JCDR - Register at Journal of Clinical and Diagnostic Research
Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X
Surgery Section DOI : 10.7860/JCDR/2020/46423.14355
Year : 2020 | Month : Dec | Volume : 14 | Issue : 12 Full Version Page : PE01 - PE05

Impact of COVID-19 Pandemic on Urology Practice: Review of Literature

Mohammad Shazib Faridi1, Jasim Khan2, Hemant Goel3, Rajeev Sood4

1 Assistant Professor, Department of Urology and Renal Transplant, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India.
2 Fellow, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35233, USA.
3 Associate Professor, Department of Urology and Renal Transplant, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India.
4 Professor, Department of Urology and Renal Transplant, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India.


NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Mohammad Shazib Faridi, Assistant Professor, Department of Urology and Renal Transplant, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India.
E-mail: drshazibfaridi@gmail.com
Abstract

Coronavirus Disease (COVID-19) pandemic is a challenge to the healthcare system including urology which is big and formidable. The present scenario has changed the health preferences to emergency and essential services only. Reallocation of healthcare providers, wards and equipments resulted in suspension of all outpatient and elective activities to select only non-deferrable and critical procedures. Consequently, all health care workers including urologists must abide by the recommendations when dealing with the COVID-19 patients. This pandemic has also disrupted the training and education programs of urology residents also. Subsequently, in this review article, authors have discussed the influence of COVID-19 on urological practice. Authors have also reviewed the recommendations on triaging of urology procedures (emergent and non-emergent), office based urological procedures, oncologic surgeries, paediatric urology, urology-pathology interaction and economic burden on healthcare system during COVID-19 pandemic.

Keywords

Introduction

The World Health Organisation (WHO) named the causative virus as Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-COV-2), the resulting pneumonia as COVID-19 [1] and declared it as a pandemic [2] on 11th March 2020. The global number of cases has exponentially increased to 37,704,153 with 1,079,029 COVID-19 related deaths [3].

Coronaviruses are enveloped single stranded Ribonucleic Acid (RNA) viruses that affect respiratory, enterohepatic and neurologic systems in humans and mammals [4]. SARS-COV-2 is a highly infectious disease with three main routes for transmission- human-to-human, aerosol transmission, and transmission by touch [5]. Literature stated that urologists may have to deal with COVID-19 patients presenting only with fever and may misinterpret as urosepsis. Therefore, the awareness about the symptoms and their prevalence is important for all medical personnel even surgeons [6].

COVID-19 has emerged as the worst challenge to the global health care system in the modern era leading to net shift from patient-centred medicine to a community centred approach. This has resulted in a major redistribution of health resources in the form of reallocation of health care personnel, suspension of all non-urgent surgical procedures, limitation of inpatient and outpatient services to critically ill patients, closure of urology wards and the availability of anaesthetists [7-9]. Furthermore, many urology conferences including the European Association of Urology (EAU), the American Association of Urology (AUA) annual meetings were postponed during this pandemic [10]. Moreover, the current pandemic has also jeopardised the clinical researches which may affect their final outcomes [11]. Currently, the major concern is that there is no reliable provision on the duration of this pandemic and its economic and social consequences.

Covid-19 Affinity for Urology

Certain organs (including urothelium of bladder, proximal convoluted tubules in kidney) have high risk of viral invasion, based on the Angiotensin Converting Enzyme 2 (ACE2)-positive cells expression. SARS-COV-2 has a specific spike protein 3-D structure that has strong binding affinity to the ACE2 receptors [12] leading to Acute Kidney Injury (AKI) and sepsis [13,14]. A significant mortality rates (60-90%) were associated with AKI patients [13].

In the study for COVID-19 recovered patients, the viral RNA remained positive in the urine samples of 6.9% patients even after the throat swab turned to be negative [15]. On the contrary, another study showed that SARS-COV-2 was not identified in the urine specimens [16].

Furthermore, there is a major apprehension over the possibility of COVID-19 transmission through semen or sperm donation required for assisted reproductive techniques. Study conducted by Li D et al., found, semen testing of 6 (15.8%) patients out of 38 were positive for SARS-CoV-2 [17]. Although such detection should not come as a surprise, the contribution of semen to virus transmission and hence, further studies are required to determine the epidemiology and disease burden.

Recommendation for the triaging of the urology patients:

A five point scale for surgical priority tiers has been developed ranging from score 0 as emergency to score 4 as non-emergency case, requires urgent treatment to score 0 as non-essential procedures can be delayed [18]. The aim is to be prepared to suspend the surgical procedures on the basis of urgency in a staged manner.

