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EU ROP E AN U RO LO GY 7 8 (2 02 0) 21– 28 available at www.sciencedirect.com journal homepage: www.europeanurology.com Brief Correspondence – Editor’s Choice European Association of Urology Guidelines Office Rapid Reaction Group: An Organisation-wide Collaborative Effort to Adapt the European Association of Urology Guidelines Recommendations to the Coronavirus Disease 2019 Era Maria J. Ribal a,*, Philip Cornford b, Alberto Briganti c, Thomas Knoll d, Stavros Gravas e, Marek Babjuk f,g, Christopher Harding h, Alberto Breda i, Axel Bex j,k, on behalf of the GORRG Group, Jens J. Rassweiler l, Ali S. Gözen l, Giovannalberto Pini m, Evangelos Liatsikos n, Gianluca Giannarini o, Alex Mottrie p,q, Ramnath Subramaniam r, Nikolaos Sofikitis s, Bernardo M.C. Rocco t, Li-Ping Xie u, J. Alfred Witjes v, Nicolas Mottet w, Börje Ljungberg x, Morgan Rouprêt y, Maria P. Laguna z,aa, Andrea Salonia c, Gernot Bonkat bb, Bertil F.M. Blok cc, Christian Türk dd,ee, Christian Radmayr ff, Noam D. Kitrey gg, Daniel S. Engeler hh, Nicolaas Lumen ii, Oliver W. Hakenberg jj, Nick Watkin kk, Rizwan Hamid ll, Jonathon Olsburgh mm, Julie Darraugh nn, Robert Shepherd nn, Emma-Jane Smith nn, Christopher R. Chapple oo, Arnulf Stenzl pp, Hendrik Van Poppel qq, Manfred Wirth rr, Jens Sønksen ss,tt, James N’Dow uu, on behalf of the EAU Section Offices and the EAU Guidelines Panels a b Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; Liverpool University Hospitals Foundation NHS Trust, Liverpool, UK; c Department of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; d Department of Urology, Sindelfingen- e Böblingen Medical Centre, University of Tübingen, Sindelfingen, Germany; Department of Urology, University Hospital of Larissa, Larissa, Greece; f Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; g Department of Urology, Medical University of h Vienna, Vienna, Austria; Urology Department, Freeman Hospital, Newcastle-upon-Tyne, UK; i Oncology Urology Unit, Department of Urology, Fundació j Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; The Royal Free London NHS Foundation Trust and UCL Division of Surgery and k Interventional Science, London, UK; Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; l Department of Urology, SLK Kliniken Heilbronn, University of Heidelberg, Heilbronn, Germany; m Department of Urology, Ospedale San Raffaele–Turro, Milan, Italy; n Urology Department, University of Patras, Patras, Greece; o Urology Unit, Academic Medical Centre Hospital “Santa Maria della Misericordia”, Udine, Italy; p Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium; q ORSI Academy, Melle, Belgium; r Department of Paediatric Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK; s Department of Urology, Medical School, University of Ioannina, University Campus, Ioannina, Greece; t Department of Urology, University of Modena and Reggio Emilia, Modena, Italy; u Department of Urology, The First Affiliated Hospital, School of v Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China; Department of Urology, Radboud University Medical Center, Nijmegen, w x The Netherlands; Department of Urology, University Hospital, St. Etienne, France; Department of Surgical and Perioperative Sciences, Urology and y Andrology, Umeå University, Umeå, Sweden; Urology, Sorbonne University, GRC 5 Predictive onco-uro, AP-HP, Pitie-Salpetriere Hospital, Paris, France; z aa bb Department of Urology Medipol Mega, Istanbul Medipol University, Istanbul, Turkey; Amsterdam UMC, Amsterdam, The Netherlands; Alta Uro AG, $ Please see the Supplementary material for all members of the Guidelines Office Rapid Response Group (GORRG), the EAU Guidelines Panels, and the EAU Section Offices. * Corresponding author. Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Villarroel 170, Escalera 12, planta 1a, 08036?Barcelona, Spain. Tel.: +34 93 227 55 45; Fax: +34 93 227 55 45. E-mail address: m.ribal@uroweb.org (M.J. ). https://doi.org/10.1016/j.eururo.2020.04.056 0302-2838/© 2020 Published by Elsevier B.V. on behalf of European Association of Urology. 22 E URO P EA N U ROL O GY 7 8 ( 20 20 ) 21 –2 8 cc Merian Iselin Klinik, Center of Biomechanics and Calorimetry, University Basel, Basel, Switzerland; Department of Urology, Erasmus MC, Rotterdam, dd ee The Netherlands; Department of Urology, Hospital of the Sisters of Charity, Vienna, Austria; Urologische Praxis mit Steinzentrum, Vienna, Austria; ff gg Department of Urology, Medical University of Innsbruck, Innsbruck, Austria; Department of Urology, Sheba Medical Centre, Tel-Hashomer, Israel; hh ii jj Department of Urology, Cantonal Hospital St Gallen, Switzerland; Department of Urology, Ghent University Hospital, Ghent, Belgium; Klinik und Poliklinik für Urologie, Universitätsmedizin Rostock, Rostock, Germany; kk NHS Foundation Trust, St. George’s University Hospitals, London, UK; ll Department mm of Female, Functional and Restorative Urology, University College London Hospitals NHS Foundation Trust, London, UK; Department of Urology and nn Transplant, Guy's & St Thomas' NHS Trust Hospitals, London, UK; European