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1.
Urology ; 2022.
Article in English | ScienceDirect | ID: covidwho-1799681

ABSTRACT

Objective : To assess changes to the experiences and wellbeing of urology trainees in the United States(US) and European Union (EU) during the COVID-19 pandemic. Methods : A 72-item anonymous online survey was distributed September 2020 to urology residents of Italy, France, Portugal, and the US. The survey assessed burnout, professional fulfillment, loneliness, depression and anxiety as well as 38 COVID specific questions. Results : Two hundred twenty-three urology residents responded to the survey. Surgical exposure was the main educational concern for 81% of US and 48% of EU residents. E-learning was utilized by 100% of US and 57% of EU residents with two-thirds finding it equally or more useful than traditional didactics. No significant differences were seen comparing burnout, professional fulfillment, depression, anxiety, or loneliness among US or EU residents, 73% of US and 71% of EU residents reported good to excellent quality of life during the pandemic. In the US and EU, significantly less time was spent in the hospital, clinic, and operating room (p<0.001) and residents spent more time using telehealth and working from home during the pandemic and on research projects, didactic lectures, non-medical hobbies and reading. The majority of residents reported benefit from more schedule flexibility, improved work life balance, and increased time for family, hobbies, education, and research. Conclusions : The COVID-19 pandemic has resulted in significant restructuring of residents’ educational experience around the globe. Preservation of beneficial changes such as reduction of work hours and online learning should be pursued within this pandemic and beyond it.

2.
Prostate Cancer Prostatic Dis ; 2022 Apr 14.
Article in English | MEDLINE | ID: covidwho-1795806

ABSTRACT

According to current studies, COVID-19 might have an impact on semen quality. Therefore, SARS-CoV-2 may affect other traits of male reproductive system, including the prostate. Thus, we recruited patients who experienced COVID-19 infection in-between prostate biopsy and radical prostatectomy and compared prostate samples inflammation, measured with IRANI score, to those who did not. Indeed, we recruited 20 patients, aged 69 (62-73) years, finding no difference between the 10 patients with COVID-19 infection and the others in IRANI score and all its sub-scores. Hence, according to our exploratory and limited results, COVID-19 infection might have no gross effect on prostate inflammation.

4.
Andrology ; 2021 Dec 08.
Article in English | MEDLINE | ID: covidwho-1575098

ABSTRACT

BACKGROUND: There is evidence that, after severe acute respiratory syndrome coronavirus 2 infection, male reproductive function and semen quality may be damaged OBJECTIVES: To evaluate a panel of inflammatory mediators in semen in patients recovered from coronavirus disease 2019. MATERIAL AND METHODS: Sexually active men with previous severe acute respiratory syndrome coronavirus 2 infection and proven recovery from coronavirus disease 2019 were enrolled in a prospective cohort study. Clinical, uro-andrological data and semen specimens were prospectively collected. For previously hospitalized coronavirus disease 2019 patients, data on serum inflammatory markers were retrospectively collected. RESULTS: A total of 43 men were enrolled in the study. Of these, 32 men were normozoospermic, three were oligozoospermic, and eight were crypto-azoospermic. Serum inflammatory markers (procalcitonin and C-reactive protein) were analyzed in previously hospitalized patients both at admission and at peak of infection. Levels at admission were statistically significantly higher in patients resulting in crypto-azoospermic with respect to those resulting in normozoospermic (p = 0.05; p = 0.03 and p = 0.02, respectively) after healing. Seminal cytokine levels were similar among all groups. Interleukin-1ß and tumor necrosis factor-α levels were significantly negatively related to sperm total number and concentration, whereas interleukin-4 was correlated with sperm motility. DISCUSSION AND CONCLUSION: Negative correlations between interleukin-1ß and tumor necrosis factor-α and sperm number and the overall high levels of semen cytokines indicate a potential detrimental role of severe acute respiratory syndrome coronavirus 2 driven inflammation on spermatogenesis. Overall, our results indicate that male patients recovering from coronavirus disease 2019 deserve accurate follow-up for their fertility status.

