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Safety of uro-oncology practice and robot-assisted surgery during the peak of COVID-19 pandemic: A report from India

1 Departments of Uro-Oncology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India
2 Departments of Anaesthesia, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India

Date of Submission21-Jul-2020
Date of Decision30-Dec-2020
Date of Acceptance12-Jan-2021
Date of Web Publication17-Jul-2021

Correspondence Address:
TB Yuvaraja,
Department of Uro-Oncology, Kokilaben Dhirubhai Ambani Hospital, Rao Saheb, Achutrao Patwardhan Marg, Four Bungalows, Andheri West, Mumbai - 400 053, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_1006_20

 > Abstract 

Aim: The pandemic by novel coronavirus disease 2019 (COVID-19) is the biggest threat to global health care. Routine care of cancer patients is affected the most. Our institute, situated in Mumbai, declared as the hotspot of COVID-19 in India, continued to cater to the needs of cancer patients. We did an observational study to review the experience of managing uro-oncology patients and who underwent either open, endoscopic, or robot-assisted surgery for urological malignancy.
Materials and Methods: During the peak of COVID-19 pandemic from March 21, 2020, to June 21, 2020, all the uro-oncology cases managed in our tertiary care hospital were analyzed. Teleconsultation was started for follow-up patients. All patients requiring surgery underwent reverse transcription-polymerase chain reaction for COVID-19. Institutional protocol was formulated based on existing international guidelines for patient management. Adequate personal protection and hydroxychloroquine prophylaxis were provided to health-care professionals.
Results: During the study period, 417 outpatient consultations were made. Forty-nine patients underwent surgery for different urological malignancies. Majority of the surgeries were robot-assisted surgeries (59.2%, 29 patients), followed by endoscopic procedures (28.5%, 14 patients) and few open procedures (10.2%, five patients). Most of our patients were elderly males (mean, 62.5 years). With a median follow-up of 55 days (interquartile range, 32–77), there was no report of COVID-19 infection in any patient or health-care provider.
Conclusions: We can continue treating needy cancer patients with minimal risk by taking all precautions. Our initial experience of managing uro-oncology cases during this pandemic is encouraging. Robotic surgeries can be safely performed.

Keywords: Coronavirus, COVID-19, robot-assisted surgery, safety, uro-oncology

How to cite this URL:
Dev P, Yuvaraja T B, Waigankar SS, Ranade S, Pednekar AP, Agarwal V, Khandekar A, Badlani N, Asari A. Safety of uro-oncology practice and robot-assisted surgery during the peak of COVID-19 pandemic: A report from India. J Can Res Ther [Epub ahead of print] [cited 2022 Dec 4]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=321707

 > Introduction Top

Since the first reported case of coronavirus disease (COVID-19) in December 2019 in Wuhan city, in the Hubei province of China,[1] it has caused a global pandemic involving 187 of 196 countries. The World Health Organization declared it as a public health emergency of international concern on March 11, 2020.[2] Because of its highly infectious nature, around 8.7 million people were infected, and 462,000 people lost their lives across the world as on June 21, 2020.[3] Our institute is situated in Mumbai, which was declared a hotspot of COVID-19 in India with the maximum number of infected patients. It posed a great threat to health-care professionals and cancer patients.

Due to the pandemic, routine cancer treatment was jeopardized due to diversion of workforce and infrastructure in treating patients with COVID-19 and for fear of infection in both health-care providers and patients. Therefore, cancer patients who needed treatment at the earliest suffered the most.[4] At this point, few modifications in our standard health-care system were needed. Most of the surgical societies recommended guidelines immediately concerning about safety of laparoscopy and robotic procedures due to the fear of pandemic to safeguard the hospital staff from infection. They were based on presumptive protocols rather than on scientific evidence. Following these guidelines, most of the centers avoided robot-assisted surgeries. In this observational study, we review our experience of managing uro-oncology patients who underwent open, endoscopic, or robot-assisted surgery for urological cancers during the pandemic. We discuss the outcomes and precautions taken to prevent the transmission of COVID-19 infection.

 > Materials and Methods Top

During the peak of COVID-19 pandemic from March 21, 2020, to June 21, 2020, all the uro-oncology cases managed in our tertiary care high-volume oncology division of the hospital, which is also a designated hospital for COVID-19 care, were analyzed. We had designated 72 beds for treating patients with COVID-19 disease and one designated ICU with 22 beds for treating severely ill COVID-19 patients. As per our institutional policy of continuing cancer care, we managed urological cancer patients and continued performing surgeries in needy patients. These procedures were done according to our institute protocol and international guidelines like the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the European Association of Urology (EAU), and the EAU Robotic Urology Section (ERUS). The patients with definitive indication underwent either robot-assisted surgery, endoscopic, or open approach depending on disease status. Deferrable cases were given the option to postpone the surgery until the pandemic is over.