Association of Urology Guidelines Office, Arnhem, The Netherlands;; oo Department of Urology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK; pp Department of Urology, University Hospital Tuebingen, Tuebingen, Germany; qq Department of Urology, University Hospitals Leuven, Leuven, Belgium; rr Department of Urology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Dresden, Germany; ss Department of Urology, Herlev and Gentofte University Hospital, Herlev, Denmark; tt Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; uu Academic Urology Unit, University of Aberdeen, Aberdeen, UK Article info Abstract Article history: The coronavirus disease 2019 (COVID-19) pandemic is unlike anything seen before by Accepted April 21, 2020 modern science-based medicine. Health systems across the world are struggling to manage it. Added to this struggle are the effects of social confinement and isolation. This Associate Editor: brings into question whether the latest guidelines are relevant in this crisis. We aim to James Catto support urologists in this difficult situation by providing tools that can facilitate decision making, and to minimise the impact and risks for both patients and health professionals delivering urological care, whenever possible. We hope that the revised recommenda- Keywords: tions will assist urologist surgeons across the globe to guide the management of Coronavirus disease 2019 urological conditions during the current COVID-19 pandemic. European Association of Urology © 2020 European Association of Urology. Published by Elsevier B.?V. All rights reserved. Guidelines Office Section Offices Guidelines Pandemic 1. Introduction 2. Methods The coronavirus disease 2019 (COVID-19) pandemic is unlike The Guidelines Office commissioned a Rapid Reaction anything seen before by modern science-based medicine. As Group (GORRG) on March 19, 2020 to facilitate the of April 14, 2020, there are 1 933 800 confirmed cases globally development of adapted guidelines, to deal with a range in 210 countries and 120 434 deaths [1]. Health systems of situations and priorities. Using the resources of the globally have struggled. Anaesthetists and theatre teams have Guidelines Office, the panel chairmen, and panel members, been redeployed, and intensive care units (ICUs) struggle with in collaboration with other relevant EAU section offices demands as the entire service is refocused on managing the plus the Executive Committee, the aim was to ensure an acutely unwell. Added to this are the effects of social aligned organisation-wide consensus and response under- confinement and isolation. Staff at risk are removed from pinned by the best knowledge at our disposal describing the workforce for their own health and some of them get sick, how to react to the urgent crisis impacting urological care also limiting capacity. This brings into question whether the and services. latest guidelines based upon the best evidence and published All recommendations in the guidelines have been only 2 wk ago are relevant in this crisis. reviewed in light of the COVID-19 pandemic and have been As a scientific society and via the Guidelines, Section adapted where appropriate. Panels also had access to and Offices, and the European Urology family of journals, we reviewed a range of national and local COVID-19 guidelines believe that it is important that we try to support urologists in to ensure complementarity wherever possible. New evi- this difficult situation. We aim to do this by providing tools dence has been searched for by targeted (nonsystematic) that can facilitate decision making. Our goal is to minimise the screening of the available published literature, as well as impact and risks for both patients and health professionals including those recently accepted and in press with access delivering urological care, whenever possible, although it is provided by the publisher in strict confidence. The findings clear that it is not always possible to mitigate them entirely. It (mostly level 3/4 evidence) were discussed and approved by should be understood that there may not be high-quality panel members across 21 EAU Guideline Panels using evidence for the compromises proposed, but we hope that this electronic communication. Regarding surgical approach document will function as an important additional guide to that applies across several guidelines, it was decided that the management of urological conditions during the current the GORRG will provide general recommendations instead COVID-19 pandemic, caused by severe acute respiratory of guideline-specific surgical approach recommendations in syndrome coronavirus 2 (SARS-CoV-2), based on the current each disease area. All panels were provided the following European Association of Urology (EAU) guidelines. specific terms of reference. EUROPEAN UROLOGY 78 (2020) 21–28 23 2.1. Protocol for adaptation of guidelines recommendations to  Impact of delay on primary outcomes (for instance overall COVID-19 period survival in oncology, cancer-specific survival in oncology, risk of metastases, and kidney failure for transplant patients) 2.1.1. Review of recommendations across four broad areas  Possibility of alternative methods that could replace the procedure with less operating room requirement 1. Diagnosis  Presence of comorbidities and/or increased risk of Imaging and/or tests complications Invasive procedures  Possibility of a threat to patient life if the procedure is not 2. Surgical treatment and medical therapy performed immediately. 