EAU has also developed the recommendations based on the priority basis as follows [19]:

Life threatening situations cannot be postponed for more 24 hours (emergency). Surgeries, if postponed >6 weeks can lead to progression, metastasis of the disease, loss of organ function or deaths likely (high priority).

If postponed for 3-4 months, it is unlikely that disease progresses, metastasizes or loss of organ function occurs (intermediate priority).

If progression, metastasis or loss of function very unlikely if postponed 6 months (low priority).

Potential Effects on Urology Service

Emergency Procedures

Due to limited availability of Personal Protective Equipment (PPE), anaesthetists and ventilators during the COVID-19 pandemic, priority should be given to those procedures that can be performed under local anaesthesia even in urgent urological conditions [20,21].

For the management of upper urinary tract obstruction or infection, the use of ureteral stents or nephrostomy tubes under local anaesthesia is advocated but if not possible, then considers the ureteral stents under general anaesthesia. In case of acute retention of urine, the insertion of urethral or suprapubic catheter under local anaesthesia is advised. Furthermore, clot retention due to bladder or prostate cancer recommendation is for cystoscopic evacuation and transurethral haemostasis of the bladder or prostate cancer to limit the need for blood transfusion. Regarding patients with genitourinary trauma they recommended surgical exploration only in haemodynamically unstable patients otherwise proceed with procedures that can be performed under local anaesthesia. Lastly, the authors suggested immediate intervention of patients with priapism in the form of cavernosal aspiration or shunting, drainage and debridement for scrotal abscess or fourniers gangrene respectively, removal of device if artificial urinary sphincter or penile prosthesis got infected, surgical exploration for testicular torsion or penile fracture [21].

Non-Emergency Procedures

Oncology: Management of urological malignancies requires a multidisciplinary approach and allocation of care and risk stratification of these patients is a complex procedure. Cancer patients per se are characterised by higher susceptibility to infectious disease with 3.5 times more risk of COVID-19 related serious events in the form of requirement of critical care and mechanical ventilation or death due to their immunocompromised state associated to the nature of their malignancy and the anticancer management (chemotherapy, radiotherapy, or surgery) [21,22]. Many urology centres worldwide has suspended all elective cancer surgeries or adjuvant treatment in patients with stable cancer and surveillance strategy or other modes of treatment (chemotherapy/radiotherapy) is adopted in cancer patients with COVID-19 [22,23].

In Iran, limiting the urological surgeries to just emergencies and life threatening conditions lead to delay in the various high priority surgeries such as Transurethral Resection of Bladder Tumour (TURBT), Retroperitoneal Lymph Node Dissection (RPLND), radical cystectomy, radical nephroureterectomy, and radical prostatectomy [24]. On the contrary, if a patient is treated with radiotherapy, there will be increased number of hospital visits which further increases the exposure to infection [25]. The major risk factor for cancer patients during the COVID-19 pandemic is the inability to receive sufficient medical support [26].

Ficarra V et al., distinguished the urological cancer surgeries into different categories [20]:

Nondeferrable surgeries: Include all the procedures whose suspension may compromise oncological or functional outcomes. Consider TURBT for high risk Nonmuscle Invasive Bladder Cancer (NMIBC), any high grade bladder cancer, or tumours more than 2 cm at the time of diagnosis, whereas radical cystectomy and urinary diversion is recommended for muscle-invasive bladder cancer or refractory carcinoma in-situ. Radical orchidectomy is advocated for testicular cancer and surgery for post-chemotherapy RPLND. Radical nephrectomy is advised for renal cancers and radical nephroureterectomy for high grade upper tract urothelial carcinoma. High risk or locally advanced prostatic carcinoma or patients not suitable for radiation should be managed with radical prostatectomy with pelvic lymph node dissection. Consider partial penectomy for penile cancer, clinical T1G3 stage.

Semi-nondeferrable surgeries: Should be considered in the zones with limited diffusion of COVID-19 and comprises radical prostatectomy for intermediate and high risk prostatic cancer, TURBT for low-grade and small size bladder tumours, and for cT1b stage renal tumours, consider partial or radical nephrectomy.

Deferrable or replaceable surgeries: Include all the other urologic malignancies which can be treated by other options.

Similar recommendations were laid by Stensland KD et al., with two major differences- most prostatectomies include selected high-risk and other risk prostate cancer should be delayed or offered radiation therapy based on the National Comprehensive Cancer Network (NCCN) guidelines; and adrenalectomy is recommended for adrenal tumours larger than 6 cm [21].