Patients were given necessary documents from the hospital to get permission from regulatory authorities to travel to the hospital. The management of uro-oncology cases was based on the disease stage at presentation. Retrospective analysis from prospectively collected database of uro-oncology patients who visited in the outpatient department (OPD) or admitted in our hospital for definitive surgery was done. Various protocols followed during pre-operative work up, intraoperative course and post-operative care were noted. Incidence of new COVID-19 infection among patients and health professionals was noted. Patients were managed according to our hospital infection committee guidelines, and all the safety measures required were followed at all levels.

Preoperative workup

Patients planned for surgery underwent preoperative workup before the admission to reduce the days of hospital stay. All patients were screened for peripheral oxygen saturation and surface temperature on arrival. All patients underwent reverse transcription-polymerase chain reaction (RT-PCR) test for SARS-coronavirus 2 before admission, and few elderly patients with doubtful symptoms underwent high-resolution computed tomography (HRCT) chest. COVID-19-positive patients had to wait for 14 days or till they became negative. To minimize crowding, only one patient attendant was allowed to assist the patient during outpatient visits and inpatient period. Strict protocols were followed during patient care, shifting the patient from wards with the face mask, shifting to the preoperative room just a few minutes before surgery, and reducing contact with hospital staff.

Intraoperative management and precautions by health-care professionals

Health-care professionals were provided with tablet hydroxychloroquine (HCQ) as prophylaxis with a dose of 800 mg on day 1 and followed by 400 mg once a week for the next 7 weeks.[5] Only a limited number of designated hospital staff were allowed inside the operation theater. During the surgery, bedside assistants, scrub nurses, and anesthetists were provided adequate personal protection with N95 masks or respirators, disposable double gloves, goggles, face shield, or a head hood [Figure 1].
Figure 1: Personal protection with disposable surgical cap, goggles/eyeglasses, N95 respirators, face shield, gown, and disposable double gloves

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A rapid sequence intubation with a cuffed endotracheal tube was done if not contraindicated. Heat and moisture exchange filters were placed at the patient end and also at the machine end of the closed-circuit ventilator tubings, and anesthetic gas scavenging system was activated. Intubation and extubation were performed using a transparent acrylic aerosol box [Figure 2] to prevent direct exposure to the respiratory droplets. Deep extubation was done, preferably to avoid aerosol generation while coughing.
Figure 2: The use of transparent acrylic aerosol box during the process of intubation; Aerosol box is shown in picture inset

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Console surgeon was protected up to level 2 protection,[6] i.e., with N95 mask, protective eye gear, and cap. Console was cleaned with a 10% chlorhexidine solution before and after the surgery. Precautions taken during robot-assisted surgery are provided in [Table 1].
Table 1: Precautions taken during robot-assisted surgery as per our institutional protocol to prevent gas and smoke leakage

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Postoperative care

Patients were shifted to the intensive care unit if required or kept under observation for 2 h in the recovery room and shifted to their respective rooms. In the postoperative period, only minimal and adequate contacts by hospital staff and modified Enhanced Recovery After Surgery® protocol for early recovery and discharge were practiced.

 > Results Top

From March 21, 2020, to June 21, 2020, 417 outpatient consultations were made in uro-oncology. Forty-nine patients underwent surgery for different urological malignancies. Most of the patients could not reach the hospital from other parts of the country due to a lack of transportation facilities and fear of acquiring the disease among patients and relatives. As per the hospital guidelines, an online consultation option was given to patients for follow-up where physical examination was not mandatory. There was an increase in online consultations during this period, and 171 online consultations were done; most of them were follow-up patients.

Out of these patients, 72 patients needed surgery for various urological cancers. However, surgery was postponed in 18 patients as they could wait, which included 9 patients of low- and intermediate-risk prostate cancer disease for radical prostatectomy, Four patients for channel transurethral resection of the prostate (TURP), Three patients needing cystoscopy, and Two bilateral orchidectomy patients (were given luteinizing hormone-releasing hormone analogs). Among 16 patients preplanned for surgery in April, only five patients came for surgery. During the study period, five patients who were planned for surgery were detected with COVID-19 on RT-PCR test, and surgery had to be postponed for 14 days and till test became negative. All patients who underwent surgery were negative for COVID-19. HRCT was done in borderline symptomatic patients (n = 18), which was negative.

