Functional urology surgery and SARS-CoV-2: How and why surgical activity should be resumed now, adapting to the new reality

Garde-García, H; González-López, R; González-Enguita, C.
doi:10.1016/j.acuroe.2020.06.001
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Following the outbreak of the SARS-CoV-2 pandemic&#44; normal surgical activity has been relegated to the new hospital reorganization required to ensure continuity of care&#44; except for those surgical emergencies and oncological surgical procedures whose delay would result in unacceptable risk to the patient&#46; In the present phase&#44; it is necessary to resume the activity that was delayed together with all surgical procedures&#44; oncological or not&#44; that are indicated in the consultation activity&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The objective of this article is to collect the recommendations with the greatest scientific evidence to guarantee patient safety in these procedures&#44; as well as tools that help in the selection of patients taking into account resource optimization criteria&#44; focusing on an area of urology that deals with non-oncological pathology&#58; functional urology&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">A review of the existing literature and the recommendations of the Spanish Association of Surgeons &#40;AEC&#44; for its acronym in Spanish&#41;&#44; American College of Surgeons &#40;ACS&#41;&#44; American Urological Association &#40;AUA&#41;&#44; Royal College of Surgeons &#40;RCS&#41;&#44; European Association of Urology &#40;EAU&#41;&#44; Center for Disease Control and Prevention &#40;CDC&#41;&#44; National Health System &#40;NHS&#41; and the World Health Organization &#40;WHO&#41; has been conducted from March 14&#44; 2020&#44; the date of the declaration of the state of alarm in Spain&#44; to the present&#46; Information regarding the criteria for delaying surgical urological procedures that necessarily occurred during the peak of the pandemic&#44; the existing protocols and current recommendations regarding the perioperative period&#44; from preoperative to discharge&#44; and possible tools that may be helpful in the selection of the most appropriate patients when it comes to resuming surgical activity in functional urological surgery today&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="par0020" class="elsevierStylePara elsevierViewall">The British NHS was the first to publish guides on general surgical prioritization criteria on 11 April 2020&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The EAU published their recommendations on 14 April 2020&#46; These guides are not only related to surgery&#44; but they include diagnosis and follow-up as well&#44; in a more detailed way&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">On April 28&#44; 2020&#44; a consensus document was published by all American Urogynecological associations and collected by the AUA&#44; which in addition classified these pathologies by levels<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In this scenario&#44; patient safety and safe surgery&#44; aspects on which the WHO has been working for years&#44; gain special importance&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The AUA and the RCS have published recommendations for the resumption of surgical care&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> They highlight the importance of knowing the community&#8217;s prevalence and incidence&#44; the capability to perform CRP on both patients and health care workers&#44; the availability of protective equipment&#44; the facility capacity such as ICU beds or ventilators&#44; the prioritization of procedures according to resources and ensuring safe&#44; high-quality care&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In this line&#44; the CDC recommends being prepared to rapidly detect an increase of COVID-19 cases in the community&#44; providing care in the safest way possible by minimizing in-person appointments and gradually expanding to provide elective services&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The AEC has outlined 5 phases organized according to objective criteria such as the percentage of hospitalization&#47;ICU beds occupied by patients with SARS-CoV-2&#44; the need for emergency triage in patients with respiratory symptoms&#44; the impact on resources and the impact on surgical activity&#46; Depending on the stage we are at&#44; certain types of procedures would be justified&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">The SARS-CoV-2 pandemic has challenged the identity of medical professionals because&#44; as experts in our corresponding fields&#44; we are used to knowing the answers&#44; have some predictive ability&#44; rely on routines&#44; and have a sense of competence in what we do&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">This situation has had an unexpected beginning that has forced us to slow down&#44; producing feelings of fear &#40;for patients and for the personnel involved in their care&#41; to which we must respond with courage and acknowledging our vulnerabilities&#46; It creates uncertainty&#44; to which we must respond from the scientific method&#44; and a sense of loss of control&#44; to which we must act from medical knowledge&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The pandemic has led to under-utilization of medical services in patients with urgent and emerging problems&#44; creating a situation that creates a &#34;second wave&#34; of patients needing health care for problems not related to SARS-CoV-2&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In the most acute phase of the pandemic&#44; it has been essential to reorganize all hospital resources&#44; both human and material&#44; to provide healthcare services for patients with SARS-CoV-2&#44; focusing all responses on knowing how long the various surgical procedures could be delayed<span class="elsevierStyleSup">&#8211;3</span>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">However&#44; at the present time&#44; the infection rate has dropped significantly&#44; as we can see in the last update of the Ministry of Health and Consumer Affairs consulted for this publication&#46; In this update&#44; the Community of Madrid has registered 59 cases requiring hospitalization and 7 cases