between patients and appropriate time schedules) to ensure maximal safety for both patients and healthcare workers.

Overall, the “big picture” delineated by all these facts and figures highlights that our Unit, as in many other Departments in Italy, has already started the process of rebuilding the foundations of a new “routine” urological practice, adapting (and eventually overcoming) to the challenges met during the first acute phase of the COVID-19 emergency.

Nonetheless, my global perspective is that urologists should remain vigilant and resilient, keeping the focus on ensuring safety and cost-effective use of resources. This is important, as the COVID-19 epidemic could potentially flare-up in the near future if all safety measures recommended by Hospitals and the Government were not strictly followed by the population.

Moreover, I believe this unprecedented emergency scenario, which has profoundly revolutionized our healthcare system as well as our way of thinking and behaving, should be leveraged to understand which steps should be prioritized to move Urology forward from both clinical, logistical, educational and scientific perspectives.

In this view, the lessons we can learn as a Community from this pandemic for the future include:

– the need for appropriate (evidence-based) selection of candidates for urological procedures, taking into account also patients’ values and expectations;

– careful prioritization of surgeries, based on the potential impact of delay on important patient outcomes [8];

– rational use of all available treatment modalities for urological cancers (including active surveillance), strengthening the value of team-work and developing a truly multidisciplinary spirit;

– refinement of surgical informed consents, tailoring them to such emergency scenarios [9];

– increased use of virtual Urology learning programs for education of residents [10];

– implementation of teleproctoring and telementoring technologies into everyday surgical practice [11];

– inclusion of telemedicine into routine pathways of care for urological patients [11].

By doing so, we may be able not only to be more prepared for similar future emergency scenarios, but also to take significant steps toward improvement of Urology as a specialty, as well as ourselves as individuals.

Riccardo Campi, MD

– Resident in Urology, Dept. of Urology, Careggi University Hospital, Florence (Italy)
– Ph.D. student, Doctoral Program in Clinical Sciences, Dept. of Experimental and Clinical Medicine, University of Florence, Florence (Italy)
– Member of the EAU Young Academic Urologists – Renal Cancer Working Group
– Associate Member of the EAU Section of Oncological Urology
– Twitter: @Ric_Campi

References

[1] Stensland KD, et al. Considerations in the Triage of Urologic Surgeries During the COVID-19 Pandemic. Eur Urol. 2020 doi: 10.1016/j.eururo.2020.03.027.

[2] Ribal MJ, et al. EAU Guidelines Office Rapid Reaction Group: An organisation-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era. Eur Urol 2020 (In Press); available at: https://www.europeanurology.com/covid-19-resourceEAU

[3] Ahmed K, et al. Global challenges to urology practice during COVID‐19 pandemic. BJU Int 2020. In Press. https://doi.org/10.1111/bju.15082

[4] Amparore D, et al. Impact of the COVID-19 pandemic on urology residency training in Italy. Minerva Urol Nefrol. 2020. doi: 10.23736/S0393-2249.20.03868-0

[5] Porpiglia F, et al. Slowdown of urology residents’ learning curve during the COVID-19 emergency. BJU Int. 2020 [Epub ahead of print] doi: https://doi.org/10.1111/bju.15076.

[6] Campi R, et al. Assessing the Burden of Nondeferrable Major Uro-oncologic Surgery to Guide Prioritisation Strategies During the COVID-19 Pandemic: Insights from Three Italian High-volume Referral Centres. Eur Urol. 2020 [Epub ahead of print] doi:10.1016/j.eururo.2020.03.054

[7] Novara G, et al. Risk of SARS-CoV-2 Diffusion when Performing Minimally Invasive Surgery During the COVID-19 Pandemic. Eur Urol Apr 2020;0(0). Available at: https://www.europeanurology.com/article/S0302-2838(20)30247-5/abstract

[8] Wallis CJD, et al. Risks from Deferring Treatment for Genitourinary Cancers: A Collaborative Review to Aid Triage and Management During the COVID-19 Pandemic. Eur Urol 2020. In Press. DOI: https://doi.org/10.1016/j.eururo.2020.04.063

[9] Bryan AF, et al. Unknown unknowns: Surgical consent during the COVID-19 pandemic. Annals of Surgery 2020. In Press. https://journals.lww.com/annalsofsurgery/Documents/Unknown%20unknowns%20.pdf

[10] Claps F, et al. Smart Learning for Urology Residents during the COVID-19 pandemic and beyond: Insights from a Nationwide Survey in Italy. Minerva Urol Nefrol 2020. In Press.