5.
Eur Urol Open Sci ; 34: 5-9, 2021 Dec.
Article in English | MEDLINE | ID: covidwho-1487720

ABSTRACT

In response to the COVID-19 pandemic, the European Association of Urology (EAU) Guidelines Office Rapid Reaction Group (GORRG) defined priority groups to guide the prioritization of surgery for nonmetastatic renal cell carcinoma (RCC). In this study we explored the diversity and predictors of histopathological findings across the EAU GORRG priority groups using a large database of 1734 consecutive patients undergoing elective surgery for nonmetastatic renal masses between 2017 and 2020 at a referral institution. Overall, 940 (54.2%), 358 (20.6%), and 436 (25.2%) patients were classified as low-, intermediate-, and high-priority, respectively. The low-, intermediate-, and high-risk groups significantly differed regarding all primary histopathological outcomes: benign histology (21.6% vs 15.9% vs 6.4%; p < 0.001); non-organ-confined disease (5.0% vs 19.0% vs 45.4%; p < 0.001); and adverse pathological features according to validated prognostic models (including the median Leibovich score for clear-cell RCC: 0 vs 2 vs 4; p < 0.001). On multivariable analysis, beyond the EAU GORRG priority groups, specific patient and/or tumor-related characteristics were independent predictors of the aforementioned histopathological outcomes. To the best of our knowledge, our study shows for the first time the value of the EAU GORRG priority groups from a histopathological standpoint and supports implementation of such a prioritization scheme beyond the COVID-19 pandemic. PATIENT SUMMARY: During the COVID-19 pandemic, the European Association of Urology designed a scheme to prioritize patients needing surgery for kidney cancer according to their tumor characteristics and symptoms. We used results from our hospital database to test the scheme and found that the priority classification can be used to predict cancer outcomes after surgery. This scheme may be useful in prioritizing kidney cancer surgeries after the COVID-19 pandemic.

6.
Eur Urol Open Sci ; 31: 37-40, 2021 Sep.
Article in English | MEDLINE | ID: covidwho-1313107

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has led to significant changes in urology practice and residency programs. One year ago, the first nationwide survey on this topic showed a dramatic impact of the acute phase of the pandemic on residents' training activities. Aiming to assess for the first time how the COVID-19 scenario reshaped the pattern of urology training over a whole pandemic year, a cross-sectional, 38-item, web-based survey was developed. Residents scored the percentage decrease of their involvement in various clinical and surgical activities during the period of March 2020-March 2021 (as compared with the pre-COVID period). Overall, 312/585 (53.3%) residents from 27 schools of urology were included. The proportions of those experiencing a significant decrease of training exposure were 13.6%, 28.8%, 26.7%, 46.9%, 37.6%, and 33.3% (as compared with 40.2%, 85.8%. 82.3%, 69.7%, 59.7%, and 50.2% in the previous survey) for on-call activities, outpatient visits, diagnostic procedures, endoscopic surgery, open surgery, and minimally invasive surgery, respectively. The most impactful reductions in training activities were reached by final-year residents. Our findings highlight that, even if less burdensome than expected, urology residency training (especially in endoscopic surgery) was highly affected throughout the whole past year. This critical gap of skills may jeopardize residents' training even beyond the COVID-19 pandemic. PATIENT SUMMARY: In this study, we assessed whether the training activities of Italian urology residents were impacted negatively by a whole year of COVID-19 pandemic (March 2020-March 2021). We also compared our results with those reported in a previous survey evaluating how the coronavirus disease 2019 (COVID-19) pandemic changed the training pattern of urology residents during the peak of the outbreak in March 2020. We found a critical decrease in residents' activities (especially for those in their final years of residency and for surgical procedures) that, even if lower than expected, might negatively impact their education and training in the future.