Benign Diseases

Recommendation is to suspend all benign elective surgeries till the end of COVID-19 emergency including surgery for male urethral disease, urinary incontinence, reconstructive urological, benign prostatic hyperplasia, infertility, erectile dysfunction, prosthetic implantation and genitourinary prolapse [20,21].

Renal Transplantation

The COVID-19 pandemic represents a serious hazard for the transplant patients, donors, and transplant programs around the world. The co-morbidities associated with increased mortality during COVID-19 pandemic are not uncommon in patients of Chronic Kidney Disease (CKD) and who are undergoing dialysis [27]. CKD patients are at increased risk of developing infectious diseases as compared to general population due to their status of immunosuppression [28,29]. The clinical presentation, treatment, and prognosis of COVID-19 pneumonia may differ in the patients of CKD from the general population, hence the importance of early SARS-CoV-2 screening, in those cases where the infection is suspected [30]. COVID-19 has not been reported in the donor-recipient transmission of solid organ transplants [31]. However, related viruses such as the SARS-CoV and the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) were demonstrated in transplant recipients during previous outbreaks of these viruses [32,33]. Based on experiences with previous infections, it is well known that any recipient exposed to the virus would become infected. The reasons of donor-derived infection could be exposure of the donor, the viral load of individuals during the incubation period and asymptomatic people [32,33]. The viral load and the viability of the virus within the blood and other organs would also affect the risk of donor transmission [34]. Several renal transplant guidelines recommend that SARS-COV-2 testing must be done in donors of high suspicion, history of travel to an epidemic region [35-37] with universal screening of all patients irrespective of history [30].

Specific consideration for transplant recipients is required due to their chronic immunosuppression status. Screening tests is advocated in the recipients suspected for COVID-19 [30]. Kidney transplant recipients infected with SARS-CoV-2 have treatment recommendations on the basis of symptomatology. Mild symptoms (without dyspnea/tachypnea/fever) advised on telephone for home quarantine and contact to hospital if condition deteriorates. Moderate/severe symptoms, (temperature >38°C or poor general condition) is recommended for evaluation at the hospital [30]. However, apart from symptomatic support therapy, no specific treatment for COVID-19 positive renal transplant patients has been confirmed till yet [38].

Minimally invasive surgery (Laparoscopic/robotic)

The safety of laparoscopy procedures (conventional or robot-assisted) is a major concern now-a-days due to potential risk of dissemination of COVID-19 by the smoke generated [39]. Initial studies had reported the presence of hepatitis B virus [40], HIV [41] in the smoke generated during laparoscopic procedures. While concrete evidence of viral contamination during laparoscopy procedure is still awaited precautions should be taken as COVID-19 virus is viable in aerosol for three hours [42]. While Intercollegiate General Surgery Guidance advocated that laparoscopy should not be used [43], others advised to use laparoscopy procedures with discretion [44] or prefer for open approach if possible [45]. In this setting, it is recommended to keep laparoscopy instruments clean, avoid using faulty trocars with air leakage, prefer to use bipolar energy, adjust electrocautery settings to minimum in order to reduce smoke formation. Furthermore, keep the pneumoperitoneum and trendelenburg position to minimum, use devices that are able to aspirate the smoke from the pneumoperitoneum and usage of drains should be minimum as exposure of body fluids demand extra-caution and additional PPE during post-operative period [45,46]. Finally, the guidelines of EAU Robotic Urology Section (ERUS) suggested a list of non-deferrable and semi-nondeferrable robot-assisted procedures based on impact of COVID-19 at different centres and advocated that the surgery ought to be performed by an experienced robotic surgeon to limit the use of medical resources [47]. Guidelines for endoscopic procedures are same as for laparoscopy. All surgeons must wear goggles or shield visor mask during surgery and careful cleaning of head support of the console between two cases [46].

Outpatient Clinics and Office based Procedures

Majority of outpatients clinics were postponed or cancelled depending upon the impact of COVID-19 pandemic. In some centres, clinics were prioritised and non-urgent cases were consulted over phone and postponed for at least six months [48].

In this pandemic, there is a concern about resource utilisation due to disproportion of supply and demand in the health care system [49]. Katz EG et al., recommended a framework regarding triage office-based procedures during the COVID-19 pandemic [50]. The procedures such as Urethral bulking (stress urinary incontinence), intravesical dimethyl sulfoxide instillation (interstitial cystitis), UroLift (lower urinary tract symptoms), intravesical Botox, percutaneous tibial nerve stimulation (overactive bladder), diagnostic cystoscopy (microscopic haematuria), surveillance cystoscopy (treatment response assessment for NMIBC, >6 months of diagnosis), intravesical BCG (Bacillus Calmette-Guerin) (high risk or intermediate NMIBC), prostate biopsy (prostate cancer) and urodynamic study should be deferred for at least 3 to 6 months depending on individual settings. They also advocated that following procedures must be done without delay including diagnostic cystoscopy (gross haematuria), surveillance cystoscopy (treatment response assessment for NMIBC, <6 months of diagnosis), ureteral stent removal after ureteroscopy.

Urology Resident Programs

It is apparent that this pandemic had a major impact on the urology resident training programs all over the world, jeopardising the clinical activities and academic curriculums. As per recommendations, surgeries have to be performed by expert surgeons, with the aim to reduce the operative time and complications [47] so, residents are least or not involved during the procedures. Moreover, to avoid gathering and footfall in the hospitals, case discussions, ward rounds and department’s meetings were cancelled [48]. A survey showed that the involvement of residents in training programs-clinical (79.8% to 87.2%) and surgical (49.3% to 73.5%) in pre-COVID-19 pandemic. However, during the COVID-19 period, there was a major suppression of training activities-clinical (41.1% to 81.2%) and surgical (44.2% to 62.1%) [51].

In view of continuing the surgical and scientific learning, new substitutes of teaching methods were implemented. The webinars are developed on various urological topics where both teachers and residents can interact with each other. The clinical staff meetings and virtual rounds were also organised in webinar format [52]. The pre-recorded videos and podcasts channels of routine urological procedures, new techniques, tips and tricks in urology can be developed [53]. Finally, in order to continue the learning curve, surgical simulation training programs (home based) can also be developed [54].

Special Considerations

Paediatric Urology

Majority of paediatric urology procedures do not require urgent care, however, delay may subsequently impair the renal function. Most of the children infected with COVID-19 present with mild to moderate symptoms such as fever, cough and nasal discharge, severe symptoms are more common among children < five-year-old [55].

According Quaedackers JSLT et al., every patient should be screened for COVID-19 prior to surgery [56]. There recommendations for paediatric urological surgeries are divided into four stages:

Stage 1, postpone all benign scrotal and penile surgery such as orchidopexy, hydrocele, circumcision; functional surgeries like incontinence surgery, meatotomy; surgeries for hypospadias, buried penis, bladder exstrophy.

Stage 2 describes to perform only semi urgent cases including endoscopic bulk-injection or ureteral reimplantation for Vesicoureteral Reflux (VUR), pyeloplasty in Pelvic Ureteric Obstruction (PUJO) without loss of differential function, urolithiasis in absence of infection or obstruction and intravesical botulinum-toxin for neurogenic bladder dysfunction.

Stage 3 delineates about the patients in whom delay will leads to subsequent progression of disease or organ damage such as pyeloplasty in PUJO or obstructed megaureter with progressive loss of differential function, Posterior Urethral Valves (PUV), urolithiasis with recurring infections.

Furthermore, stage 4 describes to perform surgery in cases of life-threatening conditions such as urosepsis with obstruction, genitourinary trauma with haemodynamic unstable patients or urinary leakage, PUV patient in whom transurethral catheter cannot be placed, oncology (wilms tumour, malignant testicular or paratesticular tumours in selected cases and testicular torsion with pain (non-neonatal).

In addition, Quaedackers JSLT et al., also advocates guidelines for paediatric urology outpatient clinic visits into four stages [56]:

Stage 1, avoid consulting outpatient cases of benign scrotal and penile pathology or incontinence.

Stage 2 recommends seeing cases of semi-urgency like follow-up ultrasound after upper tract reconstruction.

Stage 3 delineates care for immediate cases in which delay will leads to subsequent irreversible progression of disease or organ damage like severely obstructive uropathy suspected on ultrasound and voiding.

Stage 4 specifies care for those cases in which delay can be potentially life-threatening.

Urology-Pathology Interaction

During COVID-19 pandemic, urology-pathology interaction is also matter of concern. The pathologists and laboratory workers should be careful particularly when handling fresh urological specimens (urine, surgical specimens) [57]. WHO has recommended guidelines for handling COVID-19–positive specimens, defining transport conditions (delivery by hand and according to good biosafety practices), delivery of samples in non-leaking bags or containers with full patient identity and COVID-19 status [58].

The SARS-CoV-2 has the peculiarity of surviving for long duration on inanimate objects such as cryostat, used during processing of fresh-frozen sections [59]. Hence, it is suggested to restrict the submission of fresh-frozen section specimen only when absolutely necessary [60].

