INTRODUCTION
COVID-19 in Washington State has led to unprecedented challenges within the Urologic
community as physicians work to provide care that is safe for patients and staff.
In order to conserve personal protective equipment (PPE) and to ensure hospital capacity
for COVID-19 infected patients, Washington State Governor Jay Inslee directed that
elective surgical procedures should be suspended on March 19, 2020 (1). However, non-elective
Urologic care still needed to be provided.
Preventing transmission of COVID-19 has been of paramount concern during the pandemic.
Procedural care is at particularly high risk with its associated aerosol-generating
procedures: intubation and extubation (2). Patients cannot be screened for infection
solely based on symptoms, as a significant number are asymptomatic (3, 4), and many
carriers never develop symptoms(5). Providing fit-tested N95 masks to all procedural
staff is not currently feasible given the international shortage of PPE (6).
Furthermore, pre-test probability of infection is difficult to estimate as our community's
COVID-19 burden has not been established, and studies have demonstrated significant
geographic variability within the United States (7, 8). Further complicating the picture
are the wide variety of available testing modalities with a range of sensitivity,
specificity, and negative and positive predictive values. The majority of these have
been FDA approved under emergency use authorization (9).
The harm in suspending Urologic care to the community is significant. Increased surgical
waiting time (SWT) for T3 renal masses has been associated with decreased overall
survival (10), and a delay in bladder cancer treatment has been demonstrated to lead
to worse prognosis and higher pathologic stage (11). Based on Organ Procurement and
Transplantation Network Data as of May 1, 2020 there has been nearly a 50% decrease
in the number of kidney transplants performed in mid-March compared to mid-April,
impacting a pre-existing shortage in available organs (12). Delayed relief of ureteral
obstruction is associated with long-term renal dysfunction (13). Finally, the psychological
impact of a delay in surgical care cannot be underestimated, affecting patient anxiety
level and general health perceptions (14).
In order to safely provide care for those who may be harmed by a treatment delay,
on April 1st, 2020 Virginia Mason Medical Center committed to screen all patients
prior to any surgical care. This implementation appears to be an effective measure
to protect patients and staff, with no known COVID-19 cases in perioperative staff
since the advent of screening. The primary objective of this study was to evaluate
the impact of pre-operative COVID-19 screening on our ability to provide Urologic
care. This was measured using Urologic surgical volume during an interval when discretionary
surgery was suspended.
MATERIALS AND METHODS
Testing: Effective April 1, 2020 all pre-procedural patients were tested for COVID-19.
Testing occurred within 48 hours prior to the scheduled intervention or at the time
of hospital admission. A nasopharyngeal swab specimen was collected and processed
using the Abbott RealTime SARS-CoV-2 assay. Mid-turbinate testing was substituted
for nasopharyngeal swabs on May 3, 2020 in accordance with expanded CDC sampling guidelines
(15). Patients who screened positive for COVID-19 were rescheduled to a later date.
If medically stable, they were discharged home, and rescheduled for surgery following
two subsequent negative repeat screening tests. In emergent situations, patients were
either screened with a rapid ePLEX SARS-CoV-2 test or their procedure was performed
in a specially engineered negative air pressure “COVID pod,” utilizing Powered Air-Purifying
Respirators or fitted N95 face masks and eye protection. PPE for patients who tested
negative for COVID-19 included standard surgical masks and protective eye shields.
Stratification: All cases were triaged into one of five tiers: Emergent, Urgent, Planned
Procedure level 1, Planned Procedure level 2, and Discretionary Procedure (Table-1).
Proposed procedures were reviewed by an independent multidisciplinary committee to
ensure that purely discretionary procedures (defined as a delay in performing the
intervention would not result in harm to the patient) were not performed during the
March 19 to May 18, 2020 prohibition period.
Table 1
Triage levels used to determine case urgency during the COVID-19 pandemic with corresponding
urologic procedures (non-exhaustive list).
Triage Level
Example of Procedures
Emergent
Fournier's gangrene debridement, decompression for obstructive pyelonephritis
Urgent
Decompression of symptomatic nephrolithiasis, cystoscopic fulguration for active bleeding
Planned Procedure Level 1
Transurethral resection of high-grade bladder tumor
Planned Procedure Level 2
Radical prostatectomy for high-risk prostate cancer, deceased donor renal transplant
Discretionary
Inflatable penile prosthesis insertion, mid-urethral sling
Data Collection and Analysis
Data regarding Urologic operative volume was collected retrospectively. Only procedural
care based in the operating room was included in the analysis. Comparison of surgical
volumes was performed between baseline [one year prior to the COVID-19 pandemic (March
19-May 6, 2019)], pre-intervention (March 19-March 31, 2020), and post-intervention
(April 1-May 6, 2020) time periods. All statistical analyses were 2-sided, and significance
was defined as p <0.05. Statistics were performed using STATA v13.0 (StataCorp, College
Station TX).
