Guidelines on Laparoscopy Case Deferral During COVID-19
USANZ issued guidelines on Case Deferral, Laparoscopy and Virtual Meetings During COVID-19 Pandemic. The guidelines were approved by the Board of Directors on 19 April 2020.
Purpose and Scope
These recommendations were developed by USANZ to provide guidance during the COVID crisis regarding:
- safe patient deferral
- urologic laparoscopy
- virtual meetings.
The contained advice is designed to provide guidance only and the local environment of each urologist needs to be taken into consideration when making decisions.
The COVID-19 global pandemic is rapidly evolving so these recommendations are based on the best current evidence available plus advice from international colleagues, colleges and societies.
This advice is based on the principles of:
- appropriate patient care
- Our responsibility to the community regarding the preservation of Personal Protective Equipment (PPE) and the protection of all staff in the operating rooms and on the wards
USANZ has previously issued guidelines regarding Urological Case Prioritisation, the use of PPE for Urologists and Urological Unit Configuration and Case Selection during the COVID-19 Pandemic.
Process to Safely Defer Patient Investigation and Management
During this period of reduced access to usual healthcare many patients will experience delays or alterations in their usual diagnosis and treatment pathways. Patients in general understand that we live in unusual times but these variations, combined with local factors may lead to a perceived lack of equity, patient anxiety and discontent. Local agreement within your region, hospital and team about the level of care capable of being provided along with clear documentation of the discussions will be essential. This team should be collegial, multi-disciplinary, contemporary and nimble allowing local variations based on resources available.
Examples include:
- Delay in prostate biopsy with low PIRADS lesion.
- Recommendation currently not to undertake neo-adjuvant chemotherapy before cystectomy in curative bladder cancer, due to patient immunosuppression. (In an earlier advisory USANZ recommended consultation with medical oncology to discuss neoadjuvant chemotherapy)
- Delaying investigation and management of lower risk malignancies and many functional disorders.
Urologic Laparoscopy
There has been controversy, due to the lack of clear evidence and speed of the pandemic as to whether laparoscopic surgery is safe in the COVID-19 era. Conflicting advice has been provided.
Given the lack of evidence of increased risk of coronavirus spread during laparoscopic procedures compared to open procedures USANZ supports the continued use of laparoscopy in urology where appropriate. Limited evidence at this time suggests that the benefits of minimally invasive surgery outweigh the risk and benefits of open surgery for our patients and staff.
RACS has released a rapid review by ASERNIP-S on this matter. In summary the ASERNIP-S report states
Recommendations on safe surgery during the COVID-19 pandemic: laparoscopic vs open [9 April 2020]
- With respect to testing for COVID-19 and Personal Protective Equipment (PPE) use, the recommendation is that local protocols for risk stratification should be followed.
- There is no current evidence that laparoscopy presents a greater risk to the surgical team in the operating room than open surgery, with respect to viruses, but it is important to maintain a level of caution due to the possibility of aerosolisation.There
- is demonstrated value in having negative pressure theatres where available, however if unavailable then local protocols to reduce the risk to operating room staff should be followed
- During all procedures a reduction in occupational exposure to surgical plume is advisable, using an appropriate capture device. There is evidence that all energy sources which produce a surgical plume during surgery may influence viral transmission. Limited use of lower energy devices may reduce the viral load and would seem more desirable to use.
- Specifically for laparoscopic surgery, desufflation of pneumoperitoneum must be performed via an appropriate suction device attached to a HEPA filter to prevent venting into the operating room e.g., an insufflation-filtration device such as the ConMed AirSeal® (or equivalent) should be used if available, otherwise other methods need to be employed to reduce any potential release.
- The COVID-19 virus has been observed in faecal cultures; viral component staining and replication products have been detected in gastrointestinal epithelium; there is equivocal evidence of viral presence in blood; while early studies so far have not found evidence of presence in urine. However, all tissues and bodily fluids should be treated as a potential virus source.
These recommendations were developed by the Clinical Expert COVID-19 Working Group after review of the evidence synthesis prepared by the RACS Evidence Synthesis Team.
Virtual Meetings
With the advent of social distancing and working separately in teams, there was a requirement for simple, secure and accessible virtual meeting formats. A number of products fit the required format to allow effective communication.
Quite rapidly this space has been filled with numerous cheap and available products. Some simple tips for using these platforms are: keep your account details private; only advertise meetings on a 2 work email address (not on social media); and protect your meetings with a password; and be aware of your surroundings, personal appearance and habits while on video.
For patient details, the majority of these formats are not secure enough to present patient identifying information. Such a meeting format requires at least 2 levels of access authentication and should be provided by your health care facility for Multi Disciplinary Meetings (MDMs). These should allow the sharing of radiology, histopathology and clinical records in private secure network.
Contact
For more information, email the USANZ President.