Conclusion(s)

COVID-19 pandemic has presented as an unprecedented health scenario worldwide. The lack of timely management of urological conditions might produce unfavourable consequences on the overall patient outcomes. All healthcare providers including urologists should abide by the guidelines when dealing with COVID-19 patients. It seems that the repercussion of this pandemic is still unknown and difficult to quantify at present.

References

[1]Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China JAMA- J Am Med Assoc 2020 323(11):1061-69.10.1001/jama.2020.158532031570  [Google Scholar]  [CrossRef]  [PubMed]

[2]World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report- 51 [Internet]. 11 March 2020 [Internet]. Available from: https://www.who.int/docs/default-i/coronaviruse/situation-reports/20200311- sitrep-51-covid-19.pdf?sfvrsn=1ba62e57_10. [Accessed on 2020 July 22]  [Google Scholar]

[3]WHO Coronavirus disease 2019 (COVID-19) Dashboard [Internet]. 13 October 2020 [Internet]. Available from: https://covid19.who.int. [Accessed on 2020 October 14]  [Google Scholar]

[4]Chen J, Qi T, Liu L, Ling Y, Qian Z, Li T, Clinical progression of patients with COVID-19 in Shanghai, China J Infect 2020 80(5):e01-06.10.1016/j.jinf.2020.03.00432171869  [Google Scholar]  [CrossRef]  [PubMed]

[5]Yang Y, Peng F, Wang R, Guan K, Jiang T, Xu G, The deadly coronaviruses: The 2003 SARS pandemic and the 2020 novel coronavirus epidemic in China J Autoimmun 2020 109:10243410.1016/j.jaut.2020.10243432143990  [Google Scholar]  [CrossRef]  [PubMed]

[6]Bai Y, Yao L, Wei T, Tian F, Jin DY, Chen L, Presumed asymptomatic carrier transmission of COVID-19 JAMA 2020 Feb 21 10.1001/jama.2020.256532083643  [Google Scholar]  [CrossRef]  [PubMed]

[7]Naspro R, Da Pozzo LF, Urology in the time of corona Nat Rev Urol 2020 Mar 23 10.1038/s41585-020-0312-132203310  [Google Scholar]  [CrossRef]  [PubMed]

[8]Spinelli A, Pellino G, COVID-19 pandemic: Perspectives on an unfolding crisis Br J Surg 2020 Mar 19 10.1002/bjs.1162732191340  [Google Scholar]  [CrossRef]  [PubMed]

[9]Gan H, Zhang Y, Yuan M, Wu XY, Liu ZR, Liu M, Epidemiological analysis on 1,052 cases of COVID-19 in epidemic clusters Zhonghua Liu Xing Bing Xue Za Zhi 2020 41:E027doi: 10.3760/cma.j.cn112338-20200301-00223. [Epub ahead of print]  [Google Scholar]

[10]Rimmer A, Covid-19: Medical conferences around the world are cancelled after US cases are linked to Massachusetts meeting BMJ 2020 368:m105410.1136/bmj.m105432169834  [Google Scholar]  [CrossRef]  [PubMed]

[11]Pellino G, Spinelli A, How COVID-19 outbreak is impacting colorectal cancer patients in Italy Dis Colon Rectum 2020 Mar 17 10.1097/DCR.000000000000168532384401  [Google Scholar]  [CrossRef]  [PubMed]

[12]Zou X, Chen K, Zou J, Han P, Hao J, Han Z, Single-cell RNA-seq data analysis on the receptor ACE2 expression reveals the potential risk of different human organs vulnerable to 2019-nCoV infection Front Med 2020 Mar 12 10.1007/s11684-020-0754-032170560  [Google Scholar]  [CrossRef]  [PubMed]

[13]Yang XH, Sun RH, Chen DC, Diagnosis and treatment of COVID-19: Acute kidney injury cannot be ignored Zhonghua Yi Xue Za Zhi 2020 100(0):E01710.3760/cma.j.cn112137-20200229-0052032204907  [Google Scholar]  [CrossRef]  [PubMed]

[14]Naicker S, Yang CW, Hwang SJ, Liu BC, Chen JH, Jha V, The novel coronavirus 2019 epidemic and kidneys Kidney Int 2020 Mar 7 doi: 10.1016/j.kint.2020.03.001. [Epub ahead of print]  [Google Scholar]