requiring ICU admission&#44; with an increase in confirmed cases of 0&#46;1&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In this scenario&#44; it is no longer sufficient to continue delaying procedures if the hospital situation allows it&#44; based on objective criteria such as those established by the AEC&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Although obviously the risks assumed with a patient undergoing surgery during the incubation period are high&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> there are already delayed pathologies&#44; and others that cause quality of life deterioration which makes the patient want to undergo surgery&#44; especially when we do not know how long the pandemic will last&#44; or if there will be a second wave in the fall requiring a new redistribution of resources with the necessary delay of non-urgent procedures&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">There is little information regarding selection criteria for surgical indication&#44; except for the previously mentioned delaying criteria&#44; and we found interesting the classification proposed by Prachand et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> adopted by the ACS&#46; Since the term &#34;elective surgery&#34; may seem to refer to &#34;optional&#34; surgery&#44; they propose the MeNTS scale&#58; Medically Necessary&#44; Time-Sensitive&#46; It refers to a case prioritization process based on medical necessity and time sensitivity&#46; It is a scale based on 21 factors structured in 3 domains&#58; underlying disease&#44; respiratory pathology&#47;SARS-CoV-2 and surgical procedure&#44; in which a score ranging from 21 to 105 points is obtained&#44; not being recommended to intervene a patient above a score of 57&#44; because of its association with poorer outcomes&#44; increased risk for healthcare team and excessive hospital resource use&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">We find the review of this methodology interesting for functional urology&#44; since it is not only limited to delay&#44; but it takes into account non-oncological pathologies and can serve as an additional objective criterion in this phase of the pandemic in which we are at&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Regardless of the selection criteria&#44; it is essential&#44; in order to resume surgical activity&#44; to follow all the safe surgery recommendations of the WHO<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> together with those of the different medical societies&#44; such as the ACS&#44; which emphasize &#34;ensuring safe&#44; high-quality&#44; high-value care of the surgical patient across the Five Phases of Care continuum&#46;&#34;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> These phases are&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Preoperative period&#58;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">consider repeating ancillary tests</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">identify new comorbidities</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">screen for symptoms or contact with SARS-CoV-2 infection patients</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall">perform PCR testing&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0120" class="elsevierStylePara elsevierViewall">Immediate Preoperative Period&#58;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall">review surgery&#44; anesthesia and nursing checklists for potential need to be revised and adapted to the new situation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">Intraoperative Period&#58;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">follow the recommendations regarding intubation</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0140" class="elsevierStylePara elsevierViewall">waiting times</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">use of protective equipment</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">specimen pick-up protocol&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Postoperative period&#58;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">adhere to established protocols to optimize hospital stay and efficiency&#44; decreasing complication rates&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Discharge Period&#58;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">provide home care to minimize situations that require re-entry&#46;</p></li></ul></p><p id="par0175" class="elsevierStylePara elsevierViewall">The main limitations we find are the lack of information regarding functional urology&#44; the precariousness of publications at this stage and the uncertainty generated in the near future by possible outbreaks of the pandemic&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In conclusion&#44; once the continuity of health care services is guaranteed at the time of the pandemic&#44; it is required&#44; with strict scientific criteria and according to the various medical societies&#44; to make the adaptation to the new reality&#44; maximizing the safety of patients and personnel&#46; In this regard&#44; as the number of SARS-CoV-2 positive patients continues to decline&#44; delayed procedures will be less justified&#46; Likewise&#44; tools are needed to help in the correct selection of &#34;operable&#34; patients such as those in functional urology&#44; which although they present benign pathologies&#44; affect the patients&#39; quality of life&#46;</p></span></span>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Levels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Delay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Interventions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NHS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1st&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Up to 24&#8239;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Renal obstruction with infection&#44; renal&#47;ureteral trauma requiring open surgery&#44; bladder trauma requiring open surgery&#44; genital trauma&#47;amputation&#44; Fournier gangrene&#44; and hematuria that does not resolve with conservative treatment or causes hemodynamic instability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1b&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Up to 