Remember me
ORIGINAL ARTICLE
Year : 2022 | Volume
: 33
| Issue : 4 | Page : 182-186
Impact of COVID-19 pandemic on urological service: Experience at a Taiwanese tertiary center
Chang-Ho Chiang1, Wei-Jen Chen1, I-Shen Huang2, Eric Yi-Hsiu Huang2, Hsiao-Jen Chung2, William J Huang2
1 Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan
2 Department of Urology, Taipei Veterans General Hospital; Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
Correspondence Address:
William J Huang
Department of Urology, Taipei Veterans General Hospital, No. 201, Section 2, Shipai Road, Taipei 11217
Taiwan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/UROS.UROS_119_21
Purpose: The Taiwan Central Epidemic Command Center raised the coronavirus disease 2019 (COVID-19) pandemic alert to level 3 throughout the nation since May 19, 2021, and asked hospitals to reduce patient intake. Surgical departments were the worst affected. The aim of this study is to share experiences of urological practice adjustment in a tertiary medical center during the pandemic and to evaluate the impact of the COVID-19 pandemic on the urological service in Taiwan under a level 3 epidemic alert. Materials and Methods: This observational study was conducted from June 1, 2021, to June 31, 2021, when a level 3 pandemic alert was declared. Data of patients visiting the urology department at the Taipei Veterans General Hospital were recorded and compared with data 1 year before the COVID-19 outbreak in Taiwan (June 1, 2020, to June 31, 2020). Data included outpatient visits, elective surgeries, emergent surgeries, functional urological examinations, and diagnostic procedures in outpatient settings. Results: There was no significant decrease in all types of uro-oncological surgeries, except bladder urothelial carcinoma (UCB)-related procedures. The total number of UCB-related procedures showed 66.67% reduction. Stone-related surgeries were reduced by 45.7%. Only 12% of all transurethral prostate resections were performed in the pandemic. There was a significant decrease in all types of functional urology and andrology procedures. More than 30% reduction was noted in the number of patients visiting the urology department in June 2021 compared to that in June 2020. Conclusion: Our data provide a reference of how the urological service was affected during the level 3 pandemic alert in Taiwan. We postponed most elective surgeries and outpatient visits or diagnostic outpatient examinations procedures according to prioritization guidelines. Uro-oncology-related service was less affected because oncology patients have a stronger motivation for treatment. Benign urological condition-related procedures were significantly influenced. After the epidemic slowdown, the backlog should be gradually managed based on priority.
Keywords: Coronavirus disease 2019 pandemic, Taiwan, urological service
The coronavirus disease 2019 (COVID-19) was initially reported in China in December 2019 and spread rapidly throughout the world. According to the World Health Organization, there have been 478650474 confirmed cases of COVID-19 worldwide as of February 20, 2022 To date, the total number of deaths attributed to COVID-19 has already crossed 5 million.[1] The COVID-19 epidemic drastically altered people's daily lives and caused a worldwide medical care crisis. To minimize the spread of coronavirus to the uninfected, most surgical departments in hospitals were directed to postpone all elective surgeries.[2],[3],[4] Consequently, several international urological organizations recently issued a set of recommendations to guide the prioritization of clinical and surgical activity during COVID-19.[5],[6] Furthermore, the diversion of personnel to deal with the COVID-19 emergency response has significantly impacted the continuation of urology department activities. Generally, an epidemic level 3 warning is issued when more than 10 cases with an unknown source of infection are reported per day in Taiwan, together with at least three cluster infection episodes. Since May 19, 2021, the Taiwan Central Epidemic Command Center (CECC) has elevated the epidemic alert to level 3 throughout Taiwan, including local areas over Taipei City and New Taipei City, after newly diagnosed cases exceeded 100 per day for 5 days.[7]
In the meantime, the CECC has outlined several significant medical response strategies to maintain medical capacities, such as lowering patient intake, strengthening community surveillance, reporting and testing, and improving employee health monitoring.[8] The COVID-19 pandemic had the greatest impact on surgical departments because most surgeries were elective and thus had to be postponed. As patients were also concerned about the potential for infection while in the hospital, many sought to postpone elective surgical procedures.
