We have retrospectively evaluated all patients who underwent elective surgery in the urology department of our institution from March 9 to April 24, 2020.
All patients were listed in order of priority: red, yellow and green codes in order to stratify the risk of disease progression or immediate complications.
We identified non-deferrable patients (red codes) that needed to be treated within one month: Muscle Invasive Bladder Cancer (MIBC), high risk non-MIBC, first observation bladder cancers >2cm, renal cancers, testis cancer, high grade Upper Tract Urothelial Cancers (UTUC), high risk locally advanced prostatic cancer, obstructive or acute infected stones. All patients included have followed a dedicated pathway from the day-hospital till the discharge.
The exclusion criteria were deferrable benign urologic conditions and critical patients who required or likely to require ICU assistance postoperatively that were transferred to non-COVID-19 hospitals in consideration of the limited availability of anaesthesiologists and ventilators.
The diagnosis of infection was based on clinical suspect of SARS-CoV-2 infection, radiological imaging features at chest X-ray and/or virological diagnosis confirmed through real-time PCR.
If the patients did not pass any of the “check-points” before the admission to hospital because of a suspected infection, they were ruled out and started again the protocol after a 14 days waiting.
Sixty-four (64) patients were enrolled. Two (2) of them were found to be infected because of radiological and swab positivity.
Clinical data, as nasopharyngeal swabs, chest X-ray, type of anaesthesia, type of surgical procedure and days of hospitalization were collected. Moreover, individual risk factors for COVID-19 pneumonia, as advanced age, ongoing malignancy, high blood pressure and coronary artery disease, were analysed.
The onset of possible COVID-19 symptoms, as fever, cough, dyspnoea, anosmia or ageusia, headache and gastrointestinal symptoms were collected by telephone interviews. A median follow-up of at least 14 days after discharge has been adopted.
Protocol: Safe pathway for elective surgical patients
- Phone call
All patients were phone-called 2/3 days before the day-hospital. The patients’ interview was focused on suspected symptoms for COVID-19, professional exposure or contacts with infected people in the last 14 days.
If a possible infection was suspected, the patient had to respect a home quarantine, as indicated by the Lombardy Region in DPCM of 8th March 2020 , and the protocol would be repeated after 14 days.
Conversely, the physician gave to the patient an appointment for the day-hospital. If the patient developed symptoms in the two days before the admission to hospital, he had to take a nasopharyngeal swab, performed externally, and had to inform the staff.
- Hospital entrance check
The day-hospital was programmed 24-48 hours before the planned operation-day.
At the hospital entrance every patient was controlled. A nurse verified the body temperature and made the same focused interview on COVID-symptoms, to have a second security check. In case of suspect, the nurse suggested to reach directly the Emergency Department (ED).
If check point was passed, the patient would be admitted to hospital. A surgical mask and alcohol based hand gel were given. The use of masks for patients and all the hospital workers is compulsory.
- Day Hospital
The patient reached the dedicated area. A nurse performed a nasopharyngeal swab, blood sample with pre-operative exam and an electrocardiogram. The patient also underwent a Chest X-Ray. Last steps were the consultations with the urologist and the anesthesiologist.
- Nasopharyngeal swab and chest x-ray result
24 hours after the day-hospital, if one of swab or X-ray resulted positive or suspected for COVID-19, the patient was called and suggested to follow the indication for a home quarantine. If all the exams were negative, the patient was programmed for surgery the next day.
- Surgery day
Patients had to perform once again the same control at the hospital entrance (point 2). After that, they reached directly the “free ward”, a dedicated ward in which only patients checked negative were allowed.
The patients were not allowed to exit from their room and must wear surgical masks all time.
To reach the surgical theater, the patients were transported in a different path form the one used for the COVID-19 patients and a dedicated operating room for not infected patients was used.
All health workers wore constantly surgical mask and gloves.
- Post-operative hospitalization
During the hospitalization if patient developed fever or suspected symptoms, a Chest imaging was performed. If there was a suspect of infection, the patient was soon transferred to a “grey ward” in a single room to guarantee the isolation and repeated the nasopharyngeal swab.
A summarized flowchart of the protocol that we have proposed is represented on Figure 1.