Impact of the COVID-19 Pandemic on Urological Care Delivery in the United States.

PURPOSE: We examined changes in urological care delivery due to COVID-19 in the U.S. based on patient, practice, and local/regional demographic and pandemic response features. MATERIALS AND METHODS: We analyzed real-world data from the American Urological Association Quality (AQUA) Registry collected from electronic health record systems. Data represented 157 outpatient urological practices and 3,165 providers across 48 U.S. states and territories, including 3,297,721 unique patients, 12,488,831 total outpatient visits and 2,194,456 procedures. The primary outcome measure was the number of outpatient visits and procedures performed (inpatient or outpatient) per practice per week, measured from January 2019 to February 2021. RESULTS: We found large (>50%) declines in outpatient visits from March 2020 to April 2020 across patient demographic groups and states, regardless of timing of state stay-at-home orders. Nonurgent outpatient visits decreased more across various nonurgent procedures (49%-59%) than for procedures performed for potentially urgent diagnoses (38%-52%); surgical procedures for nonurgent conditions also decreased more (43%-79%) than those for potentially urgent conditions (43%-53%). African American patients had similar decreases in outpatient visits compared with Asians and Caucasians, but also slower recoveries back to baseline. Medicare-insured patients had the steepest declines (55%), while those on Medicaid and government insurance had the lowest percentage of recovery to baseline (73% and 69%, respectively). CONCLUSIONS: This study provides real-world evidence on the decline in urological care across demographic groups and practice settings, and demonstrates a differential impact on the utilization of urological health services by demographics and procedure type.

How the COVID-19 Wave Changed Emergency Urology: Results From an Academic Tertiary Referral Hospital in the Epicentre of the Italian Red Zone.

OBJECTIVE: To quantify and characterize the burden of urological patients admitted to emergency department (ED) in Lombardy during Italian COVID-19 outbreak, comparing it to a reference population from 2019. METHODS: We retrospectively analysed all consecutive admissions to ED from 1 January to 9 April in both 2019 and 2020. According to the ED discharge ICD-9-CM code, patients were grouped in urological and respiratory patients. We evaluated the type of access (self-presented/ambulance), discharge priority code, ED discharge (hospitalization, home), need for urological consultation or urgent surgery. RESULTS: The number of urological diagnoses in ED was inversely associated to COVID-19 diagnoses (95% confidence interval -0.41/-0.19; Beta = -0.8; P < .0001). The average access per day was significantly lower after 10 March 2020 (1.5 ± 1.1 vs 6.5 ± 2.6; P < .0001), compared to reference period. From 11 March 2020, the inappropriate admissions to ED were reduced (10/45 vs 96/195; P = .001). Consequently, the patients admitted were generally more demanding, requiring a higher rate of urgent surgeries (4/45 vs 4/195; P = .02). This reflected in an increase of the hospitalization rate from 12.7% to 17.8% (Beta = 0.88; P < .0001) during 2020. CONCLUSION: Urological admissions to ED during lockdown differed from the same period of 2019 both qualitatively and quantitatively. The spectrum of patients seems to be relatively more critical, often requiring an urgent management. These patients may represent a challenge due to the difficult circumstances caused by the pandemic.

Laparoscopic and Robotic Urology Surgery during Global Pandemic COVID19.

Known laparoscopic and robotic assisted approaches and techniques for the surgical management of urological malignant and benign diseases are commonly used around the World. During the global pandemic COVID19, urology surgeons had to reorganize their daily surgical practice. A concern with the use of minimally invasive techniques arose due to a proposed risk of viral transmission of the coronavirus disease with the creation of pneumoperitoneum. Due to this, we reviewed the literature to evaluate the use of laparoscopy and robotics during the pandemic COVID19. A literature review of viral transmission in surgery and of the available literature regarding the transmission of the COVID19 virus was performed up to April 30, 2020. We additionally reviewed surgical society guidelines and recommendations regarding surgery during this pandemic. Few studies have been performed on viral transmission during surgery. No study has been made regarding this area during minimally invasive urology cases. To date there is no study that demonstrates or can suggest the ability for a virus to be transmitted during surgical treatment whether open, laparoscopic or robotic. There is no society consensus on restricting laparoscopic or robotic surgery. However, there is expert consensus on modification of standard practices to minimize any risk of transmission. During the pandemic COVID19 we recommend the use of specific personal protective equipment for the surgeon, anesthesiologist and nursing staff in the operating room. Modifications of standard practices during minimally invasive surgery such as using lowest intra-abdominal pressures possible, controlled smoke evacuation systems, and minimizing energy device usage are recommended.

Forecasting the Future of Urology Practice: A Comprehensive Review of the Recommendations by International and European Associations on Priority Procedures During the COVID-19 Pandemic.

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.

Urologic Surgery and COVID-19: How the Pandemic Is Changing the Way We Operate.

The coronavirus disease 2019 (COVID-19) pandemic has had a global impact on all aspects of health care, including surgical procedures. For urologists, it has affected and will continue to influence how we approach the care of patients preoperatively, intraoperatively, and postoperatively. A risk-benefit assessment of each patient undergoing surgery should be performed during the COVID-19 pandemic based on the urgency of the surgery and the risk of viral illness and transmission. Patients with advanced age and comorbidities have a higher incidence of mortality. Routine preoperative testing and symptom screening is recommended to identify those with COVID-19. Adequate personal protective equipment (PPE) for the surgical team is essential to protect health care workers and ensure an adequate workforce. For COVID-19 positive or suspected patients, the use of N95 respirators is recommended if available. The anesthesia method chosen should attempt to minimize aerosolization of the virus. Negative pressure rooms are strongly preferred for intubation/extubation and other aerosolizing procedures for COVID-19 positive patients or when COVID status is unknown. Although transmission has not yet been shown during laparoscopic and robotic procedures, efforts should be made to minimize the risk of aerosolization. Ultra-low particulate air filters are recommended for use during minimally invasive procedures to decrease the risk of viral transmission. Thorough cleaning and sterilization should be performed postoperatively with adequate time allowed for the operating room air to be cycled after procedures. COVID-19 patients should be separated from noninfected patients at all levels of care, including recovery, to decrease the risk of infection. Future directions will be guided by outcomes and infection rates as social distancing guidelines are relaxed and more surgical procedures are reintroduced. Recommendations should be adapted to the local environment and will continue to evolve as more data become available, the shortage of testing and PPE is resolved, and a vaccine and therapeutics for COVID-19 are developed.

Assessing the Burden of Nondeferrable Major Uro-oncologic Surgery to Guide Prioritisation Strategies During the COVID-19 Pandemic: Insights from Three Italian High-volume Referral Centres.

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.