All hospitals across Taiwan were asked to suspend visitation and postpone most surgeries. As urologists must assess the priority of the diagnostic or therapeutic operation, it is crucial to make a trade-off between the potential risk of COVID-19 exposure and delayed elective action.[5] To accommodate COVID-19 patients, some ordinary wards were closed and renovated with negative pressure equipment. Furthermore, the policy of labor diversion by cabin and flow resulted in a lack of medical service capacity and limited handling of emergent circumstances. Several urologists were asked to assist in managing vaccine-related services and in the care of COVID-19 patients.
The study aims to share experiences of adjusting urological practice at a tertiary medical center during a pandemic and evaluate the impact of the COVID-19 pandemic on urological service in Taiwan following the declaration of a level 3 epidemic alert.
Materials and MethodsThis observational study was conducted from June 1 to 31, 2021, in which a level 3 pandemic alert was declared. Data on patients visiting the urology department (either outpatient or inpatient setting) at Taipei Veterans General Hospital (VGHTPE), a tertiary medical center in northern Taiwan, were collected and compared with data collected 1 year before the COVID-19 outbreak in Taiwan (June 1, 2020, to June 31, 2020).
Outpatient visits (either face-to-face or via telemedicine), elective surgeries, emergent surgeries, functional urological examinations (cystometry, uroflowmetry, pressure flow study, and video urodynamics), and diagnostic procedures in the outpatient setting were all gathered (transrectal ultrasound [TRUS]-guided prostatic biopsy and cystoscopy). The surgeries were categorized into oncology-related and nononcology-related procedures and then further categorized based on indications. This was an anonymous, noninteractive, unobtrusive study. All data obtained were unidentifiable; thus, it was conducted without ethical permission, according to the exemption requirements published by the VGHTPE's Institutional Review Board.
ResultsImpact of coronavirus disease 2019 on oncology-related surgeries
Apart from bladder urothelial carcinoma (UCB)-related procedures, there was no significant decline in all forms of uro-oncological surgery. All UCB-related surgeries, including cystoscopy, transurethral resection of bladder tumor (TURBT), and radical cystectomy, showed a reduction of 66.67% (48 in June 2020 vs. 16 in June 2021). The total number of upper tract UC-related procedures, such as diagnostic ureteroscopy, radical nephroureterectomy, and bladder cuff excision, also showed a notable decrease. However, the proportion of radical prostatectomy, radical nephrectomy, partial nephrectomy, adrenalectomy, and radical orchiectomy was comparable during the COVID-19 epidemic and pre-COVID-19 period [Figure 1].
Figure 1: Comparison of the number of urologic oncology-related surgeries before and during coronavirus disease 2019 pandemic. UTUC = upper tract urothelial carcinomaImpact of coronavirus disease 2019 on nononcology-related surgeries
Stone-related procedures were reduced by 45.7% (70 obstructive uropathy cases in 2020 vs. 38 in 2021). The number of vesicolithotripsy procedures showed the highest decrease. Furthermore, other procedures, including bladder neck sling surgery, intravesical botulinum injection, microdissection testicular sperm extraction, and varicocelectomy, have been postponed. A reduction of 88% was observed for transurethral resection of the prostate [Figure 2].
Figure 2: Comparison of the number of non-oncology-related surgeries before and during coronavirus disease 2019 pandemic. BPH = benign prostatic hyperplasiaImpact of coronavirus disease 2019 on functional urology examinations
There was a significant decrease in functional urology examinations. Particularly, pressure flow and video urodynamic studies were the most impacted. A 20% and 68% reduction was observed in cystometry and uroflowmetry procedures, respectively [Figure 3].
Figure 3: Comparison of the number of functional urology examinations before and during the coronavirus disease 2019 pandemic. CMG = cystometrogram; UFR = uroflowmetry; VUDS = video-urodynamic study; P-F = pressure flow studyImpact of coronavirus disease 2019 on outpatient procedures
During the lockdown, there was a considerable decrease in the number of outpatient procedures conducted. The procedures with the highest cut-down rate were follow-up cystoscopy, TRUS-guided prostate biopsy, testicular biopsy, and extracorporeal shock wave lithotripsy. By contrast, blood clot evacuation for hematuria, DJ insertion, and DJ stent removal was less affected [Figure 4].
Figure 4: Comparison of the number of outpatient procedures before and during the coronavirus disease 2019 pandemic. TRUS biopsy = transrectal ultrasound-guided prostate biopsy; TESE = testicular sperm extraction; ESWL = extracorporeal shock wave lithotripsyImpact of coronavirus disease 2019 on outpatient visits
During the COVID-19 pandemic in June 2021, the number of outpatient visits in this hospital's urology department decreased to 4200 patients, 216 of which received follow-ups via telemedicine platforms. In June 2021, there was a more than 30% reduction in patient visits.