[11] Karim JS, et al. Bolstering the surgical response to COVID‐19: how virtual technology will save lives and safeguard surgical practice. BJU Int 2020. In Press. https://doi.org/10.1111/bju.15080

[12] Connor MJ, et al. COVID‐19 pandemic – is virtual urology clinic the answer to keeping the cancer pathway moving? BJU Int 2020. In Press. https://doi.org/10.1111/bju.15061

COVID-19 and Prostate Cancer — Challenges and Solutions

May 22, 2020/by Ash Tewari

The numbers are staggering. As of the date of this brief commentary, the World Health Organization has reported more than 4.6 million cases and upwards of 311,840 deaths worldwide from the COVID-19 pandemic. The virus responsible for the disease known as COVID-19, SARS-CoV-2, is highly infectious and the risks are clearly significant for nearly everyone. Nonetheless, the risk is much higher for some of us than for others. In particular, we have begun to understand the distinct risks faced by men with prostate cancer and the unique intersection of biological, health, and lifestyle factors in COVID-19 and prostate cancer. Although there is a great deal yet to be learned, there are indeed many aspects of the overlap between COVID-19 and prostate cancer that we have already been able to discern and which we have begun to address. Perhaps most striking, older men who are at greatest risk for prostate cancer may also be at greatest risk for COVID-19.

New York City

Biology Makes a Difference – COVID-19 and prostate cancer share some common biological features. A gene responsible for male traits or characteristics, the androgen receptor, which is dysregulated or impaired in prostate cancer, is also important in COVID-19. Androgens can suppress the body’s immune response to infections and may explain the reason for higher rates of infection in men. At the same time, a gene known as TMPRSS2 is also highly expressed in both COVID-19 and prostate cancer. In fact, these issues may be related—more androgens could signify greater expression of TMPRSS2 which could create greater susceptibility to the virus. These biological risks are compounded by a number of critical health conditions and lifestyle issues.

Common Risk Factors – Studies from around the world have shown that several chronic health conditions or comorbidities create greater risk for contracting the virus, becoming more severely ill, or dying from COVID-19. It is indeed concerning that many of these are the same risks we see in prostate cancer: hypertension, diabetes, COPD, and obesity. Prostate cancer patients with multiple comorbid conditions may be at even greater risk. Cancer patients in general have weakened immune systems which makes them more vulnerable to infectious disease, further compounding the unique factors affecting men with prostate cancer. Some of the lifestyle factors that may contribute to chronic health conditions also appear to be risk factors for COVID-19 infection, most importantly smoking and high levels of alcohol consumption. We are especially concerned about men who are active smokers, as smoking has been clearly linked to worse outcomes in men who have become ill with COVID-19. We believe that the guidance we generally offer to prostate cancer patients is as, if not more, relevant now in this time of the COVID pandemic—adopt healthy habits, including smoking cessation, a nutritious diet, exercise, and proper management of chronic conditions most notably diabetes.

Looking Ahead – As the pandemic evolves and we look to the future, we are focused on ways to prevent the spread of infection and to create viable treatments for those who become ill. Worldwide, more than nine million men currently face decisions about biopsy, active surveillance, surgery, radiation, hormonal therapy, or chemotherapy related to prostate cancer in the context of COVID-19 and another 3 million more will find themselves facing these decisions by the end of this year. We are working intensely to address their needs. More than 1,460 clinical trials are underway to test therapeutic interventions to treat COVID-19. What we have come to understand about the shared biology between COVID-19 and prostate cancer and common risk factors will be invaluable. We must learn everything we can about the ways in which the virus impacts lung function as it relates to prostate cancer—the respiratory symptoms that result from infection have been especially lethal—and continue to explore the role of androgens in response to new drugs. Many drugs originally intended and approved for other uses are being tested for potential “repurposing” and new drugs and vaccines are under investigation. New clinical guidelines have been established for the treatment of prostate cancer patients at risk of or for those who have contracted the virus, and these guidelines will continue to evolve and be updated.