3. Follow-up/telemedicine (give updated recommenda-  Possibility of a threat of permanent dysfunction of the tions on follow-up tailored for the COVID-19 era, with organ system if the treatment is not performed the aim of limiting as much as possible health care  Probability of a risk of rapidly progressing severe resources without losing our ability to timely diagnose symptoms that are time sensitive disease recurrences/progressions) The criteria derived from COVID-19 pandemic are as follows: 4. Emergencies  Current and projected COVID-19 cases in the facility and 2.1.2. Levels of priority region; the final decisions should be made in consultation Panels were asked to provide tables with recommendations with the hospital, surgeon, patient, and other public based on the level of priority, not necessarily covering all health professionals recommendations on the recently published updated EAU  Supply of personal protective equipment (PPE) to the guidelines 2020 [2], but those that the panels felt were facilities in the system critical drivers of outcome and would especially be  Staffing availability impacted by the current crisis, and always based on the  Bed availability, especially ICU beds highest level of evidence that was possible and referenced  Availability of adjuvant treatments (ie, chemotherapy) whenever possible to maintain a transparent link from without which the primary treatment is less/not effective evidence to adapted recommendation. In order to achieve  Ventilator availability this, the GORRG produced a colour-coded risk stratification  Health status and age of the patient, especially given the tool (Table 1) for completion by guideline panels to aid them risks of concurrent COVID-19 infection during recovery with the adaption of their recommendations:  Urgency of the procedure Low priority: clinical harm (progression, metastasis, and  Risk of bleeding/transfusion—there is a lack of red blood loss of function) very unlikely if postponed for 6 mo (green cell units because blood donors do not go to the hospital. colour) Co-morbidities such as chronic obstructive pulmonary Intermediate priority: cancel but reconsider in case of disease should be taken into account; patients taking increase in capacity (not recommended to postpone for >3 anticoagulants/antiplatelet therapy (due to increased risk mo): clinical harm (progression, metastasis, and loss of for transfusion) organ function) possible if postponed for 3 mo, but unlikely  Length of hospitalisation (yellow colour)  Risk of acquiring the COVID infection by the patient High priority: the last to cancel, prevent delay of >6 wk; during the treatment course clinical harm (progression, metastasis, loss of organ function,  Risk of contamination of the staff by asymptomatic but and deaths) very likely if postponed for >6 wk; (red colour) already positive patient Emergency: cannot be postponed for >24 h; life threat-  Capacity of COVID-19 testing ening—organ function threatening condition (black colour) 2.1.4. Peer-reviewing process 2.1.3. Criteria for prioritisation Once submissions of adapted recommendations were The criteria established for prioritisation regarding proce- received from all 17 EAU Guideline Panels, the GORRG dure and disease are the following: proceeded with a first round of peer review and ensured Table 1 – Levels of priority. Priority Low priority Intermediate High priority Emergency category priority Definion Clinical harm very Clinical harm Clinical harm very likely Life-threatening unlikely if possible if if postponed for >6 wk situaon; likely to postponed for 6 postponed for 3–4 have presented via mo mo, but unlikely A&E despite the current pandemic A&E = accident and emergency department. 24 E URO P EA N U ROL O GY 7 8 ( 20 20 ) 21 –2 8 uniformity of the format of recommendations, checked for After the second round of peer-review process, different consistency, and limited duplication across panel recom- recommendations have been released and these can be mendations. consulted in 17 guideline topics provided in Supplementary Finally, a second-step peer-reviewing process was done Tables 1–17. by seven independent Section Office members (three experts in oncology and three in nononcology, and one to 3. Discussion comment on both oncology and nononcology); we also sought peer-review comments from China, given the The guidance produced is based on expert opinion and significant experience they have had with COVID-19 and consensus building across the EAU with contributions from being a few months ahead of Europe in terms of stage of all 250 members of the EAU Guidelines Office and with pandemic and recovery. contributions from the 130 key opinion leaders forming the Table 2 – General recommendations applicable during the COVID-19 pandemic.a General recommendations for surgical procedures  Depending on the resources and capacity, we recommend treating only high-priority and emergency cases surgically during the COVID pandemic.  