In this study, descriptive statistics were the most widely used statistical method. Furthermore, the Chi-square test revealed a significant change in the distribution of primary diagnoses (malignancy or nonmalignancy) before and after the COVID-19 pandemic (P < 0.001).
DiscussionFollowing the confirmation of the first COVID-19 patient in Taiwan in January 2020, many personal and community-level prevention policies were implemented to control disease transmission. Disease control strategies included promoting personal cleanliness (e.g., hand washing, remaining at home, and face masks), patient isolation, appropriate quarantine, and the storage of household goods. In addition, other community-level strategies included regional quarantine, social distance, limiting public assembly and public transit, disease control in schools, and closing public facilities.[9],[10] The implementation of these restrictions helped reduce the incidence of COVID-19 in Taiwan, facilitating the resumption of routine elective surgeries. However, as of May 15, 2021, the number of newly diagnosed cases per day increased abruptly to >100 cases.[11] In response, the CECC raised the level of epidemic warning to 3, and hospitals were advised to reduce their service capacity to prepare for the expected high demand for the treatment of COVID-19 patients. Consequently, all surgeries were halted except those with urgent indications. Meanwhile, the cystoscope room's reverse transcription–polymerase chain reaction (RT-PCR) policy was similar to that of the operating room: every patient getting an examination or surgical intervention needed a negative RT-PCR certificate within 3 days; this impacted urological service. For a history of urothelial cancer, several patients refused RT-PCR testing and postponed follow-up cystoscopy. Furthermore, in our facility, most patients who underwent postureteroscopic lithotripsy also received a double-J ureteral stent (DJ stent) removal within 2 weeks. However, patients were sometimes unwilling to pay for RT-PCRs, which delayed procedures such as DJ stent removal. These conditions were usually noted among patients who did not have malignant conditions.
Outpatient appointments and scheduled outpatient procedures were also reduced or canceled abruptly. According to a study that examined the influence of COVID-19 on urological services, there was a considerable decline in all types of urological services, and the magnitude corresponded closely to the severity of the outbreak.[2] Surgeries for benign conditions were affected more significantly than those for malignant urological conditions. Particularly, a 93%, 85%, 84%, 82%, and 77% reduction was noted for benign prostatic hyperplasia surgeries, including laser prostatectomy and transurethral resection of the prostate; female urinary incontinence procedure such as sling operation; male infertility treatment such as testicular sperm extraction, testis biopsy, and varicocelectomy; renal stone treatment procedures such as percutaneous nephrolithotomy and retrograde intrarenal surgery; and bladder stone removal surgery, respectively.[2] Our series yielded comparable results: 88%, 100%, 84%, 80%, and 100% reduction were observed for procedures on the five benign urological disorders stated above, respectively. By contrast, obstructive ureteric stone surgery was less affected because it frequently resulted in an emergency. Except for patients with suspected higher-risk prostate cancer, most urological associations or societies (UASs) worldwide advocated postponing prostate biopsy.[5] In our series, there was a 92% decrease in TRUS-guided prostate biopsy. However, despite lingering concerns over COVID-19 infection, there was no change in the number of radical prostatectomy cases. Most patients still preferred to undergo surgery as scheduled after shared decision-making.
Several UASs recommended conducting cystoscopy to diagnose and follow-up patients with a history of higher-risk, nonmuscle-invasive bladder cancer. Compared with those conducted in the previous prepandemic year, an 83% reduction in cystoscopy procedures was still observed during the pandemic. This trend may be attributable to the additional charges for RT-PCRs, which most patients were unwilling to pay since a negative RT-PCR is required outpatient cystoscopy operations under hospital quarantine policy. Cystoscopy for microscopic hematuria surveys may be postponed during the pandemic, and painless gross hematuria may not be sufficient motivation for patients to visit the outpatient urologist because of COVID-19 concerns when visiting the hospital. Consequently, the number of newly diagnosed bladder cancer patients lessened, and scheduled second-look TURBTs were postponed, resulting in a 58.1% reduction in TURBT surgeries. By contrast, kidney tumors detected after a physical examination, by chance during another imaging process, or because of a well-reported high suspicion of malignancy prompted people to seek medical counsel. Thus, compared with the pre-COVID-19 period, the number of kidney cancer-related procedures, including partial and radical nephrectomy, did not change during the pandemic.
