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Editorial
Urological recommendations regarding surgical care of suspected or confirmed SARS-CoV-2 or COVID-19+ patients
Recomendaciones en urología para pacientes quirúrgicos sospechosos o confirmados con SARS-CoV-2 o con COVID-19
M. Estebana,
Corresponding author
ESTEBOTE@telefonica.net

Corresponding author.
, L. Prietob, J.L. Álvarez-Ossorioc, A. Gómezd, J.R. Cortiñase, A. Serranof, J.M. Cózarg
a Servicio de Urología, Hospital Nacional de Parapléjicos, Toledo, Spain
b Servicio de Urología, Hospital Universitario San Juan, Alicante, Spain
c Servicio de Urología, Hospital Universitario Puerta del Mar, Cádiz, Spain
d Servicio de Urología, Hospital Virgen de la Salud, Toledo, Spain
e Servicio de Urología, Hospital Clínico Universitario, Valladolid, Spain
f Servicio de Urología, Hospital Universitario Clínico San Carlos, Madrid, Spain
g Servicio de Urología, Hospital Universitario Virgen de las Nieves, Granada, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In relation to the very high infectivity of SARS-CoV-2&#44; we communicate the transmission mechanisms of SARS-CoV-2 with reasonable and prudent measures respecting the urological surgical patient&#46; This is a message with safety purposes and with the knowledge as of 03&#47;24&#47;2020&#44; considering the absence of solid scientific evidence and with current data&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The most common transmission route of the infection is respiratory&#44; person-to-person&#46; The infection is spread by respiratory fl&#252;gge droplets in the air over up to 2&#8239;m distance&#44; which also remain on surfaces&#46; Transmission between presymptomatic people is possible and recent studies indicate that its proportion is close to 50&#37; of cases&#46; In addition&#44; transmission can occur after recovery&#44; which is why isolation measures are recommended for at least 2 additional weeks&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Fecal-oral transmission is unlikely&#44; however&#44; there are demonstrated cases with initial digestive symptoms as entry routes&#46; The presence of the virus can be detected in all respiratory secretions&#44; in nasal smears&#44; in the pharynx&#44; it is found in blood and its presence in urine is unusual&#46; Perinatal transmission has not yet been published as there is no experience&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Objectives</span><p id="par0020" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Maximize the safety of patients with indication of urgent elective surgery which cannot be delayed and COVID-19&#43;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Protect healthcare personnel from the risks of SARS-CoV-2 infection&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Protect hospitalized patients from the risks of SARS-CoV-2 infection&#46;</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Indication of urgent&#47;elective surgery</span><p id="par0040" class="elsevierStylePara elsevierViewall">The first premise in these patients is that surgical interventions will only be addressed in the transmission phase when they cannot be delayed &#40;14&#8211;21 days&#41;&#46; We will wait for the negative results of the respiratory tests as long as possible&#46; The decision to perform a surgical procedure will always be individualized&#44; with an adequate balance of risks and benefits&#46; It is advisable that the surgical indication is carefully corroborated with the necessary complementary tests and its concordance with the patient&#39;s clinical situation&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In some cases of specific diseases&#44; non-surgical alternatives which are safe for the patient should be considered&#46; The team that will perform the intervention must know the protocol of action and wear protective equipment&#46; The surgical area must have personal protective equipment &#40;PPE&#41;&#44; which must be requested in advance&#46; The number of personnel required for the anesthetic-surgical intervention should be minimized&#44; and their level of training or experience should be maximized&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Transport to the operating room will be done by the shortest and least crowded route&#44; using the &#8220;restricted use&#8221; elevators&#46; All the necessary material for the surgical intervention &#40;instruments&#44; devices&#44; etc&#46;&#41; must be available to minimize in and out transit of the operating room once the patient has arrived&#46; All devices &#40;masks&#44; endotracheal tubes&#44; etc&#46;&#41;&#44; fluid replacement therapy and medication must be prepared to reduce manipulation of the anesthesia carts&#46; It is also advisable to label the doors &#40;main and intermediate&#41; of the operating room with &#34;COVID-19 &#43;&#34; signage&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Personal protective equipment for surgical procedures for patients with suspicion or at risk of coronavirus infection</span><p id="par0055" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Moving patients to the operating room will be done following the designated paths&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Both the patient and the operating room staff in contact with him will wear a surgical mask until the entrance to the operating room&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Before entering the surgical area&#44; proceed to hand hygiene with an alcohol-based hand rub &#40;ABHR&#41; and to put on a cap&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Whenever possible&#44; the operating room should have a scrub area&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">All staff must be aware of the potential risk of exposure and must be registered in the occupational risk prevention