How Brazil Is Dealing with COVID-19 Pandemic Arrival Regarding Elective Gynecological Surgeries.

To the Editor:

Brazil, a continental country with 210 million people, is starting to have an increase in the number of infected cases and in mortality owing to the coronavirus disease (COVID-19) outbreak that started in February [1]. Whereas the pandemic has spread worldwide, and our curve is weeks behind other epicenters such as the United States, Italy, and Spain, our main obstetric and gynecologic society (Brazilian Federation of Gynecology and Obstetrics Associations) and several affiliated societies (e.g., Brazilian Association of Urogynecology and Pelvic Floor and Brazilian Endometriosis and Minimally Invasive Society) have been preparing to counsel our members.

Several nonpharmaceutical interventions were oriented nationally [2], and discussions between healthcare providers and decision makers have helped several hospitals [3] before the explosion of cases. Obstetric and oncology services had a smaller reduction in cases than services that are mainly referred for elective surgeries. We have prepared documents in a frequently asked questions format for counseling gynecologic surgeons to reschedule elective surgeries for benign diseases [4], discussed implementing telemedicine in many outpatient clinics, and analyzed how to reorganize surgical scenarios for gynecologic oncology patients and/or emergency surgeries. However, we are still facing many regional barriers such as lack of massive testing for patients, either asymptomatic or symptomatic; disparities between the number of COVID-19 patients admitted in public intensive care units (ICUs) versus private ICUs (and also the number of available ICUs throughout the country); possible underreporting of national data for several reasons; and most importantly not all facilities have sufficient personal protective equipments.

Our guidelines are aligned with the joint statement previously published on the American Association of Gynecologic Laparoscopists website with several societies [5] recommending that elective surgeries should be postponed or rescheduled, and that this should be a joint decision between surgeon and patient; that the risk factors for COVID-19 should be discussed with the patient; and that the absence of COVID-19 symptoms should exhaustively be confirmed in case the patient needs to undergo a surgery. Testing should be massively encouraged before surgery. Within the operating room, N-95 masks (as well as the rest of the accessories: shoe covers, gown, protective head covering, gloves, and eye protection) should be guaranteed for the surgical team, the number of personnel inside the operating room should be restricted, and there should be a conversation with the anesthesia team before each procedure.

For vaginal and abdominal surgeries, the use of N-95 masks plus face shields should be mandatory and smoke dispersion should be avoided as much as possible. Regarding laparoscopic procedures, they can be performed if, after informed consent is obtained from the patient, the entire operating room team has access to the necessary personal protective equipments and extreme care is taken to reduce pneumoperitoneum escape [6]. It is important to remember that at this moment, no data are available proving that COVID-19 viral particles were identified in surgical smoke. Finally, most urogynecological disorders can be treated conservatively.

We are still uncertain whether we are flattening the curve, and discussions about reopening elective surgeries are still controversial; however, we believe that we are ready to fight this battle, and we are extensively advising patients to seek out hospitals if their symptoms are worsening during the quarantine.