A Global Perspective – It is critical that we understand the COVID-19 pandemic both on the level of individual experience and global impact. For prostate cancer patients, this means recognizing the way that biology, related chronic health conditions, and lifestyle choices come together to impact the risk of disease, disease severity, and outcomes. Prostate cancer patients and their doctors must come together to find the way forward during this time of unprecedented crisis and opportunities for improving outcomes and quality of life for prostate cancer patients.

Ash Tewari, Zach Dovey and Dimple Chakravarty

Covid-19: Collection of urology papers

May 3, 2020/2 Comments/by Admin

Following on from our blog and recent podcasts on how the corona virus (Covid-19) is affecting urological operations in three countries: Italy, China and South Korea, we have put together a collection of the latest BJUI-published articles on the topic.

The first article by Connor and coworkers from Imperial Prostate discusses the potential costs to cancer patients if outpatient activity is cancelled by NHS trusts in order to free up resources for Covid-19 patients. They recommend that a virtual clinic consultation takes place in the first instance. So, what is life like in Isreal under COVID-19? Mostly quiet and a little surreal. In other words, very much like it is here. Israel was very aggressive in its early efforts to combat the spread of the virus, taking immediate measures to limit public gatherings, closing all non-essential businesses, and cancelling almost every major event in the country. Extreme yes, but also very safe.

The second article is by Ahmed, Hayat and Dasgupta from King’s Health Partners, London UK and discusses the national situation as of the end of March 2020: all non-urgent elective surgical procedures have been put on hold for three months to free up hospital beds and theatre staff; the discharge process for surgical inpatients has been accelerated and staff are being redeployed from non-essential services. But what impact will this have on the mental health of those patients missing out on treatment for their infertility or incontinence? And how are conditions categorized? The Cleveland Clinic Urology department has developed a five-point scale to aid in risk-stratifying patients – the following table is a more general version.

Surgical Procedure	Summary of Impact of COVID-19 on selected Urological procedures
Endoscopic/Outpatient procedures	Diagnostic work should be avoided where possible, only emergency procedures under local anesthetic ideally. Only urgent outpatient procedures should be carried out, these include biopsies of the prostate, cystoscopies for suspected bladder malignancy or hematuria.
Open/Laparoscopic	-Only urgent procedures, assessment for COVID-19 should be carried out, reduce chances of the need for post-surgery critical care. Full personal protection equipment should be worn. Urgent procedures may include trauma, ureteric stones, torsion and high-risk cancer patients -The safety of carrying out laparoscopic work remains undetermined -The merits of local versus general anesthetic should be considered on a case by case basis if applicable
Selected points on general theatre safety	-The number of staff in theatre should be minimised and all must wear personal protective equipment in full with visors -Positive pressurisation should be put on hold in theatre during a procedure and only 20 minutes after the patient has left the theatre, should it be restarted – Need for COVID 19 testing of the patients and the clinical team prior to the procedure

Table 1. Adapted from RCS Intercollegiate General Surgery Guidance on COVID-19 (https://www.rcseng.ac.uk/coronavirus/joint-guidance-for-surgeons-v2/) and BJUI “COVID-19 and Urology” blog.

Again, the idea of virtual clinics is raised as is the future training of medical and surgical students to enable them to be quickly deployed in the case of another pandemic, and a suggestion for parallel healthcare systems.

Testing, of course, is also of paramount importance.

In a comprehensive review of the situation as of the end of March 2020, Bernardo Rocco and co-workers describe what we know about the SARS-CoV-2 virus so far and what has been done, at least within Europe, to cope with the pandemic.

It is thought that kidney cells are particularly prone to invasion by the virus, as evidenced by the numbers of kidney dysfunction in COVID-19 patients, and this may be due to the presence of angiotensin-converting 2 enzyme receptors on a small percentage (2-4%) of these cells to which the SARS-CoV-2 virus has an affinity.