We operated 49 patients with urological malignancies [Table 2]. Thirty patients (61.2%) were from Mumbai, and 19 patients (38.7%) traveled from other parts of the country. Most of the patients were in the elderly age group (mean, 62.5 years; range, 15–81), and there were 4 (8.2%) female and 45 (91.8%) male patients. Most of our surgeries constituted robot-assisted procedures (59.2%, 29 patients). Fourteen patients (28.5%) underwent endoscopic procedure (transurethral resection of bladder tumor [TURBT] or TURP), open procedures such as high inguinal orchidectomy and partial penectomy were done in five patients, and one patient underwent laparoscopic deroofing of symptomatic large renal cyst. Robot-assisted procedures included nine cases (31%) of radical cystectomy (two post neoadjuvant chemotherapy) with ileal conduit or neobladder, nine cases (31%) of either partial or radical nephrectomy, seven cases (24.1%) of robotic-assisted radical prostatectomy, two cases (6.8%) of bilateral video-endoscopic inguinal node dissections, and one case each of simple prostatectomy and nephroureterectomy (robot-assisted nephroureterectomy).
Table 2: Patient characteristics, surgical procedures, and outcomes

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Best surgical practices were followed, and we did not face any mortality during this period. One patient had Clavien Grade 3 complications who required pigtail insertion for abdominal lymph fluid collection, and the other two patients had Grade 2 complications with prolonged hospital stay. All of our patients recovered well; two had a surgical indication for intensive care management who recovered well later on. None developed symptoms of COVID-19 or the disease during the hospital stay. The patients' average hospital stay was 3.5 days, which was less when compared to pre-COVID era (6 days). All patients were followed up in the postoperative period to know their status. At the median follow-up of 55 days (interquartile range, 32–77), there was no report of COVID-19 in any patient. None of the hospital staff with immediate contact with our patients developed the symptoms nor were tested positive for COVID-19 during the aforementioned period.

 > Discussion Top

Continuing cancer care is an integral part of medical practice. Prostate cancer, carcinoma bladder, and renal malignancy account for 7.1%, 3%, and 2.2% of all cancers, respectively.[7] The delay in treating cancer patients may impact short-term progression and mortality.[8] In this pandemic, Mumbai is deemed as a hotspot for COVID-19 disease in India. Surgeries performed in epicenters and COVID-designated hospitals like our institute carry a very high risk to health-care personnel and patients. In Italy, 9% of COVID-19 cases occurred in health-care workers.[9] Hence, proper care and safe surgery is the key for both patients and health-care providers.

The number of patients visiting the OPD for follow-up or newly detected malignancy visiting the regular OPD had come down due to lack of transportation and fear of acquiring diseases. Although the critical point of clinical examination is missed, telemedicine and long-distance follow-up have become a reality. It has become a new accessory tool for the physicians worldwide; patients in the USA and UK are attending National Health Service (NHS) over Zoom, Microsoft team, etc.[10] Recently, the Ministry of Health and Family Welfare of India also provided guidelines for carrying telemedicine.[11] We did teleconsultation over Skype in 171 patients; most of them were follow-up patients.

It has been a challenging time as we were unaware of the exact biology and treatment of this disease. However, we continued giving care to the needy patients as it is difficult to postpone the cancer treatment infinitely, although with precautionary measures to prevent the transmission of COVID-19. Wang and Zhang reported that the nonavailability of sufficient medical support is a significant risk factor for cancer patients during the COVID-19 pandemic.[4]

Due to the socioeconomic and psychological impact of cancer and COVID-19 infection, it is prudent to discuss in detail all the possibilities with patients elaborately and decide who needs urgent care and who can be postponed safely. We postponed surgeries in 18 patients and safely performed in 49 others. The Indian Council of Medical Research recommended the prophylactic use of HCQ in asymptomatic health-care workers who were treating suspected cases.[5] Few studies doubt its efficacy given lack of data and associated significant complications like QT prolongation.[12] However, a study from Lee et al. reported definitive advantages for prophylaxis due to its longer half-life and higher concentration in the lung (500 times more than serum).[13] In our institute, all health-care workers were provided with HCQ prophylaxis as per recommendation.

Most of the studies have reported the sensitivity of RT-PCR to be 71%–83.3% which leads to a large number of false-negative results.[14],[15] This may be due to genetic diversity and rapid evolution of virus or due to nature of sampling.[16],[17] Computed tomography chest has a good sensitivity of 98% and used as a screening tool in doubtful patients with negative RT-PCR.[14],[15] Surgery was postponed in five patients seen in outpatient who were COVID positive. All the patients admitted for surgery underwent RT-PCR and additional HRCT chest was done in 18 patients, which was negative for COVID-19.

