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Managing change in the urology department of a large hospital in Italy during the COVID‐19 pandemic

2020; Wiley; Volume: 27; Issue: 9 Linguagem: Inglês

10.1111/iju.14298

1442-2042

Francesco Chiancone, Paolo Fedelini,

COVID-19 and healthcare impacts

Italy was the first European nation to be affected by COVID-19. As of 23 April 2020, the total number of assessed cases in Italy was 189 973 (25 549 deaths), and Italy had the third highest number of patients after the USA (854 696) and Spain (213 024). On 8 March 2020, when the total COVID-19 cases in Italy were just 7375 (366 deaths), the Italian Government implemented extraordinary measures to prevent the spread of the disease. As a consequence, many hospitals reduced different healthcare services to better manage COVID-19 patients, in particular regarding intensive care admissions.1 "Cardarelli Hospital" (Naples), in the south of Italy (892 hospital beds), implemented urgent measures to reduce specialist visits, outpatient procedures and use of operating theaters2 to reserve manpower (in particular, anesthesiologists and nursing staff) for the COVID-19 Department. We evaluated the activity of the Urology Department during the first 4 weeks (from 9 March to 5 April 2020) of extraordinary measures of the Italian Government, compared with the same period of 2019 (from 11 March to 7 April 2019). The evaluation was concerned with outpatient visits, surgical procedures, prehospitalization activity and the whole activity of the department. Prehospitalization activity was reserved only for oncological patients, whereas outpatients visits were reserved only for people with significant urological problems. Scheduled outpatient visits were screened. Patients with non-significant pathologies were consulted through short message service and rescheduled. Prostatic biopsies and cystoscopies for patients at high risk of malignancy were allowed to proceed. Surgical procedures were proposed to all oncological patients and patients with severe sepsis.3 Elective surgery patients were consulted by telephone and postponed. Obstructive uropathy patients were postponed and given a warning to refer to the emergency department in case of colic with fever. Table 1 shows detailed information about the surgical and ambulatory activity during the two periods of analysis. A total of 32 out of 426 (7.5%) planned visits were carried out. The reason for the outpatient visits were known or suspected malignancy (18 patients), obstructive uropathy with severe hydronephrosis and/or fever (three patients) and immediate postoperative cases (11 patients). A total of 24 out of 28 patients (85.7%) with suspicious prostate cancer underwent biopsy, and 36 out of 38 (94.7%) patients with suspicious bladder cancer underwent cystoscopy. As suggested by panels of experts, intravesical BCG therapy should be continued during the COVID-19 pandemic. Consequently, 42 out of 42 patients (100%) received the treatment.4 Furthermore, 61 out of 83 oncological patients (73.5%) accepted the prehospitalization activity. The number of surgical procedures carried out during the pandemic period was inferior (99 vs 181 patients) compared with the same period in 2019, as well as the number of oncological procedures (61 vs 92 patients). A total of 61 out of 90 (67.8%) oncological patients accepted the suggested surgical treatment. A total of 25 patients with obstructive uropathy who reached the Emergency Department were treated with ureteral stenting or nephrostomy tube placement under local anesthesia, sparing a ventilator.5 Laparoscopic and robot-assisted procedures continued to be carried out using some precautions (the use of a continuous circulation of insufflation, the minimization of the gas leakage around the ports by matching skin incision with port size and the use a low-pressure pneumoperitoneum),6 despite some evidence suggesting that laparoscopy can cause a higher concentration of surgical smoke in the abdomen and cause viral aerosolization.7 In our population, anxiety of COVID-19 has spread faster than the virus. All 22 patients who refused prehospitalization activity and 19 out of 29 oncological patients (65.5%) who had a disease with a high risk of progression refused surgery, reporting fear of a greater risk of contagion regarding COVID-19 infection.3 Another five patients had low-risk prostate cancer (three patients) and a very small renal tumor (two patients), and they chose to delay surgery.3 For five patients (11.1%), surgery was postponed due to several comorbidities that required admission in the intensive critical units. Furthermore, the number of patients who reached the emergency department was lower in the pandemic period. This underscores the fact that emergency departments are usually consulted for non-urgent conditions. In addition, staff movement was reduced in high-risk areas only in the case of emergency to improve safety for patients and health workers. Finally, to minimize COVID-19 spread, multidisciplinary oncological meetings were held by video conferencing. None declared.