The article further discusses the situation for medical students, transplant clinics and oncology, focussing on China, Italy and the UK. It also outlines extra precautions to take to limit virus transmission given the unknowns about its presence in blood, urine and faeces.

Returning to the subject of medical students, in particular in Italy, this paper by Porpiglia and coworkers explains that residents are unable to practise as the areas in which they usually work have been suspended (benign pathologies, lower urinary tract surgery and andrology), as have case meetings and outpatient clinics, and major surgery is being carried out by senior colleagues. Alternative teaching methods, via video link, are being introduced, e.g. surgeryinmotion-school.org, a well-established website showing recorded and live surgeries. The use of webinars for presentation of cases and social media, such as Twitter’s Journal Club, allow discussions to take place. Daily staff meetings can also take place via the web.

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safe way.

Covid-19 and urology

March 16, 2020/7 Comments/by Riccardo Campi, KH Rha, Andrea Gavazzi and Guohua Zeng

As the BJUI is a Global journal, we felt that we could learn from our global friends amidst a global infectious disease. I asked my colleagues Guohua Zeng from Guangzhou, China, KH Rha in Seoul, Korea and Riccardo Campi from Florence, Italy as to what they had been doing as urologists. Their texts are below but please also listen to these two podcasts from Italy by Andrea Gavazzi and Riccardo Campi.

How are they dealing with outpatient clinics?
Have they stopped elective operating
What about the management of cancers?
What about emergencies such as ureteric stones, trauma and torsion?
Are urologists learning how to treat critically ill patients

I was recently in India as Visiting Professor moving between Mumbai – Vellore – Kolkata. While at Vellore I received the news that a confirmed COVID case had been found near our lab at KCL. My personal assistant took precautionary isolation and I warned my team to await further instructions from Public Health England and the university. I was debating whether to myself travel from Vellore to Kolkata on the final leg of my tour as I did not want to come into contact with my elderly parents in their 80s. Thankfully my handwritten scribbles in my diary confirmed that I had been in my lab area 14 days prior to detection of the case as above. Since I had no symptoms at all, the advice from the hospital in Kolkata that I was visiting was to continue with my travel as planned.

A few days later I left Kolkata for London via New Delhi by Air India. At the Indian capital, I was screened just like all other international passengers and given clearance to travel. I am told that at New Delhi airport this is now routine and crowding at immigration and luggage counters is being minimised to avoid close contact between travellers. While it is impossible to be certain about what happens next, COVID-19 infection in India seems lower than most other countries.

While the response of each nation will be slightly different depending on scientific advice and their local population, here is what our colleagues elsewhere have been doing. Hopefully we can learn and adapt for the weeks and months ahead.

Prokar Dagupta
BJUI Editor-in-Chief

Italy

From: Dr. Riccardo Campi, resident in Urology and PhD student at the Department of Urology and Renal Transplantation, Careggi University Hospital in Florence, Italy.

I am grateful for the opportunity to share with you my perspective on the coronavirus epidemic in Italy and its impact on Urological practice at my Institution.

Prof Dasgupta and Dr Campi, Florence, Italy

As of 15^th March 2020, the number of laboratory-confirmed cases in Italy was 24 747. Of these, 1809 patients died.

This makes Italy the country with the highest cumulative number of reported COVID-19 cases per 100 000 people in the world according to the European Centre for Disease Prevention and Control.

In Italy the coronavirus epidemic has led to profound repercussions from social, healthcare, economic and political perspectives and unfortunately it appears we are still living its rising phase. Thus, we are striving to manage this complex scenario day by day, learning from real-life experience, joining our forces and doing our best to minimize further infection of the population while ensuring effective care of COVID patients.

To tackle the rapidly spreading coronavirus infection, in the past weeks the Italian Government has released several orders that progressively led to the complete closure of schools, universities, commercial activities, as well as to strict recommendations toward social lockdown.

This is now a really challenging scenario, far more serious than most of us thought just a few weeks ago while watching at a distance the worrying reports from China.