72&#8239;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Upper urinary tract obstruction&#44; renal lithiasis causing pain or worsening renal function&#44; penile fracture and penile implant&#47;testicular&#47;stent infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Up to 4 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Testicular&#44; penile&#44; bladder&#44; muscle-invasive bladder&#44; high-risk non-muscle invasive&#44; renal&#44; transitional cells of the upper urinary tract&#44; acute urinary retention due to post-prostatectomy bladder neck sclerosis and inguino-scrotal sarcoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Up to 3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High and intermediate risk prostate cancer&#44; catheter changes&#44; investigation for hematuria&#44; low risk non-muscular invasive bladder cancer and low-grade penile cancer and pre-malignant lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">More than 3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Benign female pathology&#44; andrology&#44; endourological treatment of uncomplicated lithiasis&#44; low risk prostate cancer&#44; small renal masses&#44; benign penoscrotal surgery and prostate surgery for lower urinary tract obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">EAU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Emergency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cannot be postponed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High priority&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Up to 6 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intermediate priority&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Up to 3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Low priority&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Up to 6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">All urinary incontinence procedures are low priority except for those with suspected underlying cancer pathology and patients with fistulas that delay cancer treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AUA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Up to 4 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Surgeries for urinary incontinence&#44; prolapse&#44; asymptomatic mesh extrusions&#44; neuromodulation and diverticulectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Between 4 and 12 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fistula repair and mesh extrusions causing infection or pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Up to 4 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mesh bowel intrusion&#44; an irreducible prolapse with pessary and causing hydronephrosis&#44; urinary obstruction after suburethral sling procedure and incarcerated prolapses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2397981.png"
              ]
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Recommendations of the NHS&#44; EAU and AUA for urological and urogynecological procedures in the context of the SARS-CoV-2 pandemic&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:14 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Coronavirus &#187; Specialty guides &#91;Internet&#93;&#46; &#91;citado 23 de mayo de 2020&#93;&#46; Disponible en&#58; https&#58;&#47;&#47;www&#46;england&#46;nhs&#46;uk&#47;coronavirus&#47;secondary-care&#47;other-resources&#47;specialty-guides&#47;&#35;surgery&#46;"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Professionals S-O&#46; COVID-19 Recommendations &#91;Internet&#93;&#46; Uroweb&#46; &#91;citado 23 de mayo de 2020&#93;&#46; Disponible en&#58; https&#58;&#47;&#47;uroweb&#46;org&#47;guideline&#47;covid-19-recommendations&#47;&#63;type&#61;appendices-publications&#46;"
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Joint Statement on Re-introduction of Hospital and Office-based Procedures in the COVID-19 Climate &#91;Internet&#93;&#46; SGO&#46; 2020 &#91;citado 23 de mayo de 2020&#93;&#46; Disponible en&#58; https&#58;&#47;&#47;www&#46;sgo&#46;org&#47;clinical-practice&#47;management&#47;joint-statement-on-re-introduction-of-hospital-and-office-based-procedures-in-the-covid-19-climate&#47;&#46;"
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "OMS &#124; La Cirug&#237;a Segura Salva Vidas &#91;Internet&#93;&#46; WHO&#46; World Health Organization&#59; &#91;citado 23 de mayo de 2020&#93;&#46; Disponible en&#58; http&#58;&#47;&#47;www&#46;who&#46;int&#47;patientsafety&#47;safesurgery&#47;es&#47;&#46;"
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "April 17 O&#44; 2020&#46; Local Resumption of Elective Surgery Guidance &#91;Internet&#93;&#46; American College of Surgeons&#46; &#91;citado 23 de mayo de 2020&#93;&#46; Disponible en&#58; https&#58;&#47;&#47;www&#46;facs&#46;org&#47;covid-19&#47;clinical-guidance&#47;resuming-elective-surgery&#46;"
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "sitecore&#92;jpjadwat&#64;rcseng&#46;ac&#46;uk&#46; Recovery of surgical services during and after COVID-19 &#91;Internet&#93;&#46; Royal College of Surgeons&#46; &#91;citado 23 de mayo de 2020&#93;&#46; Disponible en&#58; https&#58;&#47;&#47;www&#46;rcseng&#46;ac&#46;uk&#47;coronavirus&#47;recovery-of-surgical-services&#47;&#46;"
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "CDC&#46; Coronavirus Disease 2019 &#40;COVID-19&#41; &#91;Internet&#93;&#46; Centers for Disease Control and Prevention&#46; 2020 &#91;citado 24 de mayo de 2020&#93;&#46; Disponible en&#58; https&#58;&#47;&#47;www&#46;cdc&#46;gov&#47;coronavirus&#47;2019-ncov&#47;hcp&#47;framework-non-COVID-care&#46;html&#46;"
                ]
              ]
            ]
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              "identificador" => "bib0040"
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              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Recomendaciones para la programaci&#243;n de cirug&#237;as durante la pandemia COVID-19 &#40;16&#47;05&#47;20&#41; &#124; aecirujanos&#46;es &#91;Internet&#93;&#46; &#91;citado 24 de mayo de 2020&#93;&#46; Disponible en&#58; https&#58;&#47;&#47;www&#46;aecirujanos&#46;es&#47;Recomendaciones-para-la-programacion-de-cirugias-durante-la-pandemia-COVID19-160520&#95;es&#95;116&#95;518&#95;0&#95;345&#46;html&#46;"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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