service&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">The personnel in the operating room must be reduced to the essential minimum&#44; without there being any additional person&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Grouping preparation and action activities is recommended to minimize the frequency of proximity to the patient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">During surgery&#44; a clean assistant will be in charge of supplies&#44; records&#44; and observations&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Circulating personnel must wear a disposable gown and a surgical mask&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Equipment kept in the operating room must be minimized to what is essential for patients care&#46; In the same way&#44; everything potentially necessary for surgery must be available inside the operating room to avoid opening doors after the patient&#39;s entry&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Although it is a general rule&#44; it is reminded that the operating room doors will remain closed during the operation&#46;</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">Staff must wear the following elements of PPE&#44; which will be prepared in the following sequence&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Before entering the operating room&#58;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">o</span><p id="par0125" class="elsevierStylePara elsevierViewall">Antiseptic hand hygiene with ABHR solution or with disinfectant soap&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">o</span><p id="par0130" class="elsevierStylePara elsevierViewall">Wear a mask with a particle filter such as FFP2 protection during surgical procedures&#44; or a FFP3 mask in the case of aerosol-generating procedures&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">o</span><p id="par0135" class="elsevierStylePara elsevierViewall">Full face shield &#40;preferably against body fluid splashes&#41; and tight full-frame eye protection &#40;for aerosol-generating procedures such as hematuria lavage&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">o</span><p id="par0140" class="elsevierStylePara elsevierViewall">Surgical hand washing with ABHR or with disinfectant soap&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Inside the operating room&#58;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">o</span><p id="par0150" class="elsevierStylePara elsevierViewall">Single-use&#44; waterproof gown &#40;commonly used in urology operating rooms&#41; with long sleeves&#46; In case of unavailability&#44; placement of sterile gown over waterproof gown&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">o</span><p id="par0155" class="elsevierStylePara elsevierViewall">Surgical glove&#46;</p></li></ul></p><p id="par0160" class="elsevierStylePara elsevierViewall">After surgery&#44; the PPE used by healthcare personnel will be removed inside the operating room&#46; The doffing of the PPE will follow this sequence &#40;along with hand washing after taking off each part of the equipment&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Gloves and waterproof gown at the same time&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Disinfectant hand hygiene with ABHR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Cap and face mask or splash-proof goggles or full-frame eyewear &#40;in case of aerosol generation techniques&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">FFP2 or FFP3 mask &#40;for aerosol generation techniques&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Disinfectant hand hygiene with ABHR&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Considerations for the operating room</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">During intubation&#44; only the anesthesia and nursing staff who will assist surgery will be present in the operating room and will wear the same PPE elements during the intubation procedure&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">In endoscopic procedures&#44; the chest or abdomen should be decompressed from any positive pressure before the trocars are removed to avoid spraying materials from the cavities&#46;</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">In urological endoscopic procedures with spinal anesthesia&#44; previous enemas should be avoided&#44; in prevention of diarrhea&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Lungs and other organs may contain viruses&#44; and additional respiratory protective measures must be taken during aerosol-generating procedures &#40;for example&#44; the use of power saws&#44; hematuria and bowel irrigation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">The production of aerosols&#44; surgical smoke&#44; should be minimized during surgery&#44; taking the following precautions&#58;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">When oscillating saws are used&#44; use vacuum aspiration systems&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Avoid splashing when removing&#44; manipulating or washing the organs&#44; especially lung tissue&#44; intestines&#44; bladder lavage and catheters&#46;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">&#8226;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Avoid aerosolization prior to sampling for culture with the use of screw cap containers&#46;</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall">High pressure water spray systems should not be used&#46;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">&#8226;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Cutting or piercing instruments should be avoided as much as possible&#46; In case of using them&#44; they must be equipped with biosafety systems&#46;</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8226;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Fingers