8.
Ann Surg ; 2021 Jan 22.
Article in English | MEDLINE | ID: covidwho-1045790

ABSTRACT

OBJECTIVE: To assess the degree of psychological impact among surgical providers during the COVID-19 pandemic. SUMMARY BACKGROUND DATA: The COVID-19 pandemic has extensively impacted global healthcare systems. We hypothesized that the degree of psychological impact would be higher for surgical providers deployed for COVID-19 work, certain surgical specialties, and for those who knew of someone diagnosed with, or who died, of COVID-19. METHODS: We conducted a global web-based survey to investigate the psychological impact of COVID-19. The primary outcomes were the Depression Anxiety Stress Scale-21 (DASS-21) and Impact of Event Scale-Revised (IES-R) scores. RESULTS: 4283 participants from 101 countries responded. 32.8%, 30.8%, 25.9% and 24.0% screened positive for depression, anxiety, stress and Post-Traumatic Stress Disorder (PTSD) respectively. Respondents who knew someone who died of COVID-19 were more likely to screen positive for depression, anxiety, stress and PTSD (OR 1.3, 1,6, 1.4, 1.7 respectively, all p < 0.05). Respondents who knew of someone diagnosed with COVID-19 were more likely to screen positive for depression, stress and PTSD (OR 1.2, 1.2 and 1.3 respectively, all p < 0.05). Surgical specialities that operated in the Head and Neck region had higher psychological distress among its surgeons. Deployment for COVID-19-related work was not associated with increased psychological distress. CONCLUSIONS: The COVID-19 pandemic may have a mental health legacy outlasting its course. The long-term impact of this ongoing traumatic event underscores the importance of longitudinal mental health care for healthcare personnel, with particular attention to those who know of someone diagnosed with, or who died of COVID-19.

10.
Urology ; 147: 21-26, 2021 01.
Article in English | MEDLINE | ID: covidwho-791647

ABSTRACT

OBJECTIVES: To explore the perspective of urological patients on the possibility to defer elective surgery due to the fear of contracting COVID-19. METHODS: All patients scheduled for elective urological procedures for malignant or benign diseases at 2 high-volume centers were administered a questionnaire, through structured telephone interviews, between April 24 and 27, 2020. The questionnaire included 3 questions: (1) In light of the COVID-19 pandemic, would you defer the planned surgical intervention? (2) If yes, when would you be willing to undergo surgery? (3) What do you consider potentially more harmful for your health: the risk of contracting COVID-19 during hospitalization or the potential consequences of delaying surgical treatment? RESULTS: Overall, 332 patients were included (51.5% and 48.5% in the oncology and benign groups, respectively). Of these, 47.9% patients would have deferred the planned intervention (33.3% vs 63.4%; P < .001), while the proportion of patients who would have preferred to delay surgery for more than 6 months was comparable between the groups (87% vs 80%). These answers were influenced by patient age and American Society of Anesthesiologists score (in the Oncology group) and by the underlying urological condition (in the benign group). Finally, 182 (54.8%) patients considered the risk of COVID-19 potentially more harmful than the risk of delaying surgery (37% vs 73%; P < .001). This answer was driven by patient age and the underlying disease in both groups. CONCLUSIONS: Our findings reinforce the importance of shared decision-making before urological surgery, leveraging patients' values and expectations to refine the paradigm of evidence-based medicine during the COVID-19 pandemic and beyond.


Subject(s)
COVID-19/prevention & control , Elective Surgical Procedures/standards , Pandemics/prevention & control , Urologic Diseases/surgery , Urologic Surgical Procedures/standards , Aged , Aged, 80 and over , COVID-19/epidemiology , COVID-19/transmission , COVID-19/virology , Decision Making, Shared , Evidence-Based Medicine/standards , Female , Hospitals, High-Volume/standards , Humans , Infection Control/standards , Infectious Disease Transmission, Professional-to-Patient/prevention & control , Male , Middle Aged , Patient Preference/statistics & numerical data , Prospective Studies , SARS-CoV-2/pathogenicity , Surveys and Questionnaires/statistics & numerical data , Time-to-Treatment/standards , Urology/standards
11.
Eur Urol ; 78(2): 265-275, 2020 Aug.
Article in English | MEDLINE | ID: covidwho-598126

