key: cord-0850566-1nu8trfv
authors: Ingels, Alexandre; Bibas, Steeven; Abdessater, Maher; Tabourin, Thomas; Roupret, Morgan; Chartier‐Kastler, Emmanuel; Barker, Gwendolyn; Tobbal, Nouha; Doizi, Steeve; Cussenot, Olivier; Prost, Doriane; Desgrandchamps, Francois; Ouzaid, Idir; Rollin, Paul; Hermieu, Jean‐Francois; Audenet, Francois; Userovici, Mickael; Mejean, Arnaud; Anract, Julien; Roux, Sabine; Peyromaure, Michael; Couteau, Nicolas; Lebacle, Cédric; Irani, Jacques; Vordos, Dimitri; Yiou, René; Hoznek, Andras; Champy, Cecile M; Da Costa, Jose Batista; De La Taille, Alexandre
title: Urology surgical activity and COVID‐19: Risk assessment at the epidemic peak the parisian multicenter experience
date: 2020-07-08
journal: BJU Int
DOI: 10.1111/bju.15164
sha: f077ea0a12f80fab996a1579cbd3cad8975be5f4
doc_id: 850566
cord_uid: 1nu8trfv

OBJECTIVES: To evaluate the risk of contracting severe COVID‐19, defined as COVID‐19 specific intensive care unit (ICU) admission or death, for patients undergoing urological surgery during the epidemic. To define consequences of receiving surgery for COVID‐19 patients. PATIENTS AND METHODS: This is a multicenter observational cohort study. Every patient receiving a urological procedure in Paris academic urological centers during the 4 initial weeks of surgical restrictions were included. Their status was updated minimum 3 weeks after the procedure. The main outcomes were the COVID‐19 specific ICU admission and death. Statistics were mostly descriptive. The Post‐operative COVID‐19 confirmed group was compared with non‐COVID patients using Chi‐square tests for categorical and Wilcoxon test tests for continuous variables. RESULTS: During the 4‐week period, 552 patients received surgery within 8 centers. At follow‐up, 57 (10%) patients were lost. Among the 11 preoperative COVID‐19 cases, one remained in ICU, no new admission, and no death. For the non‐COVID patients, 57 (12%) developed COVID‐related symptoms; only one case (0.2%) required COVID‐19 specific ICU and 3 (0.6%) patients died of COVID‐19 after surgery. CONCLUSIONS: Performing urological surgery during the COVID‐19 epidemic peak has a limited impact on ICU admissions but presents a real (0.6%) risk of specific mortality. Surgical activities should be maintained according to this risk.

The Coronavirus Virus Disease 2019 (COVID-19) had a global impact on surgical activities. Precautionary principles pushed to restrain elective surgeries activities. The European Association of Urology Guidelines Office commissioned a Rapid Reaction Group to adapt the guidelines recommendations for the pandemic situation (1) . Some major keypoints were treating only high-priority and emergency cases surgically, considering older patients with comorbidity at severe risk of COVID infection and fatal outcome and testing staff and patients when resources were available However, little is known about the COVID-19 specific nosocomial risk for patients undergoing urological surgery.

The Paris area was particularly struck by the pandemic .The regional mortality rate from 2 nd March to 17 th April was increased of 96% as opposed to the same 2019 period

(2).

The aim of this study was to determine the risks associated with surgery and COVID-19.

The main outcomes were the COVID-19 specific death and Intensive Care Unit (ICU) admission. To achieve this, we collected clinical data on patients undergoing urological operations during 4 weeks at the epidemic peak from the 8 academic urology department of the Paris area.

This is a multi-center cohort study. All of the 8 Paris area academic urology centers (Assistance Publique Hôpitaux de Paris) participated. The protocol received the institutional review board approval and waived the informed consent obligation, since this is a non-interventional study based on regular healthcare data. Since we aimed to assess the nosocomial risk for the surgical population, all the patients receiving surgery during the 4 first weeks of national surgical restriction were included. The patients' clinical status was updated a minimum 3 weeks after the surgery to pass the potential incubation period. This status was collected from the medical file in case of death or current hospitalization or with a phone call when the patients were discharged.

A patient was considered as COVID-19 confirmed in case of a positive reverse transcription Polymerase Chain reaction (rt-PCR) test or presence of pathognomonic signs on chest computed tomography scanner (CT-scan).

The data collected included the academic center, patients demographic information, comorbidities, date of surgery, operation title, surgical approaches, emergency or oncologic indications, type of anesthesia (general, spinal, local), pre/post operative COVID-19 tests, post-operative symptoms (date, type) and more specifically fever, dry cough, muscle aches, shortness of breath, anosmia, ageusia, diarrhea, vomiting, sore throat or other, COVID-19 specific hospitalization/ICU admission/death, symptoms among patients surroundings.

From 13 th March 2020 to 9 th April 2020, 552 patients received surgery within the 8 academic centers; 495 (90%) patients' status were updated at a median time of 37 days and minimum 3 weeks after surgery, 57(10%) were lost of follow-up. At the time of status update, 10/495 patients (2%) had been admitted in an ICU and 8/495 (1.6%) died.

Patients characteristics are reported in Table 1 .

Regarding the type of surgeries, 166/552 (30%) patients presented for emergencies, 235 (43%) had oncologic indications. The details on surgeries are reported in Table 2 .