[15]Ling Y, Xu SB, Lin YX, Tian D, Zhu ZQ, Dai FH, Persistence and clearance of viral RNA in 2019 novel coronavirus disease rehabilitation patients Chin Med J (Engl) 2020 Feb 28 10.1097/CM9.000000000000077432118639  [Google Scholar]  [CrossRef]  [PubMed]

[16]Wang W, Xu Y, Gao R, Lu R, Han K, Wu G, Detection of SARS-CoV-2 in different types of clinical specimens JAMA 2020 Mar 11 10.1001/jama.2020.3786  [Google Scholar]  [CrossRef]

[17]Li D, Jin M, Bao P, Zhao W, Zhang S, Clinical characteristics and results of semen tests among men with coronavirus disease 2019 JAMA Netw Open 2020 3(5):e20829210.1001/jamanetworkopen.2020.8292  [Google Scholar]  [CrossRef]

[18]Haber G, Cleaveland Clinic Department of Urology Surgical Priority Tier Chart 2020 21 Mar 2020. [Internet] Available form: [https://twitter.com/haberurology/status/1241403948189302784. Accessed on 2020 Apr 17  [Google Scholar]

[19]European Association of Urology Guidelines. [Internet] Available at https://uroweb.org/guideline/covid-19-recommendations/. [Accessed on 19 April 2020]  [Google Scholar]

[20]Ficarra V, Novara G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, Urology practice during COVID-19 pandemic Minerva Urol Nefrol 2020 Mar 23 10.23736/S0393-2249.20.03846-1  [Google Scholar]  [CrossRef]

[21]Stensland KD, Morgan TM, Moinzadeh A, Lee CT, Briganti A, Catto J, Considerations in the triage of urologic surgeries during the covid-19 pandemic Eur Urol 2020 Apr 9 10.1016/j.eururo.2020.03.02732279903  [Google Scholar]  [CrossRef]  [PubMed]

[22]Liang W, Guan W, Chen R, Wang W, Li J, Xu K, Cancer patients in SARSCoV- 2 infection: A nationwide analysis in China Lancet Oncol 2020 21(3):335-37.10.1016/S1470-2045(20)30096-6  [Google Scholar]  [CrossRef]

[23]Ueda M, Martins R, Hendrie PC, McDonnell T, Crews JR, Wong TL, Managing cancer care during the COVID-19 pandemic: Agility and collaboration toward a common goal J Natl Compr Canc Netw 2020 18(4):366-69.10.6004/jnccn.2020.756032197238  [Google Scholar]  [CrossRef]  [PubMed]

[24]Nowroozi A, Amini E, Urology practice in the time of COVID-19 Urol J 2020 Mar 24 doi: 10.22037/uj.v0i0.6065. [Epub ahead of print]  [Google Scholar]

[25]Ahmed K, Hayat S, Dasgupta P, Global challenges to urology practice during COVID-19 pandemic BJU Int 2020 Apr 10 doi: 10.1111/bju.15082. [Epub ahead of print]10.1111/bju.1508232275792  [Google Scholar]  [CrossRef]  [PubMed]

[26]Wang H, Zhang L, Risk of COVID-19 for patients with cancer Lancet Oncol 2020 21(4):e18110.1016/S1470-2045(20)30149-2  [Google Scholar]  [CrossRef]

[27]Alberici F, Delbarba E, Manenti C, Econimo L, Valerio F, Pola A, Management of patients on dialysis and with kidney transplant during SARS-COV-2 (COVID-19) pandemic in Brescia, Italy Kidney Int Rep 2020 Apr 4 10.1016/j.ekir.2020.04.00132292866  [Google Scholar]  [CrossRef]  [PubMed]

[28]Basile C, Combe C, Pizzarelli F, Covic A, Davenport A, Kanbay M, Recommendations for the prevention, mitigation and containment of the emerging SARS-CoV-2 (COVID-19) pandemic in haemodialysis centres Nephrol Dial Transplant 2020 Mar 20 10.1093/ndt/gfaa06932196116  [Google Scholar]  [CrossRef]  [PubMed]

[29]Xiao Y, Qian K, Luo Y, Chen S, Lu M, Wang G, Severe acute respiratory syndrome coronavirus 2 infection in renal failure patients: A potential covert i of infection Eur Urol 2020 Apr 9 10.1016/j.eururo.2020.03.02532279905  [Google Scholar]  [CrossRef]  [PubMed]

[30]López V, Vázquez T, Alonso-Titos J, Cabello M, Alonso A, Beneyto Recommendations on management of the SARS-CoV-2 coronavirus pandemic (Covid-19) in kidney transplant patients Nefrologia 2020 Apr 3 10.1016/j.nefro.2020.03.00232278616  [Google Scholar]  [CrossRef]  [PubMed]

