The COVID-19 pandemic is providing a major challenge for modern medicine in 2020. It has changed many aspects of medical services, with urology being no exception, and has forced medical providers to adapt their approach towards patient care, including outpatient care, inpatient care, and surgery services.16,17 This study investigated the impact of the COVID-19 pandemic on urology daily practice in Indonesia by means of a web-based questionnaire survey. This study had a 76% and 100% response rate for urologists and urology residents, respectively, which is considered a very high response rate.18 Moreover, it was found that less than 10% of the questions in each section were incomplete.
Two urologists and five urology residents reported having contracted COVID-19. This suggests that urology residents were more likely than urologists to contract COVID-19. Residents are often on the front line of medical services, thus, extra precaution, particularly proper use of PPE, is a necessity. Among the 9.5% urologists and 27% urology residents who had been designated as a suspected case of COVID-19, only 60% of the urologists and 62.7% urology residents had been quarantined or undergone self-isolation. The reason behind this could not be determined from the responses. However, this should be investigated because all suspected cases supposed to undergo quarantine to stop the spread of the virus.
As of 5 May 2020, there had been a total of 12,071 confirmed cases of COVID-19 in Indonesia. However, only 88,924 people have been tested out of a population of more than 266 million (approximately 0.33 test per 1,000 people).19,20 This testing rate is lower than in other counties in the region, such as Singapore (21.1 tests per 1,000 people), South Korea (12.49 tests per 1,000 people), Malaysia (6.59 tests per 1,000 people) and India (0.86 tests per 1,000 people).21 This is why the number of COVID-19 cases in Indonesia is considered to be the “tip of the iceberg”. To overcome this limitation, Indonesia’s Ministry of Health has stratified suspected cases of COVID-19 into PIM and PUS.
In Singapore, interhospital movement of health providers is forbidden, thus all residents have to stay at an affiliated hospital for the full rotation. In Indonesia, however, the majority of urology center asked for all their residents to return from affiliated hospitals.22 This might have been a good decision since lack of shift rotation between residents and reduced working time provide residents with more time to rest. The questionnaire did not ask urology residents specifically regarding the impact of the COVID-19 pandemic on their training. However, since all the surgery and outpatient clinics were greatly reduced, the effect on their training is likely to be similar to the effect on Italian urology residents that 81.1% and 62.1% of them experienced more than 80% decreased in both clinical and surgical activities, respectively .23
In reporting the results, we specifically highlighted the responses of urologists aged 60 years and older because of the more severe clinical manifestations and higher case fatality rate among people over the age of 60 years.24,25 However, we found that the practice pattern of urologists aged 60 years and older during the COVID-19 pandemic was similar to that of the respondents overall.
Indonesian urologists have a chance to practice in public and private hospitals and most of them have practices in both public and private hospitals. There might be different pattern of practice between public and private hospitals. However, it seems that the pandemic has had a similar effect on the outpatient clinic services and elective surgery services of both hospital types.
IUA, as an organization accommodating all Indonesian urologists, has published recommendations for urologists during the COVID-19 pandemic. These recommendations cover outpatient clinics, surgery services, and PPE use.26 For outpatient services, this guidance recommend teleconsultation and restricting the number of patient consultations. Most urologists had already complied with the recommendation to restrict the number of patients, but face-to-face consultation remained the primary consultation method for outpatient services. Even though telemedicine is being developed and the Indonesia government had been proactive by providing national policy support and for the development of telemedicine, telemedicine is still unpopular among urologists of whom less than one quarter have used telemedicine.27,28
According to IUA recommendations, all elective surgeries should be postponed in order to increase the availability of healthcare workers, ICU beds, and inpatient rooms, in addition to preventing transmission of SARS-CoV-2.26 However, only one-third of respondents stopped elective surgery, while most urologists reduced their elective surgery activity by more than two-thirds of cases. In line with IUA recommendations, most urologists conducted COVID-19 screening for patients undergoing elective surgery. Moreover, more than two-thirds of urologists cancelled elective surgery requiring post-operative ICU care and about 30% continued with planned elective surgery only if there was a risk of disease progression. The IUA guidance recommends that it should be assumed that all patients undergoing surgery have COVID-19 unless proven otherwise.26
Most respondents who regularly do the laparoscopic surgery had temporarily abandoned this procedure. Even though it hasn’t been proven that COVID-19 could be transmitted via laparoscopic surgical smoke, it should be avoided since several viruses, such as hepatitis B, human papillomaviruses, and HIV have a potential for laparoscopic transmission and SARS-CoV-2 might have similar properties.22
In addition to emergency surgery, there are several urological procedures which are recommended to be done due to risk of disease progression. IUA recommends that procedures for patients with severe disease should to not be deferred, including surgery for muscle invasive bladder cancer or in situ bladder cancer, testicular tumours, cT3 + kidney tumours, high-risk prostate cancer which cannot be treated by radiation therapy, upper tract urothelial tumours, adrenal cortical carcinoma, and penile tumours. This recommendation is in line with article written by Campi et al.29 which discusses the prioritisation of urological surgery in Italy during the COVID-19 pandemic. Moreover, this recommendation is also in line with respondents’ assessments of surgery priorities.
Surgical mask, face shields, medical gloves, and surgical cap were well utilized and provided by the hospital. This should be sufficient to protect healthcare workers in outpatient settings and inpatient settings without patients with suspected or confirmed COVID-19 based on IUA recommendations. However, medical gown availability appeared to be more limited among urology residents than among urologists. This study also revealed a shortage of N95 masks among urologist and urology resident in public hospitals. N95 masks are recommended for use in the care of patients with suspected or confirmed COVID-19. Therefore, this shortage of equipment needs to be addressed.