Consider not only equipment, OR, and ICU bed capacity, but also blood supplies available and drug shortage, in order to prioritise your surgeries.  Consider that even if capacity is available, low-priority patients increase the footfall and the risk of COVID transmission between patients and staff.  Consider that surgery has been reported to be harmful in asymptomatic patients who subsequently tested COVID positive [6].  Consider treating intermediate-priority patients if capacity is available but not during the COVID surge.  Consider older patients with comorbidity at severe risk of COVID infection and a fatal outcome. Therefore, carefully balance if surgery is the only alternative in high-priority cases.  Where ventilator capacity for COVID patients has been breached, high-priority surgical candidates requiring ICU ventilation should be triaged according to local recommendations—or if unavailable—age and comorbidity.  Follow the local recommendations to test staff and patients for COVID, if resources are available. These may differ across hospitals and countries; you should familiarise yourself with them. Be aware that they may change as new information is coming in.  Follow the local recommendations for personal protective equipment (PPE), if resources are available; the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) advise full PPE irrespective of COVID status of the patient. Familiarise yourself with their recommendation [16,17].  Wear full PPE for COVID-positive patients according to the World Health Organization (WHO). This should include double gloves, gowns, face shields, and virus-proof masks [17,18].  Intubation and extubation should preferably take place in a negative pressure room if available [19].  All nonessential staff should stay outside the operating room during the procedure.  Set electrosurgery units to the lowest possible settings to reach the required effect.  Avoid or reduce the use of monopolar electrosurgery, ultrasonic dissectors, and advanced bipolar devices, as these can lead to particle aerosolisation.  Use, if available, monopolar diathermy handheld devices with attached smoke evacuators.  Clean surgical equipment of COVID-positive or suspected patients separately. General guidance on what to do when faced with a known COVID-19–positive patient needing surgery (these measures are partially also applicable to COVID-19–negative patients)  A specially equipped dedicated OR has to be prepared for these cases. For endourology, a mobile C-arm fluoroscopic x-ray system for radiological imaging and an experienced personnel for its handling has to be in the special OR.  Surgeons and operating team (surgeons, anaesthetists, nurses, technicians, nursing assistants/health care workers, and hospital housekeepers) in the OR should be completely protected against infection of COVID-19 and adopt adequate protection devices.  All minimally invasive procedures should preferably be performed by experienced surgeons, and the number of experienced OR staff members required should be minimum. Additionally, no external observer is allowed in the OR [7] (https://uroweb.org/wp- content/uploads/ERUS-guidelines-for-COVID-def.pdf).  To date, there are no specific data demonstrating an aerosol presence of the COVID-19 virus released during minimally invasive abdominal surgery.  Smoke evacuation systems with active filtered smoke evacuation mode, capable of filtering the aerosolised particles from the carbon dioxide, should be provided during laparoscopic surgeries [16].  CO2 insufflation should be utilised with a closed system with appropriate filtering of aerosolised particles:  It should be ensured that 8 mm instruments are not inserted in a 12 mm da Vinci trocar without a reducer.  It should be ensured that a 5 mm instrument is not inserted in a 12 mm da Vinci trocar even with the reducer in place.  CO2 insufflation should be turned off and the gas should be vented through a filter prior to specimen extraction.  Consultation with the CO2 insufflation manufacturer used in your hospital may be necessary to ensure that proper settings are selected for maximal filtration effect.  The full recommendation of SAGES on this topic as well as the cited published evidence can be found on the SAGES website [16]. A recent publication that reports the experience of minimally invasive surgeons from China and Italy in the setting of known/suspected COVID-19 can be accessed from the Annals of Surgery [8].  For (robot-assisted) laparoscopy and retroperitoneoscopy, the lowest allowed intra-abdominal pressure with the use of intelligent integrated Insufflation systems is recommended (ERUS) [7].  It is recommended that electrocautery power setting be lowered as much as possible in order to reduce the surgical smoke production, especially in laparoscopic surgery. During access, electrocautery should be provided with automatic suction system.  