Soon after the explosion of the Covid-19 epidemic in China, the Northern Regions of Italy were hit by the coronavirus with the highest strength, putting a strain on the healthcare human and logistical resources, progressively raising concerns on the availability of qualified professionals, as well as on patient selection criteria for admission to Intensive Care Units (ICU), also from an Ethical perspective. Notably, there have been recent orders by the Italian Government that allow Residents in their final years of training to be hired with temporary contracts in hospitals that lack healthcare professionals to face the emergency.

Importantly, all hospitals across the country had to quickly re-modulate their internal logistics to increase the availability of resources in ICUs. To do so, many hospital services, including Surgical Departments, have been discontinued or reshaped to ensure sufficient numbers of available beds for patients requiring intensive care.

Both doctors and nurses are working tirelessly without breaks to guarantee effective care of COVID patients, especially those requiring long, highly demanding hospitalization periods in ICUs.

There still remains a certain degree of heterogeneity in decision-making regarding both the logistics and the internal politics across Italian hospitals and regions regarding the management of services, wards and ICUs, the remodulation of responsibilities among healthcare professionals, as well as the security practices and the operating room schedules.

Nonetheless, it is important to highlight that there has been a significant proactive spirit of participation, solidarity, and commitment among Italian healthcare professionals from all regions.

In this regard, thanks to the potential of social media and technology, it has been possible for all doctors working on the front-line to share a tremendous amount of information, experiences and recommendations on clinical management of COVID patients as well as correct application of preventive measures in relatively short timeframes.

In this scenario, Careggi University Hospital in Florence, a high-volume referral centre with >1200 beds, >45 operating rooms and >110 000 visits at the Emergency Department per year, has entirely reorganized the Emergency Service logistics to ensure a separate, specific diagnostic pathway for patients with suspected coronavirus infection.

Moreover, the logistics of available ICUs have been remodeled in order to concentrate all suspected or laboratory-confirmed cases in one ICU, leaving the others available for “COVID-free” patients.

The organization and logistics of the Internal Medicine, Infectious Diseases, Surgery and Radiology Services have been also significantly revised to ensure maximal availability of healthcare professionals and resources in the most critical departments in case of need.

At the Department of Urology and Renal Transplantation of Careggi University Hospital, directed by Prof. Sergio Serni and Prof. Marco Carini, several critical modifications of the operating room schedule and of the activities of the outpatient clinic have been ordered in the past two weeks.

Firstly, all elective medical visits and procedures in the outpatient clinical setting have been canceled, including Extracorporeal Shock Wave Lithotripsy, circumcisions, cystoscopies for benign diseases, and follow-up visits for non-urgent reasons. The only exceptions are represented by prostatic biopsies, cystoscopies for suspected bladder cancer and/or hematuria, and first visits for patients requiring urgent urological consultation after a screening phone interview.

Overall, there has been a reduction in the number of operations that are allowed to be performed in the urological operating rooms, with a subsequent reduction in the number of beds of the Inpatient Clinic.

In particular, all elective urology operations for benign conditions (such as TURP, Holep, RIRSs, PCNL, pyeloplasty, surgery for pelvic organ prolapse or urinary incontinence, as well as andrological surgery) have been canceled. In addition, renal transplantation from living donors is currently suspended.

Urological emergencies, including ureteric stones, are currently being performed in our ORs, as needed, provided adequate preventive measures for both patients and staff are in place, and after careful evaluation of the individual case.

Interventions for genitourinary cancers are currently being performed according to their priority. Cancer operations scheduled with the maximal priority (priority “A”) are currently performed according to the waiting list. These operations include TURB, radical cystectomy, partial nephrectomy, radical nephrectomy/nephroureterectomy, ureterectomy, orchiectomy, retroperitoneal lymph node dissection, penectomy, and radical prostatectomy for intermediate-high risk prostate cancer.

Cancer operations scheduled with a lower priority (priority “B”), such as radical prostatectomy for low-risk prostate cancer, are currently being postponed.

Finally, renal transplantation from deceased donors is currently being performed without restrictions, provided that the donor was negative for coronavirus infection.

To date, both residents in urology and consultant urologists at Careggi University Hospital are not being trained to treat critically ill patients with COVID infection.

Overall, the decision to allocate Urologists into ICUs in support of anesthesiologists and intensive care physicians to help cope with the emergency related to the coronavirus infection depends on several factors, including the particular hospital’s scenario, internal politics, needs and available resources.