ABSTRACT

BACKGROUND: The World Health Organization (WHO) declared coronavirus disease-19 (COVID-19) as a pandemic on March 11, 2020. The impact of COVID-19 on urological services in different geographical areas is unknown. OBJECTIVE: To investigate the global impact of COVID-19 on urological providers and the provision of urological patient care. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional, web-based survey was conducted from March 30, 2020 to April 7, 2020. A 55-item questionnaire was developed to investigate the impact of COVID-19 on various aspects of urological services. Target respondents were practising urologists, urology trainees, and urology nurses/advanced practice providers. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was the degree of reduction in urological services, which was further stratified by the geographical location, degree of outbreak, and nature and urgency of urological conditions. The secondary outcome was the duration of delay in urological services. RESULTS AND LIMITATIONS: A total of 1004 participants responded to our survey, and they were mostly based in Asia, Europe, North America, and South America. Worldwide, 41% of the respondents reported that their hospital staff members had been diagnosed with COVID-19 infection, 27% reported personnel shortage, and 26% had to be deployed to take care of COVID-19 patients. Globally, only 33% of the respondents felt that they were given adequate personal protective equipment, and many providers expressed fear of going to work (47%). It was of concerning that 13% of the respondents were advised not to wear a surgical face mask for the fear of scaring their patients, and 21% of the respondents were advised not to discuss COVID-19 issues or concerns on media. COVID-19 had a global impact on the cut-down of urological services, including outpatient clinic appointments, outpatient investigations and procedures, and urological surgeries. The degree of cut-down of urological services increased with the degree of COVID-19 outbreak. On average, 28% of outpatient clinics, 30% of outpatient investigations and procedures, and 31% of urological surgeries had a delay of >8 wk. Urological services for benign conditions were more affected than those for malignant conditions. Finally, 47% of the respondents believed that the accumulated workload could be dealt with in a timely manner after the COVID-19 outbreak, but 50% thought the postponement of urological services would affect the treatment and survival outcomes of their patients. One of the limitations of this study is that Africa, Australia, and New Zealand were under-represented. CONCLUSIONS: COVID-19 had a profound global impact on urological care and urology providers. The degree of cut-down of urological services increased with the degree of COVID-19 outbreak and was greater for benign than for malignant conditions. One-fourth of urological providers were deployed to assist with COVID-19 care. Many providers reported insufficient personal protective equipment and support from hospital administration. PATIENT SUMMARY: Coronavirus disease-19 (COVID-19) has led to significant delay in outpatient care and surgery in urology, particularly in regions with the most COVID-19 cases. A considerable proportion of urology health care professionals have been deployed to assist in COVID-19 care, despite the perception of insufficient training and protective equipment.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Pneumonia, Viral/complications , Surveys and Questionnaires , Urologic Diseases/therapy , Urologic Surgical Procedures/statistics & numerical data , Urologists/statistics & numerical data , Urology/statistics & numerical data , Adult , COVID-19 , Coronavirus Infections/epidemiology , Cross-Sectional Studies , Female , Global Health , Humans , Incidence , Male , Middle Aged , Pandemics , Pneumonia, Viral/epidemiology , Retrospective Studies , SARS-CoV-2 , Urologic Diseases/complications , Urologic Diseases/epidemiology , Workload
12.
Eur Urol Focus ; 6(5): 1032-1048, 2020 Sep 15.
Article in English | MEDLINE | ID: covidwho-437422

ABSTRACT

CONTEXT: The unprecedented health care scenario caused by the coronavirus disease 2019 (COVID-19) pandemic has revolutionized urology practice worldwide. OBJECTIVE: To review the recommendations by the international and European national urological associations/societies (UASs) on prioritization strategies for both oncological and nononcological procedures released during the current emergency scenario. EVIDENCE ACQUISITION: Each UAS official website was searched between April 8 and 18, 2020, to retrieve any document, publication, or position paper on prioritization strategies regarding both diagnostic and therapeutic urological procedures, and any recommendations on the use of telemedicine and minimally invasive surgery. We collected detailed information on all urological procedures, stratified by disease, priority (higher vs lower), and patient setting (outpatient vs inpatient). Then, we critically discussed the implications of such recommendations for urology practice in both the forthcoming "adaptive" and the future "chronic" phase of the COVID-19 pandemic. EVIDENCE SYNTHESIS: Overall, we analyzed the recommendations from 13 UASs, of which four were international (American Urological Association, Confederation Americana de Urologia, European Association of Urology, and Urological Society of Australia and New Zealand) and nine national (from Belgium, France, Germany, Italy, Poland, Portugal, The Netherlands, and the UK). In the outpatient setting, the procedures that are likely to impact the future burden of urologists' workload most are prostate biopsies and elective procedures for benign conditions. In the inpatient setting, the most relevant contributors to this burden are represented by elective surgeries for lower-risk prostate and renal cancers, nonobstructing stone disease, and benign prostatic hyperplasia. Finally, some UASs recommended special precautions to perform minimally invasive surgery, while others outlined the potential role of telemedicine to optimize resources in the current and future scenarios. CONCLUSIONS: The expected changes will put significant strain on urological units worldwide regarding the overall workload of urologists, internal logistics, inflow of surgical patients, and waiting lists. In light of these predictions, urologists should strive to leverage this emergency period to reshape their role in the future. PATIENT SUMMARY: Overall, there was a large consensus among different urological associations/societies regarding the prioritization of most urological procedures, including those in the outpatient setting, urological emergencies, and many inpatient surgeries for both oncological and nononcological conditions. On the contrary, some differences were found regarding specific cancer surgeries (ie, radical cystectomy for higher-risk bladder cancer and nephrectomy for larger organ-confined renal masses), potentially due to different prioritization criteria and/or health care contexts. In the future, the outpatient procedures that are likely to impact the burden of urologists' workload most are prostate biopsies and elective procedures for benign conditions. In the inpatient setting, the most relevant contributors to this burden are represented by elective surgeries for lower-risk prostate and renal cancers, nonobstructing stone disease, and benign prostatic hyperplasia.