Evacuation of irrigation fluid during endourological procedures (cystoscopy, TURB, BPH, endoscopic surgery, URS, RIRS, and PCNL) should be collected through a close system. General guidance for testing patients before surgery in the COVID-19 period EUROPEAN UROLOGY 78 (2020) 21–28 25  Patients with clinical symptoms such as fever and respiratory distress and/or with a travel history to endemic areas and previous contact with COVID- 19 patients should all undergo preoperative COVID-19 test. In an emergency situation, it is suggested that these patients should be handled as COVID- 19–positive patients in order to reduce the risk of contagion for both patients and health care workers.  Among patients without any clinic symptoms, without a travel history to endemic areas, and without previous contact in the past 2 wk with a COVID- 19–positive patient, testing of elective patients is recommended whenever possible within 48 h prior to surgery in an outpatient clinic setting. One may consider starting with PCR testing and withholding a chest CT only if the PCR is positive for a COVID-19 infection. However, this might have severe logistical implications (patients need to visit the hospital repeatedly), and joint testing of PCR and CT may be a more desirable and practical approach, depending on the local situation. The main reasons for that approach are as follows:  Patients may be in the incubation period of a COVID-19 infection and subsequently develop COVID-19 postoperatively, placing them at risk for adverse postoperative outcomes [6].  Patients may be asymptomatic/mildly symptomatic carriers and shedders of SARS-CoV-2 and place hospital workers at risk, particularly during intubation and aerosolising procedures.  Patients may be asymptomatic/mildly symptomatic carriers and shedders of SARS-CoV-2 and place other hospitalised patients at risk, who are often in higher age groups with comorbidities and at higher risk of severe COVID-19 disease.  The group is aware that, at present, different triage policies may be applicable depending on the region or country. Even following accounts of the false negative results of the test and the fact that PPE has to be adopted in all surgical patients, information on the test may be useful in the postoperative period.  In addition, we strongly recommend advising patients to comply with general directions regarding social distancing as stated by the government, since this will likely lower the risk for COVID-19 disease at the time of operation. General guidance on other assistance aspects beyond surgery  Telemedicine.  Potential or proven COVID-19–positive patients must be treated according to local, national, and WHO requirements [18]. In this case, a comprehensive and robust infection control workflow has to be followed [20].  A network of expert high-volume centres, at the regional, national, or even supranational level, should guarantee the continuity of the oncological care in an appropriate way, ensuring the availability of hospital beds and timely management of new patients.  Remote consultation and a multidisciplinary team are recommended to offer the optimum therapeutics.  Testing for SARS-CoV-2 should be considered before any high-dose chemotherapy.  Patients should be guided to get access to nonemergency medical services such as chronic disease treatment online to reduce the number of visitors in hospitals.  Patients should be encouraged to take full advantage of digital self-service devices to avoid contact with others, to reduce the risk of cross infections. BPH = benign prostatic hyperplasia; COVID-19 = coronavirus disease 2019; CT = computed tomography; EAU = European Association of Urology; ERUS = EAU Robotic Urology Section; ICU = intensive care unit; OR = operating room; PCNL = percutaneous nephrolithotomy; PCR = polymerase chain reaction; RIRS = retrograde intrarenal surgery; SARS-COV-2 = severe acute respiratory syndrome coronavirus 2; TURB = transurethral resection of the bladder; URS = ureterorenoscopy. a Disclaimer: The EAU Guidelines Office COVID-19 recommendations are to support health care systems under severe constrain during the pandemic, but their application should be modulated according to local pandemic conditions and restrictions in clinical and surgical activity due to local medical directives and guidance. membership of the EAU Section Offices. It is important to recommendation for staff PPE. Even following a negative emphasise that during the rapidly evolving COVID-19 COVID-19 test result, it is important to remember the pandemic, this guidance may further change and critically relatively high risk of a false negative result and, as a will require adaptation to local resources, health systems, consequence, ensure that all the necessary PPE tools and and specific circumstances of each country or city, bearing general recommendations to reduce COVID-19 transmis- in mind that different countries and indeed different cities sion are adequately followed (Table 2) [3]. It is also prudent are likely to be at different phases of the pandemic and during this pandemic, in the absence of extensive national/local health