should not be used to hold or reposition needles or scalpel blades&#46; All manipulations of tissues or sharp instruments will be performed with surgical instruments&#46;</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">&#8226;</span><p id="par0250" class="elsevierStylePara elsevierViewall">Verbal orders should be used in the exchange of cutting or piercing instruments within the surgical team&#46;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">&#8226;</span><p id="par0255" class="elsevierStylePara elsevierViewall">A neutral zone for piercing or cutting instruments should be designated at the beginning of the intervention&#44; with the use of a magnetic holder &#40; sterile magnetic drapes&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">&#8226;</span><p id="par0260" class="elsevierStylePara elsevierViewall">To ensure a safe working environment&#44; decontamination&#44; maintenance and disposal protocols -commonly used for other types of microorganisms with a similar risk of spread and transmission mechanism- must be followed&#46;</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">&#8226;</span><p id="par0265" class="elsevierStylePara elsevierViewall">All materials&#44; that have been in contact with respiratory secretions or body fluids&#44; including PPE&#44; will be segregated as special category III biomedical waste&#46;</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">&#8226;</span><p id="par0270" class="elsevierStylePara elsevierViewall">The use of alternative cutting devices&#44; such as electric scalpels&#44; in preference to the cold scalpel&#44; must be maximized&#59; using the electrosurgical unit even for the skin incision&#46;</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">&#8226;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Mechanical sutures should be prioritized over manual ones&#46;</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">&#8226;</span><p id="par0280" class="elsevierStylePara elsevierViewall">Under no circumstances should needles be recapped&#46;</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">&#8226;</span><p id="par0285" class="elsevierStylePara elsevierViewall">The surgical team should keep a container for sharp or cutting instruments within reach for disposal once they have been used&#46;</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">&#8226;</span><p id="par0290" class="elsevierStylePara elsevierViewall">All rules for protection against piercing or cutting instruments must be followed until the end of the intervention&#44; during the collection of surgical material&#46;</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">&#8226;</span><p id="par0295" class="elsevierStylePara elsevierViewall">The FFP2 or FFP3 mask has a continuous use duration of 8&#8239;h&#44; but it must be disposed after being used in aerosol generating procedures &#40;secretion aspiration&#44; intubation procedures &#8230;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">&#8226;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Once surgery is completed&#44; environmental and surface hygiene of the operating room will be carried out&#44; which will be cleaned and disinfected according to the protocol of the preventive medicine department&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Sample collection and transport</span><p id="par0305" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">&#8226;</span><p id="par0310" class="elsevierStylePara elsevierViewall">Samples will be prepared at the operating room before being sent to the laboratory&#46;</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">&#8226;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Samples should be identified and sent to designated laboratories&#46; The outside of the vial containing the sample will be disinfected with a surface disinfectant or a disinfectant-impregnated wipe and stored in a self-sealing bag&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Recommended bibliography</span><p id="par0320" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">1</span><p id="par0325" class="elsevierStylePara elsevierViewall">Coronavirus disease &#40;COVID-2019&#41; situation reports&#46; Geneva&#58; World Health Organization&#44; 2020 &#40;https&#58;&#47;&#47;www&#46;who&#46;int&#47;emergencies&#47;diseases&#47;novel-coronavirus2019&#47;situation-reports&#41;</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">2</span><p id="par0330" class="elsevierStylePara elsevierViewall">Wu A&#44; Peng Y&#44; Huang B&#44; et al&#46; Genome composition and divergence of the novel coronavirus &#40;2019-nCoV&#41; originating in China&#46; Cell Host Microbe 2020&#59; 27&#58; 325&#8722;8&#46;</p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">3</span><p id="par0335" class="elsevierStylePara elsevierViewall">Bai Y&#44; Yao L&#44; Wei T&#44; et al&#46; Presumed asymptomatic carrier transmission of COVID-19&#46; JAMA 2020 February 21 &#40;Epub ahead of print&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">4</span><p id="par0340" class="elsevierStylePara elsevierViewall">Zou L&#44; Ruan F&#44; Huang M&#44; et al&#46; SARS-CoV-2 viral load in upper respiratory specimens of infected patients&#46; N Engl J Med&#46; DOI&#58; 10&#46;1056&#47;NEJMc2001737&#46;</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">5</span><p id="par0345" class="elsevierStylePara elsevierViewall">Chen YC&#44; Huang LM&#44; Chan CC&#44; et al&#46; SARS in hospital emergency room&#46; Emerg Infect Dis 2004&#59; 10&#58; 782&#8722;8&#46;</p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">6</span><p id="par0350" class="elsevierStylePara elsevierViewall">Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 NEJM&#46; Downloaded from nejm&#46;org on March 17&#44; 2020&#46;</p></li></ul></p></span></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos