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.