RESULTS
Screening: As an institution, 840 asymptomatic patients were screened from April 1,
2020-May 6, 2020. Three patients (4%) tested positive. A total of 126 urology cases
were performed and a total of 118 urology patients were screened. None were positive.
Operative Volume: Baseline: March 19 through May 6, 2019, 295 Urologic surgeries were
performed (6.0 surgeries/day (SD=4.5)). These cases were categorized as follows: 1.9
cases/day general urology (31.9%), 1.4 cases/day oncology (23.7%), 1.2 cases/day endourology
(19.7%), 0.9 cases/day female pelvic medicine and reconstructive surgery (FPMRS) (14.6%),
0.5 cases/day transplant (8.1%) and 0.1 cases/day reconstruction (2.0%).
Prior to pre-surgical COVID-19 screening: March 19 through March 31, 2020, 21 cases
were performed (1.6 surgeries/day (SD=1.9)). Of these cases, 0 were defined as emergent
or urgent, 13 were defined as planned level 1, 8 were defined as Planned level 2,
and 0 were defined as discretionary. These cases were categorized as follows: 0.2
cases/day general urology (14.3%), 0.5 cases/day oncology (28.6%), 0.6 cases/day endourology
(38.1%), 0.3 cases/day FPMRS (19.0%), and 0 reconstruction and transplant.
After initiation of pre-surgical COVID-19 screening: April 1st through May 6, 2020,
126 Urologic surgeries were performed, (3.5 surgeries/day (SD=2.9)). Of these cases,
1 was defined as emergent, 12 were defined as urgent, 73 were defined as planned level
1, 39 were defined as Planned level 2, and 1 was defined as discretionary. These cases
were categorized as follows: 0.9 cases/day general urology (24.6%), 1.2 cases/day
oncology (34.9%), 1.0 case/day endourology (28.6%), 0.3 cases/day FPMRS (7.14%), 0.1
cases/day reconstruction (2.4%), and 0.1 cases/day transplant (2.4%).
The Urologic operative volume was significantly different between baseline and the
pre-screening period (p=0.001), between baseline and the post-screening period (p=0.004),
and between the pre-screening and post-screening period (p=0.036). There was no significant
difference between age or gender distribution between any treatment period. There
was a significant difference in the distribution of urology cases performed stratified
by subspecialty between all three treatment periods (p=0.008).
DISCUSSION
This study demonstrates the utility of pre-operative screening as a means to safely
expand Urologic care during the COVID-19 pandemic. Following the institution of this
policy, the Virginia Mason Urologic service cared for more than twice the number of
patients and mitigated the harm to our community caused by prolonged SWT. Compared
to baseline, there was a trend towards higher proportion of oncologic and endourologic
cases and fewer transplant cases performed in both pre-screening and post-screening
eras. Of interest, the proportion of FPMRS initially increased and then declined precipitously.
The inability to access timely Urologic care has an adverse impact on society. An
absence of Urologic care has been shown to increase disability-adjusted life years
in regions without access to care (16). Surgical waiting time is well established
as a risk of Urologic disease progression. Fahmy et al. performed a meta-analysis
to evaluate the effect of delay in cystectomy on patients with muscle-invasive bladder
cancer. The majority of studies evaluated suggested that treatment delay resulted
in worse prognosis and higher pathologic stage, and the authors suggest that treatment
should be performed within 12 weeks of diagnosis to ensure there is no harm to the
patient (11). Similarly, Zeng et al. showed that a delay in nephrectomy for greater
than 10 weeks in patients with pT3 renal cell carcinoma is associated with decreased
5-year overall survival (10). Finally, it has been well established that delay in
relief of ureteral obstruction can lead to long-term renal damage (13). It is therefore
not surprising that oncologic cases and endourologic cases increased proportionately
within our case volume during the COVID time periods.