There was a significant difference within centers in terms of preoperative tests (<0.001; range 5-32%). The proportion of positive tests was also significantly different (<0.001; range 0-25%). There was no significant difference in terms of COVID-19 related postoperative symptoms (p-value: 0.15) nor COVID confirmed cases (p-value: 0.79).

For the pre-operative positive cases, 11/80 patients had a positive test before surgery, one patient had a fever at the time of surgery; he required a double J stent for an obstructive pyelonephritis and did not present another symptom post operatively. Only one patient developed COVID-19 related symptoms (fever, shortness of breath and muscle aches) 22 days after a nephrostomy placement. One patient was already in ICU for his COVID and required a nephrostomy; he was still hospitalized in ICU 47 days afterward. After surgery, no patient required a transfer to ICU or died.

Regarding the pre-operative negative cases, 69/80 patients had a negative preoperative test. Twelve (17%) developed COVID related symptoms after surgery at a median time of 13 days after surgery, the most common symptoms were fever (11), muscle aches (5) and diarrhea (3) . Sixteen patients were tested (9 symptomatic, 7 non symptomatic); 3 were positive. No patient required ICU nor died after surgery.

Considering the majority of the population without pre-operative COVID-related symptoms nor a positive test: they were 485 with the minimum 3 weeks follow-up. Fiftyseven (12%) developed COVID related symptoms at a median time of 12 days after surgery. The most common symptoms were fever (40), dry cough (15) and muscle aches (18). Eighty-two patients received a test after surgery (41 symptomatic, 41 nonsymptomatic); 16 were positive. The overall post-operative positive test rate was 19.5%; it ranged from 2.4% (1/41) for asymptomatic to 36.6% (15/41) for symptomatic patients. One patient (0.2%) required COVID-specific ICU hospitalization. He devel-

This article is protected by copyright. All rights reserved oped symptoms (dry cough and sore throat) 12 days after surgery and was admitted into the ICU 6 days later. He died 28 days after surgery. Totally, 3 patients died of COVID-19 at 15, 17 and 28 days after surgery; they were 85, 89 and 75 years old. Thus, the mortality rate for COVID-positive patients is 3/16=18.7%. While comparing the COVID-19 positive patients confirmed after surgery with the non-COVID patients. We found a higher proportion of patients with cardiac insufficiency (12.5% vs. 8.7%, 0.008) and obesity (18.75% vs. 12.1%, p<0.001) among the COVID+ patients. We did not find significant differences between the two groups within the centers; emergency status; oncological indication; the type of surgery; age; comorbidities, nor surgical approach.

These results are reported in Table 1 .

This study is the first report on overall urology surgical activities during the COVID-19

pandemic. The 4-week period of this cohort inclusion was at the epidemic peak and mostly concomitant with the national lockdown (17 th March-11 th May), limiting the likelihood of extra-hospital contamination.

There are important informative facts from these outcomes. Firstly, the pre-operative COVID-19 confirmed cases evolution appeared favorable, per se, without clinical status worsening (ICU transfer or death). These outcomes are better than the series from COVIDsurg (3) and Lei et al (4). Secondly, the nosocomial burden of surgical patients on ICU department is very low with only one (0.2%) patient requiring COVID-19 specific ICU admission after being infected per-operatively. Thirdly, as reported in previous report (5,6), we found a higher proportion of patients with comorbidities (obesity and chronic cardiac failure) among the patients infected after the surgery. Fourthly, with 3 (0.6%) COVID-19 specific death after surgery, the specific mortality is low but not negligible. The mortality rate of 18.7% for patients confirmed with COVID-19 after the surgery is high. This outcome fits other series (3, 4) . However, none of the 3 studies had a systematic post-operative COVID-19 test. Therefore, the detection of post-operative disease was often made when symptoms were present and missed asymptomatic COVID-positive patients. This bias might lead to an overestimation of the mortality rate.

For instance, our series reports one positive patient out of 41 non symptomatic tested

This article is protected by copyright. All rights reserved before a second surgery or transfer to another institution. The detection of this asymptomatic COVID-positive patients could explain the slightly better outcomes in our study (18.7%) than COVIDSurg (23.8%) or Lei (20.5%). Even though we cannot completely rely on this 18.7% figure, it argues to maintain surgery for indications that could hardly be postponed, particularly for the elders and frail patients. It is noteworthy that mortality rate was higher than ICU admissions. Two deceased patients were 85 and 89 years old and not eligible for intensive cares.

A recent study from Paramore et al (7) Interestingly, their outcomes were relatively similar to ours with a 0.7% (2/305) COVID-19 specific mortality after surgery (9) .

However, It is difficult to compare with other centers who were going through the peak of the pandemic at different points than our current reported experience, when less or more may have been understood about pre-operative testing, personal protective equipment, cold sites etc… A limitation of this study is the low rate of COVID-19 tests. There was a nationwide shortage of rt-PCR at the beginning of the pandemic. The low pre-operative test rate (14%) reduces links to the nosocomial origin of the infection. The low post-operative Accepted Article test rate (17%) reduces detection of non-symptomatic patients. However, we can conclude on the severe post-operative infection rates leading to ICU admission or death.

This study reports the largest experience of urological surgery in the era of COVID-19 pandemic in a strongly affected area. It concludes with a minimal impact of the postoperative nosocomial disease on intensive care units and a limited but real risk of COVID- Table 1 : Patients' characteristics and comparison between the non-COVID patients and post-operative COVID confirmed patients Local 52 ( 9.5) 2 ( 18.2) 50 ( 9.6) 0 ( 0.0) 

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