COVID-19 pandemic. Impact on hysteroscopic procedures. A consensus statement from the Global Congress of Hysteroscopy Scientific Committee

Abstract

Introduction The emergence of the coronavirus (COVID-19) pandemic has resulted in a global public health emergency [1]. It rapidly spread globally infecting many individuals in many countries. In early March 2020, the World Health Organization designated the disease COVID-19 as a pandemic. Common symptoms include fever, severe headache, loss of smell and taste, dry cough with shortness of breath, general malaise, muscle ache, diarrhea, and abdominal pain [2]. While the majority of cases are mild, some become severe progressing to pneumonia with multi-organ failure and death [3]. Evidence shows that the virus mainly spreads during close contact and via respiratory droplets [4]. It may also be contracted by touching contaminated surfaces on which the virus can live for up to 72 hours [5]. The average time from exposure to onset of symptoms varies between two and fourteen days, with an average of five days [6]. The standard method of diagnosis is by reverse transcription polymerase chain reaction (rRT-PCR) from a nasopharyngeal swab 7, 8, 9, although rapid IgM-IgG combined antibody tests are being developed [10]. Recommended measures to prevent infection include frequent hand washing, social distancing (maintaining physical distance of at least 6 feet from others), avoid dispersing droplets of body fluids by covering the mouth and nose when coughing or sneezing, among other recommendations [11]. Aiming to enforce social distancing and to preserve hospital resources, joint statements have been produced by many professional societies, encouraging the suspension of non-essential medical visits. However, emergencies and procedures in which delay could potentially worsen the patient's outcome must be performed. There is emerging evidence regarding potential viral dissemination during gynecologic minimally invasive procedures due to the presence of the virus in blood, stool and aerosolization of the virus, especially when using smoke generating devices [12]. This risk is greater during aerosol generating procedures (AGP) such as laparoscopy or robotic surgery, especially during bowel surgery interventions, and is minimal during hysteroscopy. As hysteroscopy is not an AGP, the actual risk is unknown, but the theoretical risk is low. Hysteroscopy is considered the gold standard procedure for the diagnosis and management of intrauterine pathologies [13]. It is frequently performed in an office setting without the use of anesthesia. [13, 14] It is usually well tolerated with only a few patients reporting discomfort. [14] It allows for the diagnosis and immediate treatment, using the “see and treat” approach, of patients with intrauterine pathologies avoiding the risk of anesthesia, in particular, the need for intubation which is a procedure with high risk of droplet contamination in COVID-19 infected individuals [15]. There are several considerations that should guide the clinician who participates in hysteroscopic procedures at this time. Aiming to protect the patients and health care providers, minimizing risk of viral exposure, the following review will provide recommendations for clinicians performing hysteroscopic procedures during the COVID-19 pandemic. (Figure 1 ) Figure 1 Algorithm for the triage of the patient requiring hysteroscopic procedures during the COVID-19 pandemic. Figure 1 Recommendations for hysteroscopic procedures during the COVID-19 pandemic General recommendations 1 Hysteroscopic procedures should be limited to those patients in whom delaying the procedure could result in adverse clinical outcomes [16]. 2 Adequate screening for potential COVID-19 infection, independent of symptoms, and not limited to those patients with clinical symptoms. When possible, a phone interview to triage patients based on their symptoms and infection exposure status should take place before the patient arrives to the hysteroscopic center. Any woman with suspected or confirmed COVID-19 infection should be asked not to come to the hysteroscopic center. Patients with suspected or confirmed COVID-19 infection who require immediate evaluation should be directed to COVID-19 designated emergency areas. Once the patient arrives, a thorough history taking regarding potential viral exposure and physical examination must be performed. Consider preoperative universal COVID-19 testing. Only patients with negative COVID-19 test (if performed) and a negative history of symptoms (including body temperature below 37.3 o C) or exposure to COVID-19 should be allowed to enter the unit. 3 A maximum of ONE adult companion, under the age of 60 years per patient should be allowed access to the unit when absolutely necessary. It is understood that visitor policy may vary at the discretion of each institution guidelines. Children and individuals over the age of 60 years should not be granted access to the unit. Companions will be subjected to the same screening criteria as the patients. 4 If more than one patient is scheduled to be at the facility at the same time, ensure that the facility provides adequate space to ensure the appropriate social distancing recommendation between patients. Avoid the presence of multiple individuals in the waiting room at any given time. Ensure to space the seating in the waiting room at least 2 meters apart. Hand sanitizers and face masks should be available for patients and companions. We recommend the use of face masks by all individuals present in the hysteroscopic unit (patients, companions and staff members). The masks should always be worn and not only during the hysteroscopic procedure. 5 It is imperative that all healthcare members in close contact with the patient during the procedure wear personal protective equipment (PPE), which would include an apron and gown, a surgical mask, eye protection and gloves. Extreme caution should be implemented to avoid contamination. Healthcare providers should always wear PPE deemed appropriate by their regulatory institutions following their local and national guidelines during clinical patient interaction. 