system capacities must dictate the community testing and effective isolation/quarantine level of prioritisation implemented in line with local COVID- strategies in place, that health professionals perform their 19 policies. duties on the presumption that all patients they treat are In addition, there are some overarching principles that potentially infected with COVID-19 even if asymptomatic, should be emphasised (as presented in Table 2). In order to given that there is increasing evidence of high infection minimise the number of staff who become infected, all rates in asymptomatic individuals in countries conducting medical personnel should comply with the PPE regula- extensive community testing of their citizens [4,5]. In this tions. If possible, patients should be asked whether they regard, it is important to consider the risk not only for staff are at risk of COVID-19 prior to any visit in a practice or but also for the patients. Recent evidence from Wuhan clinic or hospital setting. Patients who are currently known reported a 20% mortality rate in asymptomatic patients to be shedding COVID-19 virus should postpone any who tested COVID positive after the surgical procedure investigations of other symptoms unless they are thought [6]. Onset of symptoms was within 2.6 d, and 44.1% to be life threatening. However, urologists working in required ICU support. Out of 20 asymptomatic COVID- hospitals treating COVID-19 patients may be required to positive patients undergoing level 3 complexity proce- perform urgent investigations on infected patients. In dures, which are equivalent to urological transabdominal these cases, procedures should be performed in dedicated or retroperitoneal interventions, seven died in ICU from consultation or operating rooms following the hospital acute respiratory distress syndrome (Table 2). 26 E URO P EA N U ROL O GY 7 8 ( 20 20 ) 21 –2 8 If surgical procedures are unavoidable, it is recom- is not demonstrated yet, it is preferable to minimise the mended that all procedures should be performed by risks of faecal transmissions. experienced urologists confident in the procedure. They Social distancing is the key player to fight against COVID- should be performed with the minimum number of staff 19 pandemic. We have a duty to avoid unnecessary members, who should also be fully trained and experienced. outpatient visits and in doing so reduce the chance of virus Furthermore, no external observers should be present transmission. Increasing use of telehealth may be an during the procedure (ie, fellows or students) [7]. Use of important way to continue to support patients and their ultrasonic scalpels or electrical equipment producing carers during this crisis. It will be interesting to see if this surgical smoke should be discouraged because such smokes change, born of necessity, is incorporated into urological could carry the COVID-19 [8]. In previous studies, activated practice beyond the pandemic (Table 2) [14,15]. Corynebacterium, papillomavirus, and human immunodefi- While it cannot be predicted when we will be able to ciency virus (HIV) have been detected in surgical smoke, revert back from the acute phase of the COVID-19 pandemic and several doctors contracted a rare papilloma virus and resume more normal levels of urological care, we need suspected to be connected to surgical smoke exposure. to plan ahead on how the urological community should do There is no reason to suppose that COVID-19 infection could this. not be spread in the same way. One study found that after The most logical step will be to reverse back through the using electrical or ultrasonic equipment for 10 min, the aforementioned prioritisation stages. During this process, particle concentration of the smoke in laparoscopic surgery we will need to confer with our fellow surgical (sub) was significantly higher than that in traditional open specialities to prioritise the available surgical time and surgery [8]. Thus, it is recommended to lower electrocau- resources among all surgical patients. tery power settings as much as possible. There is no Undoubtedly there will be cases where the optimal conclusive evidence regarding the differences in risks of surgical treatment time point will be surpassed. These open versus laparoscopic surgery for the surgical team. patients may be at risk of a suboptimal outcome or an However, laparoscopic surgery may be associated with a increased psychological burden due to delayed surgery, and higher amount of smoke particles than open surgery [9]. On should be prioritised in the long waiting lists that we will the contrary, minimally invasive surgery has the benefit of undoubtedly be facing on the other end of this crisis. reducing the length of hospital stay and reducing the risks to the patient for contracting COVID-19 whilst in hospital. 