This study was performed in the context of previous research suggesting that our pre-operative
COVID-19 screening protocol provides a safe environment for perioperative staff. Virginia
Mason Medical Center is a 336 bed private hospital based in Seattle, WA with 11 full
time Urologic surgeons. Currently, there is no pediatric or obstetric care at our
hospital. Over the course of 5 weeks the Virginia Mason operating room performed 837
procedures on asymptomatic patients without a documented case of COVID-19 amongst
procedural staff. Staff were tested if symptomatic, per institutional protocols. Prior
to institution of screening, one peri-operative staff member tested positive for COVID-19.
Although the proportion of FPMRS cases decreased from 19.0% during the pre-screening
period to 7.1% during the screening, the actual number of cases per week remained
stable between these two time periods at 0.3 cases/day. The most common procedures
performed were mesh excision followed by stage II Interstim. Options for Interstim
were to cut the externalized wires at the skin and wait until the pandemic had passed
or to complete the second stage. No stage I Interstim cases were initiated. Alternatives
for the mesh exposure and erosion patients were to provide supportive care through
reassurance, counseling, analgesia and antibiotics as necessary. However, the limitation
for these options in patients who were stressed or in pain was that the temporal end
point was unknown at the time of decision-making. Of note, a single discretionary
sling procedure was performed. It represents a “systems error,” and emphasizes the
practical difficulty of instituting hospital-wide policy change.
Transplant surgery presents a unique challenge. Suspension of renal transplant led
to the loss of viable organs for patients on dialysis in a system that already has
a significant shortage of organ donors (12). However, continuing transplantation needs
to be considered in the setting of the immunosuppression required for allogeneic organ
transplant. Admission of immunosuppressed patients to the hospital during this pandemic
increase their potential exposure and susceptibility to infection and transplant recipients
admitted for COVID-19 infection have a mortality rate approaching 25% (17). The American
Society of Transplantation has stated that both donors and recipients should be screened,
and all organ procurement should be done locally if possible (18). In an attempt to
mitigate risk to living transplant donors and recipients, it was our policy to suspend
living organ donation between 3/19/20-5/6/20, but to continue our deceased donor transplant
program. Deceased donor recipients were also required to be local and to be confirmed
not to have been sensitized. The observed trend toward fewer organ transplants during
the COVID-19 pandemic compared to baseline was likely secondary to national guidelines,
institutional policy, organ availability, patient preference.
The implementation of pre-operative screening during the directive to delay all elective
procedures has allowed us to better care for our community. We acknowledge that operating
rooms are a major driver of hospital revenue, and the financial impact of cessation
of elective surgeries on hospitals has been profound. However, safety and mitigation
of harm to our patients must be the primary driver behind this intervention. Deciding
which patients would suffer harm through significant delay in surgical care to the
extent that they require treatment in the setting of a pandemic is not a trivial decision.
Using a five-tiered triage system and a multidisciplinary hospital committee to evaluate
the need for every case to proceed ensured that patient well-being was the primary
goal.
This 5-tiered triage system reflects the approach undertaken by other organizations
(19). Rather than a tiered system, the European Association of Urology released a
list of suggested procedures during this time (20). Carneiro et al. have released
guideline proposals for urologic care during the COVID-19 pandemic in low- and middle-income
countries. Similar to other literature, they recommend COVID-19 pre-screening when
accessible, and a triaging system with continued surgical management of high-acuity
issues such as >T1a renal neoplasms and bladder neoplasms (21). This approach limits
unnecessary surgery during the COVID-19 pandemic. Although case volumes did increase
in this study, expansion was done with the clear objective of performing procedures
to manage acute disease processes, prevent harm to our patients, limit COVID-19 exposure,
and conserve PPE. As the PPE shortage is relieved and emphasis changes, this study
provides a model for expansion of a Urologic practice at a time when many institutions
are resuming elective surgery (22).
There are several weaknesses in this study: First, it was performed in a single institution.
Second, the COVID-19 pandemic is rapidly evolving. Although screening facilitates
appropriate and responsible assessment of patients prior to proceeding with care,
it is unclear if the same strategy will be effective as the disease prevalence changes.
Finally, our community currently has a relatively low penetrance of COVID-19. Applicability
to regions with far greater burden have yet to be proven.
CONCLUSIONS
We believe that pre-procedural COVID-19 testing is a scalable intervention that will
provide a means to safely reimplement care for the Urologic community. Eventually,
Urologic surgical volume will need to expand nationwide in the setting of the ongoing
COVID-19 pandemic and limited PPE. Universal COVID-19 screening of pre-operative patients
represents a viable means to meet the needs of our patients.