6 The use of electrosurgery in hysteroscopy is performed in a liquid environment. Bubbles that are generated with the use of thermal energy devices (monopolar, bipolar or laser) are cooled down rapidly and partly absorbed by the surrounding liquid [17]. Cell fragments generated are contained within the uterine cavity [18]. Any gases volatile at 37°C or lower and cell fragments are actively suctioned through the outflow channel, in a closed circuit, without aerosol generating effect, minimizing any risk of viral dissemination. In addition, it is recommended to avoid multiple insertion and removal of the hysteroscope from inside the uterine cavity. 7 The participation of learners and physicians in training should be organized by video transmission and not by physical presence in the office or operating room. 8 In the case of patients with confirmed positive COVID-19 infection and in need of urgent hysteroscopic surgery, the operation should be performed under strict protective conditions ideally in an operating room with negative pressure and independent ventilation.   1 Hysteroscopy performed in an Office Setting: 1 Pre-procedural recommendations a Patients should be advised to come to the office alone. If the examination requires a companion, a maximum of one companion to the appointment can be accepted. When coming to the unit alone, it is recommended that patients ensure secure transportation that can pick them up after the visit is over, to avoid driving immediately after the procedure. b Limit the number of the health care team members present in the procedure room. c Favor the use of instruments that do not produce surgical smoke such as scissors, graspers and tissue retrieval systems. 2 Intra-procedure recommendations a Choose the device that will allow an effective and fast procedure. b Use of the recommended PPE. c Movement of staff members in and out of the procedure room should be limited. 3 Post-procedure recommendations a When more than one case is scheduled to be performed in the same procedure room, allow enough time in between cases to grant a thorough operating room decontamination. b Allow patient to recover from the procedure in the same procedure room or in a specific standalone patient recovery room which is subject to the same disinfection rules between two patients. c Expedite patient discharge. d Follow up after the procedure should be by phone or tele-medicine. e Standard endoscope disinfection is effective and should not be modified. 2 Hysteroscopy performed in the Operating Room 1 Pre-procedural recommendations a Adequate patient screening for potential COVID 19 infection, independent of symptoms and not limited to those with clinical symptoms b Limit the number of health care team members in the operating procedure room c Surgeons and staff not needed for intubation should remain outside the operating room, but immediately available in case emergent assistance is required, until intubation is completed and should leave the operating room before extubation, to minimize unnecessary staff exposure 2 Intra-procedure recommendations a Limit the personnel in the operating room to a minimum. b Staff should not go in and out of the room during the procedure c When possible, use conscious sedation or regional anesthesia to avoid the risk of viral dissemination at the time of intubation/extubation d Choose the device that will allow an effective and fast procedure. e Favor non smoke generating devices such as hysteroscopic scissors, graspers and tissue retrieval systems. f Active suction should be connected to the outflow, especially if when using smoke generating instruments to facilitate the extraction of surgical smoke 3 Post-procedure recommendations a When more than one case is scheduled to be performed in the same room, allow enough time in between cases to grant a thorough operating room decontamination. b Expedite post-procedure recovery and patient's discharge c After completion of the procedure, remove scrubs and change into clean clothing if available. d Standard endoscope disinfection is effective and should not be modified. Conclusion The COVID 19 pandemic has caused a global health emergency. Enforcing social distancing and preservation of hospital resources requires suspension of non-essential medical visits. Procedures in which delay could potentially worsen the patient's outcome, must be performed. Adequate triage of patients with potential cancer conditions is critical to ensure patient safety during pandemic infections. Theoretical risk of “viral” dissemination in the operating theater is higher during AGP than in hysteroscopy where the theoretical risk is extremely low, or negligible. Always favor the use of mechanical energy over thermal generating devices. Also, when needed, use conscious sedation or regional anesthesia to avoid the risk of viral dissemination at the time of intubation/extubation. Health care providers must comply with a step by step reimplementation of standard operating procedures, expediting the evaluation and management of all the deferred cases as soon as the benign pathology consultations can be safely restarted. Patients with confirmed negative status for COVID-19 confirmed by PCR, requiring hysteroscopic procedures, should be treated using universal precautions. Disclaimer These recommendations are based on expert opinion and are meant to serve the general practitioner treating an average patient. They should not be considered rigid guidelines and are not intended to replace clinical judgment. These guidelines are made based on current available information and are likely to change as we gain more knowledge of the disease. Local and national guidelines should take priority over these recommendations. Women tested negative for infection with COVID-19 confirmed by PCR should be managed with standard universal precautions.