The use of masks has become more critical and is the single most crucial factor in reducing the chances of infection and transmission and was provided to all patients and attendants. N95 masks are a truly a respirator, with 30 times more excellent protection,[12] as it tightly fits to provide optimum face seal[18] and breathing is through the filter material where it filters 95% of the particles and up to 0.3 μm particle size. A face shield was provided to all health personnel for protection from the splashing of aerosols and to prevent possible transmission through the conjunctiva.

Anesthesiologists were at the highest risk of exposure to the virus, especially during airway manipulations. Personal protective measures were undertaken when caring for patients with confirmed or suspected infections. Regional anesthesia was preferred when possible, as it is associated with a lower risk of aerosol generation. Intubation, extubation, and oral/airway suctioning carry an increased risk of aerosol transmission.

Studies show in proven COVID patients, only a small percentage of blood samples (3/307, 1%) were positive for PCR, and none of the urine samples were positive (0/72) as compared to 93% with bronchoalveolar lavage fluid, suggesting that only a few cases are systemic.[19] Thus, endourological and open procedures could be done with necessary precautions taken by entire operating team. During this pandemic, when, cancer surgeons all over the world are facing a huge dilemma, Shrikhande et al published a series of 494 patients undergoing elective cancer surgeries without facing any complications due to COVID-19.[20] We performed 11 endourological procedures, mainly TURBT and TURP and postponed the nonemergency procedures low-risk. Open procedures were done in five patients, which included high inguinal orchidectomy and partial penectomy.

There have been particular concerns about robotic surgery because of the higher concentrations of particulate matter generated due to the electrosurgical devices employed, low gas motility of pneumoperitoneum, and expulsion of gas through ports or trocars. Laparoscopic or robotic procedures have a contained pneumoperitoneum, and a controlled smoke evacuator reduces the contamination rate. The British Intercollegiate General Surgery (Royal College of Surgeons [RCS]) Guidance on COVID-19 and the American College of Surgeons recommended to avoid laparoscopic surgery due to aerosol generation and contamination.[6],[21] These recommendations were made under the fear of spread of disease rather than on any data.[22] However, RCS later rephrased the guidelines and confirmed that these surgeries can be considered in selected cases. Motterle et al. reported robotic surgery's safety and clear advantage during this pandemic in reducing morbidity and hospital stay and less stress to the health-care system.[23]

ERUS guidelines provided the opinion of operating emergency cases and postponing other procedures.[24] Contradictory to it, SAGES had a different opinion, to perform laparoscopic procedures with caution.[25] We could safely perform array of robotic procedures, 29 surgeries in total. We feel that robotic surgery offers a number of advantages - 1) We could operate at lesser pneumoperitoneum pressure of 8-10 mm Hg. 2) We could contain the gas leakage efficiently 3) There was lesser overall use of instruments 4) Surgeries were done with lesser operating room staff 5) Patients could be mobilized and discharged earlier, thereby reducing the exposure.

There will be a potential leakage of pneumoperitoneum when 5 mm instruments are used through 12 mm ports,[26] so we used airtight Ethicon assistant port to reduce the leakage. One of the most common insufflators that are suggested for use is ConMed AirSeal® intelligent flow system. It possesses a trilumen tube which enables 1) CO2 inflow 2) CO2 outflow 3) filter of particles up to 0.01 μm by ultra low particulate air filter.[27] We used it for all our robotic surgeries with settings of high smoke evacuation mode with pneumoperitoneum pressure of 8–10 mmHg. It has the benefit of regularly evacuating air, thus reducing the particulate matter buildup, and CO2 is recirculated which prevents the fogging of the camera. Measures to prevent aerosol contamination were followed [Table 1]. All the patients did well and none of them developed symptoms or COVID during the period of management.

 > Conclusions Top

Our reports show that we can offer and continue treating needy cancer patients with minimal risk by taking all the precautions even in these difficult times of a pandemic. Looking forward beyond the COVID-19 pandemic and rebuilding of the health-care system along with adequate treatment of oncological patients is possible by following a few precautionary steps. Our initial experience of managing uro-oncology and robot-assisted surgeries during this pandemic is just a window view, which has to be further improvised and materialized with further consensus and will guide us all in the right path beyond COVID and living with the new normal in the post-COVID era.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 > References Top

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Kimmig R, Verheijen RH, Rudnicki M; For SERGS Council. Robot assisted surgery during the COVID-19 pandemic, especially for gynecological cancer: A statement of the Society of European Robotic Gynaecological Surgery (SERGS). J Gynecol Oncol 2020;31:e59.  Back to cited text no. 6
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Shrikhande SV, Pai PS, Bhandare MS, Bakshi G, Chaukar DA, Chaturvedi P, et al. Outcomes of elective major cancer surgery during COVID 19 at tata memorial centre. Ann Surg 2020;272:e249-52.  Back to cited text no. 20
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  [Table 1], [Table 2]


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