Subject(s)
Coronavirus Infections/epidemiology , Pneumonia, Viral/epidemiology , Practice Guidelines as Topic , Urologic Neoplasms/diagnosis , Urologic Neoplasms/therapy , Urology/trends , Ambulatory Care/trends , Betacoronavirus , COVID-19 , Europe/epidemiology , Forecasting , Hospitalization/trends , Humans , Minimally Invasive Surgical Procedures/trends , Pandemics , SARS-CoV-2 , Societies, Medical , Telemedicine/trends , Urologic Diseases/diagnosis , Urologic Diseases/therapy , Urologic Surgical Procedures/trends , Urology/organization & administration , Urology/standards
13.
Panminerva Med ; 64(1): 72-79, 2022 Mar.
Article in English | MEDLINE | ID: covidwho-381928

ABSTRACT

INTRODUCTION: Since December 2019, there has been an outbreak of a novel beta-Coronavirus (SARS-CoV-2) in Wuhan, China. On March 11, 2020, the World Health Organization (WHO) declared COVID-19 as a pandemic, with over 118,000 cases in more than 110 countries around the world. In response to the global Coronavirus disease 2019 (COVID-19) emergency, clinical trial research assessing the efficacy and safety of experimental vaccines to prevent COVID-19 are emerging at an unprecedented rate. The aim of this systematic review was to summarize the preliminary experiences and ongoing clinical trials of the major candidates and challenges of the vaccine strategies in humans. EVIDENCE ACQUISITION: After a-priori protocol registration with PROSPERO (181483), systematic research of the published literature was conducted on April 24, 2020, using Medline (via PubMed), Embase (via Ovid), and WHO databases. Moreover, to explore the more recent literature we also searched the preprint server medRxiv. Finally, we scrutinized the Cochrane COVID-19 study register and the COVID-19 section of ClinicalTrials.gov database to identify relevant ongoing clinical trials. Thereafter we selected the articles according to the PRISMA Guidelines. Animal or in-vitro experimental studies were excluded. Moreover editorials, commentaries, abstracts, reviews, book chapters, and articles not in English were not included. EVIDENCE SYNTHESIS: Our search identified 1359 published papers, 478 preprint articles and 367 ongoing clinical trials. Finally, only ten ongoing clinical trials met the inclusion criteria. Specifically, seven developed vaccines for the S protein of SARS-CoV-2 and three clinical trials assessed the protective role of BCG vaccine against COVID-19. The first group included phase I/II trials with different types of molecules (DNA or mRNA vaccine, bacterial plasmid or viral vectors), the latter were phase III/IV trials designed on the basis of a heterologous lymphocyte activation by the BCG vaccine. CONCLUSIONS: This new disease is pushing the scientific community to develop swiftly a safe and effective vaccine. Notwithstanding the limitations of our analysis, given by the absence of available results, we try to provide a comprehensive view of the ongoing clinical trials in humans. Our analysis reveals a worldwide effort of both scientists and enterprises to achieve one of the most challenging goals of our century.