4. Conclusions During laparoscopy, surgical smoke is released into theatre under pressure at several stages of surgery. It is advisable to The EAU is a family of 19 000 members, and beyond our keep intraperitoneal pressure as low as possible and to membership, the EAU feels a huge sense of responsibility aspirate the inflated CO2 as much as possible before towards each and every urologist globally, wherever they removing the trocars (Table 2) [7–9]. may be, appreciating that the EAU guidelines are now The duration and frequency of shedding of COVID-19 endorsed by national societies of 72 countries. This virus in urine are unknown [10]. However, a recent study by extended family ethos is even more important at a time Ling et al [11] reported limited persistence of SARS-CoV-2 like this when we are acutely aware of the despair that nucleic acid in urine. These data do not prove a link between nations and their citizens are experiencing around the urine spillage and virus transmission. However, although no world. For instance, we realise that our colleagues and evidence of disease transmission through urine is demon- friends in Italy, Spain, France, UK, other EU member states strated yet, urine sampling (for urine culture, dipsticks, and and increasingly in the USA are being particularly impacted, other analyses), urethral catheterisation, and endoscopic whilst on the other side of the world, our friends in China, procedures (eg, transurethral resection of the prostate, South Korea, and Japan look to rebuild and return to some transurethral resection of the bladder, ureteral stenting, form of new normality. Our thoughts are with each and etc.) should be executed with caution. As spills are every one of you. Despite these incredibly difficult times, inevitable, surfaces should be cleaned rapidly by using key opinion leaders across the breadth of our membership appropriate absorbent and by decontamination with have come together like never before to rapidly produce this chlorine (5000–10 000 mg/l) or another appropriate disin- publication on adapting EAU guideline recommendations to fectant (note that chlorhexidine is ineffective against COVID-19 that we hope will fill an important urological COVID-19 and is not appropriate) [12]. Spills should be practice void and assist urologist surgeons across the globe handled according to local guidelines. Similarly, in case of as they do their very best to deal with the crisis of our spillage leading to unwanted contact (ie, accidental expo- generation. sure) with a member of the staff, appropriate measures The EAU Guidelines Office COVID-19 recommendations should be taken following local protocols. can be consulted in Supplementary Tables 1–17. It is now clear that SARS-CoV-2 is present in the stools of COVID-19 patients. Therefore, the transmission during various procedures (eg, transrectal prostate biopsy and Author contributions: Maria J. Ribal had full access to all the data in the urinary diversions) might be possible [13]. Therefore, even if study and takes responsibility for the integrity of the data and the accuracy of the data analysis. clear evidence of COVID-19 virus spreading through faeces EUROPEAN UROLOGY 78 (2020) 21–28 27 Study concept and design: Ribal, N’Dow, Cornford, Briganti, Knoll, Gravas, Janssen, GE, BMS, Sanofi, and Astellas; has received speaker honoraria Babjuk, Harding, Breda, Bex. from Astellas, Pierre Fabre, Steba, Janssen, and Ferring; and has received Acquisition of data: Witjes, Mottet, Ljungberg, Rouprêt, Laguna, Salonia, fellowships and travel grants from Astellas, Ipsen, Sanofi, Janssen, and Bonkat, Blok, Türk, Radmayr, Kitrey, Engeler, Lumen, Hakenberg, Watkin, Roche. Börje Ljungberg has received speaker honoraria from Pfizer, Olsburgh, Hamid, Ribal, N’Dow, Cornford, Gravas, Babjuk, Harding, Ipsen, and BMS; has participated in studies run by Janssen, Astellas, and Breda, Bex. Medivation; and is a company consultant for Janssen, Novartis, and Analysis and interpretation of data: None. Ipsen Nordic. Morgan Rouprêt receives company speaker honorarium Drafting of the manuscript: Cornford, N'Dow, Ribal. from Roche, Zambon, Ipsen Pharma, Janssen, and Astellas; receives Critical revision of the manuscript for important intellectual content: Ribal, research support from GSK, Pfizer, and Roche; receives consultancy fees N’Dow, Cornford, Briganti, Knoll, Gravas, Babjuk, Harding, Breda, Bex, from Lilly, GSK, Ipsen, Astellas, Takeda, Sanofi Pasteur, and Medac; Rassweiler, Gözen, Pini, Liatsikos, Giannarini, Mottrie, Subramaniam, receives company speaker honorarium from Roche and Zambon; and Sofikitis, Rocco, Xie, Witjes, Mottet, Ljungberg, Rouprêt, Laguna, Salonia, participates in studies by Pfizer and Roche. Gernot Bonkat has received Bonkat, Blok, Türk, Radmayr, Kitrey, Engeler, Lumen, Hakenberg, Watkin, speaker honoraria from Vifor Pharma, Bionorica, and IBSA; has received Olsburgh, Hamid, Darraugh, Shepherd, Smith, Chapple, Stenzl, Van fellowship and travel grants from Vifor Pharma, Eli Lilly, and Astellas; Poppel, Wirth, Sønksen. and is a company consultant for Janssen-Cilag, Zambon, IBSA, and Vifor Statistical analysis: None. Pharma. Noam D. Kitrey has received speaker honorarium from Astellas Obtaining funding: None. and Pfizer; has participated in trials run by Astellas and Ipsen; and has Administrative, technical, or material support: Darraugh, Shepherd, Smith. received fellowship and travel