Discussion:
Mass casualty events including natural disasters (earthquakes, floods,
and landslides), biological, chemical, nuclear and radiological
disasters lead to increase the requirement for healthcare. Virus
pandemics are a kind of biological disasters and the best known virus
pandemics were Spanish Flu pandemics which killed over 20 million people
from 1918 to 1919, SARS-CoV pandemics that affected approximately 8000
people with a mortality rate 10% and MERS-CoV pandemics which affected
over 800 people with a mortality rate of 35%.8,14Therefore, it is essential to enhance the capabilities of healthcare
institutions, for mitigation of disasters’ effects. Governments and
healthcare institutions must prepare their virus pandemic plans, to be
able to intervene in time for pandemics. A sample of pandemic influenza
planning of the state of Connecticut was reported by Duley MG at
2005.15 Some of the recommendations of this report to
assure health care facility were; suspending all of the elective
outpatient and inpatient surgeries and procedures, developing strategies
to increase bed availability for influenza patients and implementing
triage to reduce non-influenza admissions.16 Covid-19
first appeared in China and spread rapidly between the countries, and
was declared as pandemics at 11-March-2020 by WHO. Similar with the
recommendations of pandemics plan of the State Connecticut, many
countries took measures stage by stage for the Covid-19 pandemic. Like
in the other specialties, several guidelines and measures were published
for urology practice during Covid-19 pandemic.7-11,16Wallis et al and Stensland et al published review and editorial articles
about the triage and the management of genitourinary cancers and the
risks of delaying in treatment.7,16 Their
recommendations for the treatment of urological cancers during Covid-19
era were as: transurethral resection of bladder tumor (TURBT) can be
performed in high-grade non–muscle-invasive bladder cancer (NMIBC)
however cystoscopic surveillance and (TURBT) for recurrence in patients
with known low-grade NMIBC can be deferred; the initial treatment of
high-grade NMIBC should be the induction Bacillus Calmette–Guérin (BCG)
and a single course of maintenance therapy (6+3); over than 12 weeks
delay in radical cystectomy (RC) was found associated with decreased
overall and progression-free survival17 so RC should
be prioritized; active surveillance should be the first option for
low-risk prostate cancer; it was reported that delaying 3 to 6 months
for the treatment of intermediate and high-risk prostate cancer patients
was not associated with adverse biochemical recurrence, pathological and
survival outcomes.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 (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 Harmoniously with these
recommendations, Pinar et al reported a decrease of 31% in the
surgeries of genitor-urinary cancers in comparison with the same time
interval of 2019 (12-27 March) and they performed un-deferrable
oncological surgeries in 8 academic urological departments of Paris,
France.20 Tinay et al evaluated the early impact of
Covid-19 on surgical urologic oncology practice in several tertiary
institutions of Turkey, and they compared the outcomes of early pandemic
period (March-11 to April-11) with the same time interval of
2019.11 They detected a decrease (from 200 to 90
cases) in the numbers of urothelial carcinoma, kidney cancer and
prostate cancer surgeries, and they pointed that the centralization of
oncological surgeries is required during the disasters like this
pandemic. A significant decrease 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 3rd and 4thweek 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, the ureteral stenting or nephrostomy tube placement are
recommended instead of definitive treatments.7,21,22The 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 accordance with the recommendations;
the numbers of elective surgeries (URS and PNL) for urolithiasis, benign
prostatic diseases and endoscopic urethrotomies have decreased and the
rates of temporary measures such as ureteral stenting, nephrostomy
placement and percutaneous cystostomy as emergent interventions have
increased during pandemic period in our study. This reflects to the
adaptation of urologic surgeons in our country to the published
recommendations.7,21,23
The healthcare institutions have to prepare strategies to increase bed
resources and availability for Covid-19 patients. The main measures for
this process include; performing the triage in outpatient clinics to
decrease other types of admissions and decreasing the number and length
of hospital stay.15 The healthcare institutions
decreased their outpatient and inpatient clinics according to
recommendations of the Ministry of Health of Turkey in our country. Due
to the measures; the number of patients admitted to the outpatient
clinics decreased with a rate of 73.7% and the number of the patients
which were treated inpatient decreased with a rate of 71.3% during
pandemic period in comparison with the same time interval of 2019 in
urology departments participated in this study. Those measures should
undoubtedly be taken by managers and chief executive officers. The
difference adaptation of tertiary referral centers, state hospitals and
private practice hospitals with regard to these measures may come from
different management options. 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 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.
Acknowledgements: none declared.