[31]Perico L, Benigni A, Remuzzi G, Should COVID-19 concern nephrologists? Why and to what extent? The emerging impasse of angiotensin blockade Nephron 2020 :01-09.10.1159/00050730532203970  [Google Scholar]  [CrossRef]  [PubMed]

[32]Kumar D, Tellier R, Draker R, Levy G, Humar A, Severe acute respiratory syndrome (SARS) in a liver transplant recipient and guidelines for donor SARS screening Am J Transplant 2003 3:977-81.10.1034/j.1600-6143.2003.00197.x12859532  [Google Scholar]  [CrossRef]  [PubMed]

[33]Alghamdi M, Mushtaq F, Awn N, Shalhoub S, MERS CoV infection in two renal transplant recipients: Case report Am J Transplant 2015 15:1101-04.10.1111/ajt.1308525716741  [Google Scholar]  [CrossRef]  [PubMed]

[34]Michaels MG, Hoz RML, Danziger-Isakov L, Blumberg EA, Kumar D, Green M, Coronavirus Disease 2019: Implications of emerging infections for transplantation Am J Transpl 2020 20(7):1768-72.10.1111/ajt.1583232090448  [Google Scholar]  [CrossRef]  [PubMed]

[35]Andrea G, Daniele D, Barbara A, Davide M, Laura A, Paolo R, Coronavirus disease 2019 and transplantation: A view from the inside Am J Transplant 2020 Mar 17 10.1111/ajt.1585332181969  [Google Scholar]  [CrossRef]  [PubMed]

[36]The Transplantation Society. An Update and Guidance on 2019 Novel Coronavirus (2019-nCov) for Transplant ID Clinicians [Internet]. Available from: https://tts.org/23-tid/tid-news/657-tid-update-and-guidance-on-2019-novel coronavirus- 2019-ncov-for-transplant-id. [Accessed on 2020 Apr, 12]  [Google Scholar]

[37]US Food & Drug Administration. Important Information for Human Cell, Tissue, or Cellular or Tissue-based Product (HCT/P) Establishments Regarding the 2019 Novel Coronavirus Outbreak|FDA [Internet]. Available from: https://www.fda.gov/vaccines-blood-biologics/safety-availability biologics/importantinformation-human-cell-tissue-or-cellular-or-tissue-based-product-hctp-establishments. Accessed on 2020 Apr,12  [Google Scholar]

[38]Zhang H, Chen Y, Yuan Q, Xia QX, Zeng XP, Peng JT, Identification of kidney transplant recipients with coronavirus disease 2019 Eur Urol 2020 Apr 2 10.1016/j.eururo.2020.03.03032249089  [Google Scholar]  [CrossRef]  [PubMed]

[39]SAGES Recommendations Regarding Surgical Response to COVID-19 Crisis- SAGES [Internet]. Available from: https://www.sages.org/recommendations-surgical-response-covid-19/#update. Accessed on 2020 Apr, 15  [Google Scholar]

[40]Kwak HD, Kim SH, Seo YS, Song KJ, Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery Occup Environ Med 2020 73(12):857-63.  [Google Scholar]

[41]Johnson GK, Robinson WS, Human immunodeficiency virus-1 (HIV-1) in the vapors of surgical power instruments J Med Virol 1991 33(1):47-50.10.1002/jmv.18903301101901908  [Google Scholar]  [CrossRef]  [PubMed]

[42]Van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, Aerosol and surface stability of SARS-CoV-2 as compared with SARSCoV-1 N Engl J Med 2020 382(16):1564-67.10.1056/NEJMc200497332182409  [Google Scholar]  [CrossRef]  [PubMed]

[43]Intercollegiate General Surgery Guidance on COVID-19 UPDATE. Available at https://www.rcsed.ac.uk/news-public-affairs/news/2020/march/intercollegiate-general-surgery-guidance-on-covid-19-update accessed on April 17, 2020  [Google Scholar]

[44]Simonato A, Giannarini G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, Pathways for urology patients during the COVID-19 pandemic Minerva Urol Nefrol 2020 Mar 30 10.23736/S0393-2249.20.03861-8  [Google Scholar]  [CrossRef]

[45]Carneiro A, Wroclawski ML, Nahar B, Soares A, Cardoso AP, Kim NJ, Impact of the COVID-19 Pandemic on the Urologist’s clinical practice in Brazil: A management guideline proposal for low-and middle-income countries during the crisis period Int Braz J Urol 2020 :4610.1590/s1677-5538.ibju.2020.04.0332271512  [Google Scholar]  [CrossRef]  [PubMed]