I do hope that this information might be of value for healthcare professionals and decision makers involved in the management of the COVID epidemic in UK, and that the Italian example might be taken into consideration to prevent further spread of the infection across Europe and worldwide.

Thank you again for the opportunity to share my perspective with all of you,

Best wishes

Riccardo Campi, MD

China

From: Professor Guohua Zeng, First Affiliated Hospital of Guangzhou Medical University

How to deal with urological patients during coronavirus epidemic?

1. First of all, we recommend that our new or old patients use online services or telephone medical advice. In my department, most of the consultants are using an online APP for free consultation during the coronavirus period. We therefore reduce the number of visiting patients remarkably.

2. For those who have to come to the hospital in person, they need to make an appointment online first. A questionnaire needs to be completed to clarify their epidemic history within the last 2 weeks. If a patient has positive epidemic history, fever, respiratory symptoms, he/she will be assigned to the designated hospital for isolation and treatment. If not, he/she could see a urologist in the temporary outpatient clinic. In the temporary shelter clinic, wearing masks and single room occupancy are obligatory. Urologists are asked to wear examination gloves, isolation gowns, surgical masks, eye protection and disposable hat and shoe covers in a single room for face to face consultation. Negative complete blood count, chest CT and oropharyngeal swab DNA test are compulsory prior to inward admission or day surgery.

3. One patient-one room policy was obligatory for inpatients. Urological treatment was implemented as routine as long as the patient was proved to be coronavirus free.

4. For coronavirus-infected urinary patients, they were referred to a designated hospital in Guangzhou. A negative pressure stretcher was used for transportation all the way along. Grade 3 protection strategies are required for all relevant staff including surgeons, scrub team, anesthetists, technicians and cleaners during the whole period of treatment.

5. In my institute, the fast track of the coronavirus screening usually needs about 6 hours: 6 hours for the swab DNA test, 2 hours for chest CT scan, 1 hour for CBC. Therefore, for emergent and urgent urological situations, such as kidney rupture needing resuscitation or testes torsion needing exploration, patient will be sent to the designated hospital in the first place. For other non-life-threatening situations such as renal colic or urinary retention, patients were allowed to stay in the temporary shelter clinics waiting for the result of coronavirus screening before they are admitted.

Guohua Zeng

-Dr and Prof in Urology
-Vice-President, the First Affiliated Hospital of Guangzhou Medical University
-Chief, Guangdong Key Lab of Urology
-President, Urological Society of Guangdong Province
-Vice-Chairman, Urolithiasis section of Chinese Urological Association
-Co-chairman and General Secretary, International Alliance of Urolithiasis(IAU)

South Korea

From: Professor KH Rha, Department of Urology at Yonsei University Medical School

To update you on the Corona story in Korea: we had a massive outbreak in Daegu stemming from a religious gathering about a month ago and the medical community put all-out effort to contain this within the region which seems quite successful (different from the Taiwan model where they stopped all international traffic).

There have been no cancellations of elective operations; rather there are layers of entrance evaluations. More importantly everyone wears a protective mask to prevent any inadvertent transmission of the virus. (This aspect is different from US/European protective guidelines which time will tell…)

Urologists are not handling critically ill patients but we take turns in screening centers and other preventive measures.

To increase awareness of the magnitude of the disease, the Korean Society of Laboratory Medicine has prepared a massive screening program since 2017 after MERS-Coronavirus attack in Korea which had 39 casualties. We can do >15 000 tests a day with more than 200+ institutions. Also every patient’s whereabouts is posted on the web and text messages are used to avoid spread. They are unsung heroes.

I think there seems to be a period of 3 weeks of spread.

KH Rha

-Professor, Department of Urology at Yonsei University Medical School
-Director of planning; Chief Operating Officer of Severance Hospital, Seoul, Korea
-Consulting Editor, BJUI
-Associate Editor, Korean Journal of Urology
-Editor-in-Chief, Asian Journal of Urology

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Dr Riccardo Campi is a resident in Urology and PhD student at the Department of Urology and Renal Transplantation, Careggi University Hospital in Florence, Italy

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