Perioperative Outcomes of Urological Surgery in Patients with SARS-CoV-2 Infection

The global incidence of severe acute respiratory virus coronavirus 2 (SARS-CoV-2) infection continues to increase daily. To date, many urological centres have prioritised their patients for urgent surgical intervention because of a reduction in operating theatre availability and the risk of hospital-acquired SARS-CoV-2 infection [1], [2]. The first confirmed case of SARS-CoV-2 infection in the Republic of Ireland was diagnosed on February 29, 2020 and as of May 8, 2020, there have been 22 385 confirmed COVID-19 cases, which represents a case rate of 453.3 per 100 000 population [3]. Here we present our perioperative outcomes for patients undergoing urological surgery during the initial stage of the SARS-CoV-2 pandemic in Ireland (between March 16 and May 1, 2020, inclusive).

Our hospital has an onsite microbiology laboratory that performs daily SARS-CoV-2 real-time reverse-transcription polymerase chain reaction testing. Our screening policies for elective and emergency urology patients are detailed in the Supplementary material. During the initial 7-wk period of the SARS-CoV-2 pandemic, 101 urological procedures were performed: 73 urgent elective (age 62 ± 13 yr, and American Society of Anesthesiologists [ASA] score 2.65 ± 0.56) and 32 emergency cases (age 51 ± 20 yr, ASA score 1.68 ± 0.82). Elective surgery was prioritised according to recent European guidelines and patients were then placed on a centralised departmental theatre waiting list [1]. Details on all elective and emergency urological procedures are summarised in Supplementary Table 1 and Supplementary Table 2, respectively.

In total, seven patients (7/101, 7%) developed symptoms of SARS-CoV-2 infection during the postoperative period, of whom three male patients (3/101, 3%) were diagnosed with symptomatic SARS-CoV-2 infection. All three SARS-CoV-2–positive patients developed significant postoperative pulmonary complications (Supplementary Fig. 1) and one patient died. The remaining four patients were subsequently diagnosed with pyelonephritis (n = 1) or postoperative atelectasis (n = 3) after a negative SARS-CoV-2 nasopharyngeal swab (Table 1 ).

Table 1.

Summary of clinical parameters and clinical course in seven patients with suspected SARS-CoV-2 after urological surgery^a.

	Patient 1	Patient 2	Patient 3	Patient 4	Patient 5	Patient 6	Patient 7
Gender	Male	Male	Male	Female	Female	Female	Male
Indication for PO SARS-CoV-2 NS	Pyrexia, dry cough, malaise	Pyrexia, dry cough, dyspnoea	Dry cough, dyspnoea, malaise	Pyrexia, dry cough	Pyrexia	Pyrexia	Pyrexia, dry cough
SARS-CoV-2 Dx	Yes	Yes	Yes	No (atelectasis)	No (atelectasis)	No (pyelonephritis)	No (atelectasis)
Positive SARS-CoV-2 NS	Yes	Yes	No	No	No	No	No
Age (yr)	53	82	67	70	49	56	77
Procedure	LN	TURBT	RARP	LN	Cystectomy	Cystectomy	Nephroureterectomy
Comorbidities	HTN	HTN, ex-smoker	Smoker	HTN, provoked DVT	Thrombophilia	HTN	T1DM, HTN
ASA score	3	3	2	2	3	2	3
BMI (kg/m2)	33.6	29.6	31.6	35.5	34.8	25	33
Time to Dx after surgery (d)	14	4	20	2	4	26	2
Onset to Dx (d)	3	6	1	1	1	1	1
Date of SARS-CoV-2 Dx	April 12, 2020	April 18, 2020	April 9, 2020	N/A	N/A	N/A	N/A
ICU support required	No	No	Yes	No	No	No	No
Fever	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Highest fever (°C)	39.1	40	35.5	38.2	38.5	39.1	38.2
Diarrhoea	No	No	No	No	No	No	No
Highest CRP (mg/l)	269	272.9	107	Not measured	282	186	224
Lymphopenia	No	Yes	No	No	Yes	Yes	Yes
Elevated sCr (μmol/l)	176	194	161	127	No	No	258
SARS-CoV-2–related events	Viral pneumonia: bilateral pleural effusions and patchy GGO on CXR	Viral pneumonia: GGO changes involving all lobes of both lungs on CT, MI	Overwhelming ARDS within 4 h of readmission	N/A (atelectasis)	N/A (atelectasis)	N/A	N/A
SARS-CoV-2 treatment	NIV (CPAP/BiPAP)	NIV (CPAP/BiPAP)	Ventilated	N/A	N/A	N/A	N/A
SARS-CoV-2 outcomes	Discharged after 27 d	Current inpatient (20 d after Dx)	Mortality	N/A	N/A	N/A	N/A

ARDS = acute respiratory distress syndrome; ASA = American Society of Anesthesiologists; BiPAP = bilevel positive airway pressure; BMI = body mass index; CPAP = continuous positive airway pressure; CRP = C-reactive protein; CT = computed tomography; CXR = chest X-ray; DVT = deep vein thrombosis; Dx = diagnosis; GGO = ground glass opacity; HTN = hypertension; ICU = intensive care unit; LN = laparoscopic nephrectomy; MI = myocardial infarction; N/A = not applicable; NIV = noninvasive ventilation; NS = nasopharyngeal swab; PO = postoperative; RARP = robot-assisted radical prostatectomy; sCr = serum creatinine; T1DM = type 1 diabetes mellitus; TURBT = transurethral resection of bladder tumour.

^aPatients 1 and 2 had a positive PO NS for SARS-CoV-2. Patient 3 had a clinical diagnosis of SARS-CoV-2. Patients 4–7 had one or more symptoms of SARS-CoV-2 and a negative NS for SARS-CoV-2.

Data on the safety of surgical procedures in SARS-CoV-2 hospitals are important so that knowledge can be provided to surgeons on perioperative SARS-CoV-2–related outcomes during the COVID-19 pandemic. At present, various guidelines and opinions on preoperative SARS-CoV-2 screening protocols are available (eg, thorax computed tomography vs nasopharyngeal swab). However, such guidelines are limited by their level of evidence as, to date, they are based on expert opinion without robust prospective data [4]. Our current departmental policy is to perform a screening telephone interview 7 d before surgery and to advise elective patients with asymptomatic COVID-19 to self-isolate. A second screening telephone interview in conjunction with a nasopharyngeal swab is carried out 24–48 h before all elective surgery cases.

Our short-term findings demonstrate that the incidence and mortality rate of symptomatic SARS-CoV-2 infection is approximately 3% and 1%, respectively, among patients undergoing urological surgery during the pandemic. Diagnosis of postoperative SARS-CoV-2 infection is difficult, as symptoms mimic common postoperative surgical complications (eg, atelectasis). Patients who experience postoperative COVID-19 are likely to develop significant respiratory complications and have a prolonged inpatient admission. Information from this study will enable surgeons to balance the risk of delaying urgent surgical procedures against the increased morbidity and mortality associated with SARS-CoV-2 infection.



Conflicts of interest: The authors have nothing to disclose.

Appendix A. Supplementary data

The following are Supplementary data to this article: