key: cord-0981609-wl09mlk1 authors: Bozkurt, Ozan; Sen, Volkan; Irer, Bora; Sagnak, Levent; Onal, Bulent; Tanidir, Yiloren; Karabay, Emre; Kaya, Coskun; Ceyhan, Erman; Baser, Aykut; Duran, Mesut Berkan; Suer, Evren; Celen, Ilker; Selvi, Ismail; Ucer, Oktay; Karakoc, Sedat; Sarikaya, Ege; Ozden, Ender; Deger, Dogan; Egriboyun, Sedat; Ongun, Sakir; Gurboga, Ozgur; Asutay, Mehmet Kazim; Kazaz, Ilke Onur; Yilmaz, Ismail Onder; Kisa, Erdem; Demirkiran, Engin Denizhan; Horsanali, Ozan; Akarken, Ilker; Kizer, Onur; Eren, Huseyin; Ucar, Murat; Cebeci, Oguz Ozden; Kizilay, Fuat; Comez, Kaan; Mercimek, Mehmet Necmettin; Ozkent, Mehmet Serkan; Izol, Volkan; Gudeloglu, Ahmet; Ozturk, Bilgin; Akbaba, Kaan Turker; Polat, Salih; Gucuk, Adnan; Ziyan, Avni; Selcuk, Berin; Akdeniz, Firat; Turgut, Hasan; Sabuncu, Kubilay; Kaygisiz, Onur; Ersahin, Veli; Ibrahim Kahraman, Halil; Guzelsoy, Muhammet; Demir, Omer title: Nation‐wide analysis of the impact of Covid‐19 pandemic on daily urology practice in Turkey date: 2020-09-30 journal: Int J Clin Pract DOI: 10.1111/ijcp.13735 sha: e0d1bf4795e2b8293432e13253dfcc267e2abb81 doc_id: 981609 cord_uid: wl09mlk1 OBJECTIVE: To present a nation‐wide analysis of the workload of urology departments in Turkey week‐by‐week during Covid‐19 pandemic. METHODOLOGY: The centers participating in the study were divided into three groups as tertiary referral centers, state hospitals and private practice hospitals. The number of outpatients, inpatients, daily interventions and urological surgeries were recorded prospectively between 9‐March‐2020 and 31‐May‐2020. All these variables were recorded for the same time interval of 2019 as well. The weekly change of the workload of urology during pandemic period was evaluated; also the workload of urology and the distributions of certain urological surgeries were compared between the pandemic period and the same time interval of the year 2019. RESULTS: A total of 51 centers participated in the study. The number of outpatients, inpatients, urological surgeries and daily interventions were found to be dramatically decreased by the third week of pandemics in state hospitals and tertiary referral centers; however the daily urological practice were similar in private practice hospitals throughout the pandemic period. When the workload of urology in pandemic period and the same time interval of the year 2019 were compared; a huge decrease was observed in all variables during pandemic period. However, temporary measures like ureteral stenting, nephrostomy placement and percutaneous cystostomy have been found to increase during Covid‐19 pandemic compared to normal life. CONCLUSIONS: Covid‐19 pandemic significantly effected the routine daily urological practice likewise other subspecialties and priority was given to emergent and non‐deferrable surgeries by urologists in concordance with published clinical guidelines. The first case in Turkey was This article is protected by copyright. All rights reserved reported at 11 March 2020 and the peak of daily cases and deaths were seen during the 4 th week of the pandemic curve in our country. 6 The workload of hospitals has increased considerably during the pandemic process and many healthcare measures were taken by governments and hospital systems. Most of the hospitals turned to pandemic or quarantine hospitals and had to serve only Covid-19 patients. Some detailed recommendations were published for the triage of urological surgeries during the Covid-19 pandemic. 7-10 Like other surgical subspecialties; cancellation of elective surgeries and utilization of solely emergent surgeries and non-deferrable oncologic surgeries that delay may cause negative impact on survival have been performed in urology clinics according the triage recommendations. 11 Also, urological outpatient clinics have been adapted to new social distancing rules in Covid-19 pandemic; the number of appointments was limited and only emergent patients could be treated in most of the urology clinics in worldwide as in our country. 8, 12, 13 In this report, we aimed to present a nation-wide analysis of the workload of urology departments in Turkey week-by-week during Covid-19 pandemic and to compare the outcomes with the same time interval of the year 2019. The study was approved by the local ethics committee. An announcement of the study was sent to all Urology clinics across Turkey via e-mail and social media. All of the centers that agreed to participate in the study were included in the study. This article is protected by copyright. All rights reserved All of these variables were also recorded week-by-week at the same time interval of the year 2019. Other surgical and diagnostic approaches were not analyzed as guidelines regarding Covid-19 pandemic suggested the postponement of nearly all surgeries for female urology, andrology and some other elective surgical operations. 8, [11] [12] [13] The centers were divided into three groups as tertiary referral centers, state hospitals and private practice hospitals. The weekly change of the workload of urology throughout the pandemic period was evaluated; also the workload of urology and the distributions of certain urological surgeries were compared between the pandemic period and the same time interval of the year 2019. All statistical analyses were performed with the Statistical Package for the Social Sciences (SPSS, Inc., Chicago IL), version 22, software for Windows. Shapiro-Wilk test was used to determine whether the data was normally distributed, since p values were found to be greater than 0.05, it was decided that the data were normally distributed. After the descriptive statistics were made, the data for the 2019 period and pandemic period were compared with the Paired-Samples T test. The results were given as mean ± standard deviation and n (%). P<0.05 was considered statistically significant. A total of 51 centers from all geographical areas participated in the study. Of these centers; 30 (58.8%) were tertiary referral centers, 15 (29.4%) were state hospitals and 6 (11.8%) were private practice hospitals. The number of outpatients, inpatients, urological surgeries and daily interventions were found to be dramatically decreased by the third week of pandemics in state hospitals and tertiary referral centers; however the daily practice were similar in private practice hospitals throughout the pandemic period. Urooncological surgeries were decreased week by week in tertiary referral centers; a huge decrease was observed for the stone surgeries at the third week of the pandemics in tertiary referral centers and state hospitals; however the number of emergent/trauma surgeries was relatively similar in both centers during the pandemics. The weekly analysis of workload of urology and urological surgeries by categories were given in This article is protected by copyright. All rights reserved When the workload of urology in pandemic period and the same time interval of the year 2019 were compared; a huge decrease was observed in all variables during pandemic period (Table 1) . In a detailed analysis of the three groups of centers; a significant decrease was detected in outpatients, inpatients, daily interventions and urological surgeries in tertiary referral centers and state hospitals; however the decrease was not statistically significant in private practice hospital in terms of inpatients and daily interventions ( Although the total numbers of temporary measures like nephrostomy placement (539 to 223; -58.7%) and percutaneous cystostomy (661 to 253; -61.8%) for certain instances decreased; the rate of these procedures for emergent-trauma surgeries has been found to increase during pandemic period (15% to 22.7% and 18.4% to 25.7%; respectively). Urologists took active role in fighting against Covid-19 with all of the centers participating in this study; 54.4±100.7, 41.0±34.6, 10.0±24.5 pandemic outpatient clinics were performed by urologist in tertiary referral centers, state hospitals and private practice hospitals, respectively. This article is protected by copyright. All rights reserved 18 The radical prostatectomy and definitive therapies can be deferred; small renal masses can be safely observed with active surveillance, and the treatment of localized kidney cancers (cT1b and cT2 tumors) can be delayed to 3-6 months without adverse affects in outcomes; however radical nephrectomy should be performed in priority in locally advanced kidney cancers This article is protected by copyright. All rights reserved (cT3+); the risk of a delay in the treatment of upper tract urothelial cancer (UTUC) is depended on the stage and grade of cancer, especially in high-grade UTUC a delay up-to 3 months was found associated with disease progression, 19 so keep in mind nephroureterectomy in these patients; avoid from delaying radical orchiectomy in testicular cancer patients; avoid from a delay in penile cancer treatments including surgeries. 16 was also detected in all of the oncologic surgical procedures during pandemic period in our study (-78.8%). As stated above, most of the urooncological surgeries are usually performed in tertiary referral centers in our country; so the highest decrease has been observed in these centers whereas no significant change was observed in private practice hospitals in terms of urooncological surgery. The lowest decrease in urooncological surgeries was detected in radical cystectomy operations in the present study as most of the above-mentioned reports and guidelines offer prioritization of radical cystectomy. 8, 16 We detected a sharp decrease within 3 rd and 4 th week of the pandemic in our country for all urological as well as urooncological cases as government and healthcare authorities suggested lock-down measures for the spread of SARS-CoV-2; and those low case load continued until the end of our study period which reflects the end of lock-down measures in our country. An interesting finding of this study was that the ratio of almost all urooncological surgeries was similar between the pandemic period and routine daily practice despite a significant decrease in total numbers. We did not deeply analyze the surgical indications, but surgery for higher risk cases for all cancer types might have been prioritized in most involved centers. TUR-BT was the mostly utilized urooncological surgical procedure for both the pandemic period and normal life conditions in our country in concordance with previous reports. 11 Cancellation of elective surgeries for urolithiasis, benign prostatic hyperplasia and urethral strictures were recommended in pandemic period. 7 If there is an obstruction in upper urinary tract, This article is protected by copyright. All rights reserved the ureteral stenting or nephrostomy tube placement are recommended instead of definitive treatments. 7, 21, 22 The EULIS Collaborative Research Working Group published the results of a survey related with routine practice of endourologists in stone diseases during the Covid-19 pandemic. 23 They pointed that the majority of the participants (89.4%) have used to perform temporary interventions like JJ placement or percutaneous nephrostomy, rather than the stone removal operations. 23 Gul et al reported that complicated ureteral stone diseases have increased in pandemic period; consequently the rate of nephrostomy placement has also increased. 24 In Pandemic patients were primarily treated by state hospitals and tertiary referral centers in our country, so the elective cases were cancelled by these hospital types whereas most private practice hospitals did not treat Covid-19 patients. Our findings demonstrated that workload for urological diseases dramatically decreased during Covid-19 pandemic. However, the workload of hospitals dramatically increased during the Covid-19 pandemic and most of the hospitals had to turn to pandemic or quarantine hospitals and serve This article is protected by copyright. All rights reserved only Covid-19 patients. A total of 2307 pandemic outpatient clinics by 8-hour shifts were done by urologists in our study. So, we detected that urologists also took active role in the front-line management of Covid-19 patients in our country. Participation of mainly tertiary referral centers in comparison with state and private practice hospitals constitute one of the limitations of the present study. Most state hospitals also turned to pandemic hospitals and did not serve for routine practice. Participation of more state hospitals would better reflect daily practice. However, 2019 results demonstrated that most of the Urology workload was met by tertiary referral centers in our country. Conclusions: Covid-19 pandemic led to a serious challenge to healthcare systems. Like the worldwide results; the number of outpatients, inpatients and daily interventions have decreased, elective surgeries mostly deferred and a priority has given to emergent and high-grade malignancy surgeries in our country. We believe that the results of the present study will help in organization of human resources and triage of urology clinics for further possible mass casualty events. Conflict of interest: none declared. This article is protected by copyright. All rights reserved World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report -182 Considerations in the Triage of Urologic Surgeries During the COVID-19 Pandemic COVID-19 and urology: a comprehensive review of the literature Changes in Urology After the First Wave of the COVID-19 Pandemic 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 The Early Impact of COVID-19 Pandemic on Surgical Urologic Oncology Practice in Turkey: Multi-Institutional Experience from Different Geographic Areas Changes in Urology After the First Wave of the COVID-19 Preserving Operational Capability While Building Capacity During the COVID-19 Pandemic: A Tertiary Urology Centre's Experience Influenza: the Mother of All Pandemics Accepted Article This article is protected by copyright. All rights reserved 15. Duley MG. The next pandemic: anticipating an overwhelmed health care system Risks from Deferring Treatment for Genitourinary Cancers: A Collaborative Review to Aid Triage and Management During the COVID-19 Pandemic Delaying radical cystectomy after neoadjuvant chemotherapy for muscle-invasive bladder cancer is associated with adverse survival outcomes Evaluating the effect of time from prostate cancer diagnosis to radical prostatectomy on cancer control: can surgery be postponed safely? A delay in radical nephroureterectomycan lead to upstaging Impact de la pandémie de COVID-19 sur l'activité chirurgicale au sein des services d'urologie de l'Assistance Publique -Hôpitaux de Paris Management, surgical considerations and follow-up of patients in the COVID-19 era Endourological Stone Management in the Era of the COVID-19 Urolithiasis Practice Patterns Following the COVID-19 Pandemic: Overview from the EULIS Collaborative Research Working Group The Increased Risk of Complicated Ureteral Stones in the Era of COVID-19 Pandemic Acknowledgements: none declared.