grants from Pfizer. Nicolaas Lumen Supervision: Ribal, N’Dow. received company speaker honorarium from Bayer and Janssen; Other: None. participated in trials run by Janssen, Roche, Pfizer Belgium, and AstraZeneca N.V.; and received grant/research support from Bayer and Janssen. Rizwan Hamid received company speaker honorarium from Financial disclosures: Maria J. Ribal certifies that all conflicts of Allergan and Laborie; participated in trials run by IPSEN and Medtronic; interest, including specific financial interests and relationships and received honoraria from Contura and grant/research support from affiliations relevant to the subject matter or materials discussed in the Allergan. Christopher R. Chapple is a consultant for Astellas, Bayer, manuscript (eg, employment/affiliation, grants or funding, consultan- Contura, Ferring, Pierre Fabre, Symimetic, and Urovant Sciences; cies, honoraria, stock ownership or options, expert testimony, received speaker honorarium from Astellas and Lupin; is an author royalties, or patents filed, received, or pending), are the following: for Allergan, Astellas, and Ferring; is an investigator for Astellas and Maria J. Ribal received company speaker honorarium from Janssen Bayer; and is a co-patent holder for Symimetic. Arnulf Stenzl is a Laboratories, Olympus Iberia S.A.U., Astellas Pharma S.A., and Ipsen company consultant/advisor for Ipsen Pharma, Roche, Janssen, Alere, Pharma; and holds a patent for “Method for non-invasive diagnosis of Bristol-Myers Squibb, Stebabiotech, Synergo, and Ferring; received bladder cancer”, European Patent Office (grant number: 13382030.8- speaker honorarium from Janssen, Ipsen Pharma, Sanofi Aventis, 1403; entity holder: Fina Biotech, S.L.U. June 2007). Philip Cornford is a CureVac, Astellas, Amgen, and AstraZeneca; participates in clinical company consultant for Astellas, Ipsen, and Ferring; received company studies by Johnson & Johnson, Roche, Cepheid, Bayer AG, CureVac, speaker honoraria from Astellas, Janssen, Ipsen, and Pfizer; partici- Immatics Biotechnologies GmbH, and GemeDx Biosciences; and pated in trials run by Ferring; and received fellowships and travel received research grants from AmgenInc, Immatics biotechnologies grants from Astellas and Janssen. Alberto Briganti is a company GmbH, Novartis AG, and Karl Storz AG. Jens Sønksen holds equity consultant for Astellas, Janssen, Opko Health, MDx Health, and Bayer; interests in Multicept A/S, Frederiksberg, Denmark. Jens J. Rassweiler, received company speaker honorarium from Astellas and Ferring; and Ali S. Gözen, Giovannalberto Pini, Gianluca Giannarini, Bernardo M.C. received research support from Sandoz. Thomas Knoll is a company Rocco, Ramnath Subramaniam, Nikolaos Sofikitis, Julie Darraugh, consultant for Storz Medical, Dornier, Olympus, and Boston Scientific; Emma Jane Smith, Robert Shepherd, Bertil F.M. Blok, Alberto Breda, received company speaker honorarium from Boston scientific; Daniel S. Engeler, Oliver W. Hakenberg, Nick Watkin, Maria Pilar received fellowship/travel grants from Cook; and received research Laguna, Christian Radmayr, Andrea Salonia, Christian Türk, Jonathon support from Dornier. Stavros Gravas is a company consultant for Olsburgh, Hendrik van Poppel, Manfred Wirth, and James N’Dow have Astellas and GSK; and has received speaker honorarium from Astellas, nothing to declare. Pierre Fabre, and Ferring. Marek Babjuk is a company consultant for Astellas; received company speaker honoraria or consultancy fees from Ipsen Pharma s.r.o., Janssen, Olympus, and Astellas; holds an advisory board position for Ferring; and participates in trials run by Funding/Support and role of the sponsor: None. Hamlet Pharma, Ferring, and Sotio. Christopher Harding is a company consultant for Teleflex Medical; received speaker honorarium from Astellas, Allergan, and Medtronic; received travel grants from Appendix A. Supplementary data Medtronic and research grants from NIHR and The Urology Foundation; and participated in a trial by Medtronic. Axel Bex has participated in a Supplementary material related to this article can be trial run by BMS. Evangelos Liatsikos is a company consultant for CooK found, in the online version, at doi:https://doi.org/10.1016/j. Medical; received speaker honoraria from Boston Scientific and Karl eururo.2020.04.056. Storz, and participates in clinical studies run by Cook Medical. Alex Mottrie is the CEO of ORSI Academy and holds equity interest in Intuitive. Li-Ping Xie participates in trials run by IPSEN (PRIORITI study) References and Olympus (TVERP study) as the primary investigator. Alfred J. Witjes is a company consultant for Spectrum, Tocagen, BioClin, Sanofi Aventis, [1] Worldometer COVID-19 data. https://www.worldometers.info/ Biocancell Ltd., and Nucleix Ltd.; received honoraria or consultation coronavirus/2020. fees from Taris Biomedical, BMS, MSD Global Medical Affairs, and Roche [2] European Association of Urology. European Association of Urology Nederland B.V.; and participated in trials run by Taris, Cepheid, Arquer, guidelines. 2020 edition. 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