Comment on the article
Endourology and Benign Prostatic Hyperplasia in COVID-19 Pandemic
Alexis M. Alva Pinto 1, Mariano Sebastián González 2
1Department of Urology, Clinica Delgado, Lima, Peru; 2 Department of Urology, Hospital Italianop de Buenos Aires, Argentina
Int. J.Braz Vol. 46 (Suppl 1): 34-38 July 2020
How to safely indicate and perform endourological and BPH surgeries during the COVID-19 pandemic? In the article of this edition, Pinto and Gonzalez recall the efforts we had to make in all fields of our lives, including urological practice, to adapt to the uncertainties and constant changes of the last year (1), besides highlighting that the challenges have their particularities in the various countries and services. The suspension of elective procedures has brought great distress to us surgeons, which is only no greater than that of the patients themselves, who have such fundamental aspects of their quality of life relegated to the background, in a new reality where the provisional may seem like an eternity. In several services, particularly in a developing country such as Brazil and other Latin American countries, patients had been waiting for surgery for BPH for a period of months to years, many with an indwelling catheter and subject to episodes of hematuria, infections, and obstructions. The pandemic has so far added almost a year to this waiting list.
The American (AUA) and European (EAU) societies have published recommendations on what characterizes urgency and what should be postponed, and the treatment of BPH is one of the surgeries that should be postponed (2). The risks of performing surgical procedures in patients with COVID-19 were highlighted in this article, with higher complication rates and mortality, even in asymptomatic patients. In one of the largest published studies on the subject, the 30-day mortality in patients with COVID-19 undergoing urological surgery was 32.3% and the rate of pulmonary complications was 57.1% (3). In a new situation and exception, it is important to remember that many recommendations are made based on retrospective data, in the opinion of experts, and extrapolation of experimental evidence.
Those who perform TURP or HoLEP know that the dispersion of fluids in surgery is not uncommon. However, this does not necessarily indicate a high transmission of SARS-Cov2, as the concentration of the virus in urine and prostate appears to be low and will be lower when diluted by infusion fluids. Little is known about the real effects of SARS-Cov2 on the prostate, although we know that the virus can be found in great concentration in renal tissue. Our group published a report of a patient who presented a severe clinical picture of COVID-19, requiring mechanical ventilation for a long time and who during hospitalization presented acute urinary retention and sepsis, with intraprostatic necrosis identified on computed tomography (4). We know that one of the main phenomena caused bySARS-Cov2 is pulmonary, renal, and cerebral microthrombosis, but so far there have been no reports on cases involving the prostate. The patient, still hospitalized but recovered from the pulmonary condition and with nasal swab negative for SARS-Cov2, was submitted to HoLEP, with complete removal of the adenoma by cystostomy. In the analysis of the surgical specimen, there was no detection of SARS-Cov2 in the prostatic tissue, but the effects of the virus on the prostatic microcirculation were observed, causing a large infarction and necrosis within the adenoma. From April to August 2020, when our hospital was fully adapted and directed to the treatment of COVID-19 (1), we operated three patients in recovery from SARS-Cov2 infection using the HoLEP technique. None of them had any complications during the postoperative period. It is important to remember that anesthesia should be with regional anesthesia (spinal block), and surgery should be performed by the most experienced member of the team, as the authors of the article pointed out. During surgery, everybody should wear the N95 mask, face-shield and impermeable protective clothes, even with the patient’s COVID-19 being negative.
We live the paradox of seeing time extended too much in the waiting of the patients forced to postpone their treatment and shortened to the limit when we need to learn and make decisions in real-time in a situation unprecedented in our history. At this time, it is necessary to associate the recommendations of the main medical and urological societies reviewed in the article by Pinto and Gonzalez to a careful evaluation of the epidemiological situation of each region and the resources of the hospitals. When more urgent situations such as in the case report we have exposed, or for those who have the privilege of having a sector prepared for elective surgeries with units completely separated from patients with COVID-19, it is possible to consider performing endourological surgeries and for BPH. All the special care described in the article should be taken and aligned with the best interests of the patient, the interests of the whole community, which cannot be neglected in a pandemic situation. Given the latest increase in the number of COVID-19 cases worldwide, new adaptations should be made at every time and we believe that Pinto and Gonzalez’s article will be useful in decision-making until we can rely on the vaccine and reestablish our routines.
Alexandre Iscaife
Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brasil
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