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2. Letter to the Editor
Risk of SARS-CoV-2 Diffusion when Performing
Minimally Invasive Surgery During the COVID-19
Pandemic
There has been widespread diffusion of pure laparoscopic
and robotic approaches for the vast majority of urological
surgeries. Severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) and the disease it causes, coronavirus disease
2019 (COVID-19), are significantly affecting urological
practice in countries that the pandemic has hit more
severely. Specifically, recommendations have been sug-
gested to guide reorganization of urological surgeries
[1]. Some surgical procedures that should still be performed
during the COVID-19 pandemic have been identified, such
as radical cystectomy for muscle-invasive or very high-risk
non–muscle-invasive bladder cancer; postchemotherapy
retroperitoneal lymph node dissection; radical nephrec-
tomy for cT3 tumors; nephroureterectomy for upper tract
urothelial cancers; and adrenalectomy for specific adrenal
cancers. It is also likely that some other surgical procedures
(eg, radical prostatectomy for high-risk prostate cancer and
partial nephrectomy for cT1b renal tumors) will be
performed in centers located in areas not severely hit by
the pandemic where the resources available are sufficient
[2]. With this in mind, we read with enormous interest the
paper by Zheng et al [3]. Based on the high prevalence of
SARS-CoV-2 in stools [4], some reports on the presence of
other viruses in surgical smoke (references 2–4 in [3]), some
cases of infections in doctors suspected to be related to
surgical smoke exposure (reference 5 in [3]), and higher
concentration of surgical smoke particles in laparoscopic
compared to open surgery, the authors postulated a
potential risk of SARS-CoV-2 diffusion during all minimally
invasive procedures with possible subsequent infection of
medical personnel working in operating rooms.
Although, to the best of our knowledge, cases of this type
of transmission have not been reported so far, this issue
must be evaluated with particular caution for urologists still
allowed to perform minimally invasive procedures during
the COVID-19 pandemic. First, the need to use appropriate
personal protective equipment should be reinforced.
Second, nasopharyngeal samples should be considered
for all patients undergoing such procedures, especially as
COVID-19 positivity could have a possible impact on their
postoperative course. Third, special care must be taken
intraoperatively to reduce smoke formation (eg, lowering
electrocautery power settings, using bipolar electrocautery,
using electrocautery or ultrasonic scalpels parsimoniously
to reduce surgical smoke, more extensive use of sutures and
clips) or smoke dispersal in the operating room. This is
especially important when removing trocars at the end of a
procedure, when making a skin incision for specimen
retrieval, and in the rare cases of conversion to open surgery.
Before such steps, generous use of suction to remove smoke
and aerosol should be recommended. In parallel, care must
be taken to limit smoke dispersal or spillage from trocars
(eg, lowering the pneumoperitoneum pressure). Finally,
pressure-barrier insufflator systems that maintain a forced-
gas pressure barrier at the proximal end of the trocar might
be of benefit [5].
Unfortunately, even urologists who have the privilege of
being able to continue performing minimally invasive
surgery must rethink details of their activities to minimize
the risks for patients and health care workers.
Conflicts of interest: The authors have nothing to disclose.
References
[1] Stensland K.D., Morgan T.M., Moinzadeh A., et al. Considerations in
the triage of urologic surgeries during the COVID-19 pandemic. Eur
Urol. In press. https://doi.org/10.1016/j.eururo.2020.03.027.
[2] Ficarra V., Novara G., Abrate A., et al. Urology practice during COVID-
19 pandemic. Minerva Urol Nefrol. In press. https://doi.org/
10.23736/S0393-2249.20.03846-1.
[3] Zheng M.H., Boni L., Fingerhut A. Minimally invasive surgery and the
novel coronavirus outbreak: lessons learned in China and Italy. Ann
Surg. In press. https://doi.org/10.1097/SLA.0000000000003924.
[4] Zhang W, Du RH, Li B, Zheng XS, et al. Molecular and serological
investigation of 2019-nCoV infected patients: implication of multi-
ple shedding routes. Emerg Microbes Infect 2020;9:386–9.
[5] Nepple KG, Kallogjeri D, Bhayani SB. Benchtop evaluation of pres-
sure barrier insufflator and standard insufflator systems. Surg
Endosc 2013;27:333–8.
Giacomo Novaraa,
*
Gianluca Giannarinib
Cosimo De Nunzioc
Francesco Porpigliad
Vincenzo Ficarrae
a
Urology Unit, Department of Surgery, Oncology and Gastroenterology,
University of Padova, Padova, Italy
E U R O P E A N U R O L O G Y X X X ( 2 0 19 ) X X X – X X X
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
EURURO-8812; No. of Pages 2
Please cite this article in press as: Novara G, et al. Risk of SARS-CoV-2 Diffusion when Performing Minimally Invasive Surgery
During the COVID-19 Pandemic. Eur Urol (2020), https://doi.org/10.1016/j.eururo.2020.04.015
https://doi.org/10.1016/j.eururo.2020.04.015
0302-2838/© 2020 Published by Elsevier B.V. on behalf of European Association of Urology.

3. b
Urology Unit, Santa Maria della Misericordia Academic Medical Centre,
Udine, Italy
c
Department of Urology, Sant’ Andrea Hospital, Sapienza University of Rome,
Rome, Italy
d
Division of Urology, Department of Oncology, School of Medicine, San Luigi
Hospital, University of Turin, Orbassano, Italy
e
Urologic Section, Gaetano Barresi Department of Human and Pediatric
Pathology, University of Messina, Messina, Italy
*Corresponding author. Urology Unit, Department of Surgery, Oncology
and Gastroenterology, University of Padova, Via Giustiniani 2, Padova
35128, Italy. Tel. +39 04 98211250; Fax: +39 04 98218757.
E-mail address: giacomonovara@gmail.com (G. Novara).
E U R O P E A N U R O L O G Y X X X ( 2 0 19 ) X X X – X X X2
EURURO-8812; No. of Pages 2
Please cite this article in press as: Novara G, et al. Risk of SARS-CoV-2 Diffusion when Performing Minimally Invasive Surgery
During the COVID-19 Pandemic. Eur Urol (2020), https://doi.org/10.1016/j.eururo.2020.04.015