Subject(s)
COVID-19 Vaccines , COVID-19/prevention & control , Clinical Trials as Topic , Animals , BCG Vaccine , Humans , SARS-CoV-2 , Vaccines, Synthetic
15.
Eur Urol ; 78(1): 11-15, 2020 Jul.
Article in English | MEDLINE | ID: covidwho-48026

ABSTRACT

The coronavirus 2019 (COVID-19) pandemic has led to an unprecedented emergency scenario for all aspects of health care, including urology. At the time of writing, Italy was the country with the highest rates of both infection and mortality. A panel of experts recently released recommendations for prioritising urologic surgeries in a low-resource setting. Of note, major cancer surgery represents a compelling challenge. However, the burden of these procedures and the impact of such recommendations on urologic practice are currently unknown. To fill this gap, we assessed the yearly proportion of high-priority major uro-oncologic surgeries at three Italian high-volume academic centres. Of 2387 major cancer surgeries, 32.3% were classified as high priority (12.6% of radical nephroureterectomy, 17.3% of nephrectomy, 33.9% of radical prostatectomy, and 36.2% of radical cystectomy cases). Moreover, 26.4% of high-priority major cancer surgeries were performed in patients at higher perioperative risk (American Society of Anesthesiologists score ≥3), with radical cystectomy contributing the most to this cohort (50%). Our real-life data contextualise ongoing recommendations on prioritisation strategies during the current COVID-19 pandemic, highlighting the need for better patient selection for surgery. We found that approximately two-thirds of elective major uro-oncologic surgeries can be safely postponed or changed to another treatment modality when the availability of health care resources is reduced. PATIENT SUMMARY: We used data from three high-volume Italian academic urology centres to evaluate how many surgeries performed for prostate, bladder, kidney, and upper tract urothelial cancer can be postponed in times of emergency. We found that approximately two-thirds of patients with these cancers do not require high-priority surgery. Conversely, of patients requiring high-priority surgery, approximately one in four is considered at high perioperative risk. These patients may pose challenges in allocation of resources in critical scenarios such as the current COVID-19 pandemic.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Hospitals, High-Volume/statistics & numerical data , Pandemics , Pneumonia, Viral/complications , Referral and Consultation , Urologic Neoplasms/surgery , Urologic Surgical Procedures/trends , COVID-19 , Coronavirus Infections/epidemiology , Humans , Italy/epidemiology , Morbidity/trends , Pneumonia, Viral/epidemiology , SARS-CoV-2 , Urologic Neoplasms/complications , Urologic Neoplasms/epidemiology
17.
Minerva Urol Nefrol ; 72(4): 505-509, 2020 Aug.
Article in English | MEDLINE | ID: covidwho-38350

ABSTRACT

In the global emergency scenario caused by COVID-19 pandemic, the Urology residents' training might be critically affected. To provide insights on this issue, a 25-item online Survey was sent to all Italian residents one month after the first case of COVID-19 in Italy, to evaluate their routine involvement in "clinical" (on-call duty, outpatient visits, diagnostic procedures) and "surgical" (endoscopic, open and minimally invasive surgery) training activities before and during the COVID-19 period. Overall, 351 of 577 (60.8%) residents completed the Survey. Before the COVID-19 pandemic, the proportion of residents routinely involved in "clinical" and "surgical" activities ranged from 79.8% to 87.2% and from 49.3% to 73.5%, respectively. In the COVID-19 period, the proportion of residents experiencing a severe reduction (>40%) or complete suppression (>80%) of training exposure ranged between 41.1% and 81.2% for "clinical" activities while between 44.2% and 62.1% for "surgical" activities. This reduction was even more pronounced for residents attending the final year of training. Our study is the first to provide real-life data on how Urology residency training can be impaired during an emergency period. To address this challenge, strategies aiming to increase the use of telemedicine, "smart learning" programs and tele-mentoring of surgical procedures, are warranted.


Subject(s)
Coronavirus Infections , Internship and Residency/trends , Pandemics , Pneumonia, Viral , Urology/education , COVID-19 , Education, Distance , General Surgery/education , General Surgery/statistics & numerical data , Humans , Internship and Residency/statistics & numerical data , Italy , Surveys and Questionnaires , Telemedicine , Urologic Surgical Procedures
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