Although there were no cases of morbidity, there was one death reported in June 2020 due to terminal metastatic prostate cancer. Furthermore, in June 2021, there were two and zero morbidity and fatality cases, respectively. These trends suggest that there was no statistically significant difference in mortality and morbidity during the pandemic.
Telemedicine has been used to replace genuine outpatient visits during the COVID-19 pandemic. It is appropriate for most patients with uro-oncological conditions and other benign diseases.[12] In addition, the main advantage of telemedicine outpatient services is the reduced risks of viral transmission. Furthermore, it allows healthcare professionals with suspected COVID-19 infections to continue practice while they are still in quarantine.[13] In June 2021, the total number of patients using outpatient telemedicine urology services was 216, which decreased by half in July 2021, when the number of COVID-19 cases in Taiwan decreased. In our facility, telemedicine is mostly conducted over the phone. First, a nurse typically calls patients' numbers and verifies their name, identity number, and birthday. Next, the doctor asks about the patient's medical history and present problem before prescribing medicine and performing tests. Finally, the nurse verifies the patient's address and mails bills and prescriptions. The tablets are obtained from a neighboring drugstore. Even in nonpandemic situations, telemedicine can be a beneficial tool because of the following advantages: patient convenience, reduced demand for office space, hospital management, and saving patient transportation/parking.[14] However, patients in Taiwan did not appear to be familiar with this new form of outpatient treatment. Furthermore, there was a lack of promotion by the government and a lack of policy coordination. Thus, whether telemedicine will be used in Taiwan after the pandemic remains unclear.
Significant changes in clinical education and training have also been observed during the COVID-19 pandemic. Because of a decrease in learning exposure, the use of online teleconference software and the viewing of online surgical videos was encouraged. Consequently, clinical training might be maintained to a minimum.[15],[16]
Following the decline of the pandemic, there will be a clear backlog of elective surgeries that must be managed, necessitating the expansion of the workforce and resources to accommodate these patients. Before resuming elective services, the following key considerations must be made: The timing of growing surgical capacity, the availability of diagnostic testing, the provision of adequate personal protective equipment, and the availability of core-interdependent services.[17] Although the number of newly diagnosed COVID-19 cases is decreasing daily, it is crucial to reserve ward beds for possible fluctuations in case numbers during the pandemic. The reduced number of total ward beds and resurrected medical demands will pose a significant challenge in clinical practice in the months following the pandemic. A model was developed in a global expert response study to anticipate the period required to clear all surgical backlogs after the pandemic slows down. Data on elective surgery postponed during the 12 week peak disruption period were gathered from 538 submissions to the expert response research, which covered 359 facilities in 71 countries. According to the report, countries would require a median of 90, 45, and 30 weeks to clear the backlog of procedures as a result of 12 weeks of disruption due to the COVID-19 pandemic based on a 10%, 20%, and 30% increase in baseline surgical volume, respectively. However, patients' medical habits in Taiwan differ considerably from those of foreigners because of the accessibility of hospitals and the convenience of services of National Health Insurance. Thus, although this model may not accurately predict the clearance efficacy in Taiwan, it can still be used as an effective reference in the future.[18]
This was a retrospective study in which all data were collected over 1 month from a single medical hospital during the COVID-19 pandemic outbreak in Taiwan. Daily, many patients in poor health are referred to VGHTPE for surgical intervention. Therefore, the percentage of surgical reduction may not accurately reflect the impact of the COVID-19 epidemic reported in other institutions.
ConclusionThe COVID-19 epidemic has already substantially impacted clinical practice in urology. Our study provides a reference for the impact on urological services in Taiwan during a level 3 pandemic alert. These findings emphasize the importance of flexibility to change the current clinical practice routine in response to the COVID-19 pandemic. During the COVID-19 pandemic, we postponed most elective procedures, outpatient appointments, and diagnostic outpatient examinations according to the prioritized recommendations. After the pandemic has subsided, the backlog should be managed in stages based on priority. Furthermore, in the future, telemedicine may serve as a new option for patients living in remote areas. However, there are still a number of challenges to overcome, including equipment, patient education, necessary legal restrictions, and policy coordination.
Financial support and sponsorship
Nil.
Conflicts of interest
Prof. William J. Huang and Dr. Shiao-Jen Chung, editorial board members at Urological Science, had no roles in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.
References
Comments (0)