[46]Zheng MH, Boni L, Fingerhut A, Minimally invasive surgery and the novel coronavirus outbreak: Lessons learned in China and Italy Ann Surg 2020 Mar 26 10.1097/SLA.000000000000392432221118  [Google Scholar]  [CrossRef]  [PubMed]

[47]ERUS (EAU Robotic Urology Section) guidelines during COVID-19 emergency. [Internet]. March 2020. Available from: https://uroweb.org/wpcontent/uploads/ERUS-guidelines-for-COVID-def.pdf. Accessed on 2020 April 19  [Google Scholar]

[48]Chan MC, Yeo SEK, Chong YL, Lee YM, Stepping forward: Urologists’ efforts during the COVID-19 outbreak in Singapore Eur Urol 2020 Mar 17 10.1016/j.eururo.2020.03.00432192816  [Google Scholar]  [CrossRef]  [PubMed]

[49]Centers for Disease Control and Prevention. Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States. [Internet]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-hcf.html. Accessed April 12, 2020  [Google Scholar]

[50]Katz EG, Stensland KS, Mandeville JA, MacLachlan LS, Moinzadeh A, Sorcini A, Triaging office-based urolog y procedures during the COVID-19 pandemic J Urol 2020 Apr 3 10.1097/JU.000000000000103432249681  [Google Scholar]  [CrossRef]  [PubMed]

[51]Amparore D, Claps F, Cacciamani GE, Esperto F, Fiori C, Liguori G, Impact of the COVID-19 pandemic on urology residency training in Italy Minerva Urol Nefrol 2020 Apr 7 10.23736/S0393-2249.20.03868-0  [Google Scholar]  [CrossRef]

[52]Nadama HH, Tennyson M, Khajuria A, Evaluating the usefulness and utility of a webinar as a platform to educate students on a UK clinical academic programme J R Coll Physicians Edinb 2019 49(4):317-22.10.4997/JRCPE.2019.41531808462  [Google Scholar]  [CrossRef]  [PubMed]

[53]Porpiglia F, Checcucci E, Amparore D, Verri P, Campi R, Claps F, Slowdown of urology residents’ learning curve during COVID-19 emergency BJU Int 2020 Apr 9 10.1111/bju.1507632274879  [Google Scholar]  [CrossRef]  [PubMed]

[54]Aydin A, Ahmed K, Van Hemelrijck M, Ahmed HU, Khan MS, Dasgupta P, Simulation in Urological Training and Education (SIMULATE)- A multicentre international randomised controlled trial assessing the transferability of simulation-based training in surgery: Protocol and development of interventional training curriculum BJU Int 2020 Mar 18 10.1111/bju.1505632189446  [Google Scholar]  [CrossRef]  [PubMed]

[55]Ludvigsson JF, Systematic review of COVID-19 in children show milder cases and a better prognosis than adults Acta Paediatr 2020. Mar 23 10.1111/apa.1527032202343  [Google Scholar]  [CrossRef]  [PubMed]

[56]Quaedackers JSLT, Stein R, Bhatt N, Dogan HS, Hoen L, Nijman RJM, Clinical and surgical consequences of the COVID-19 pandemic for patients with paediatric urological problems. Statement of the EAU guidelines panel for paediatric urology, March 30 2020 J Paediatr Urol 2020 Apr 9 doi: 10.1016/j.jpurol.2020.04.007. [Epub ahead of print]  [Google Scholar]

[57]Paules CI, Marston HD, Fauci AS, Coronavirus infections-more than just the common cold JAMA 2020 323:707-08.10.1001/jama.2020.075731971553  [Google Scholar]  [CrossRef]  [PubMed]

[58]World Health Organization. Infection prevention and control during health care when novel coronavirus infection is suspected: Interim guidance. Geneva: World Health Organization; 2020, Jan 25. [Internet]. Available from: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125. Accessed April 18, 2020  [Google Scholar]

[59]Kampf G, Todt D, Pfaender S, Steinmann E, Persistence of corona-viruses on inanimate surfaces and their inactivation with biocidal agents J Hosp Infect 2020 104:246-51.10.1016/j.jhin.2020.01.02232035997  [Google Scholar]  [CrossRef]  [PubMed]

[60]Compérat E, What does COVID-19 mean for the pathology-urology interaction? Eur Urol 2020 Apr 7 10.1016/j.eururo.2020.03.04132273180  [Google Scholar]  [CrossRef]  [PubMed]