Re: Ming-Chun Chan, Sharon E.K. Yeo, Yew-Lam Chong, Yee-Mun Lee. Stepping Forward: Urologists' Efforts During the COVID-19 Outbreak in Singapore. Eur Urol 2020;78:e38-9.

We read with interest the article by Chan et al [1] regarding the COVID-19 outbreak in Singapore and we commend the authors for sharing their experience and their useful analysis. Unfortunately, in Italy we are experiencing the same difficulties in terms of surgical and educational planning. At present, we can run the operating theatres in our institution for <10% of the usual activity level and residents are experiencing a temporary lack of teaching caused by both postponement of rotations and the reduction in clinical and surgical activity. Surgical theatres for emergency and urgent cases are guaranteed, while elective cases have been scaled down according to recommendations [2], [3], [4] and common sense. However, we are surprisingly experiencing a huge decrease in urgent urological cases presenting to the emergency department.

Italy has experienced exponential growth in COVID-19 cases from the end of January 2020 until the lockdown imposed by the government on March 9, 2020. We reviewed all urological consultations in the emergency department over the last 60 d and divided them into three groups: group A, from January 29 to February 17; group B, from February 18 to March 8; and group C, from March 9 to March 28. Group A comprised 63 patients (3.15 patients/d), group B 38 (1.9 patients/d), and group C only 17 (0.85 patients/d). Stone-related cases accounted for 35 patients in group A (55.5%), 18 in group B (47.3%), and only six (35.3%) in group C. Haematuria was the reason for consultation for 11 patients in group A (17.5%), nine in group B (23.7%), and four (23.5%) in group C. While it is reasonable to expect that lockdown and quarantine might decrease the number of case presentations for some reasons such as urological trauma, urological infections, and related conditions (eg, acute urinary retention), it is more difficult to understand a huge decrease in presentations for renal colic.

On the one hand this scenario may reflect chronic abuse of the hospital by low-complexity cases that could be managed by general practitioners, while on the other hand there might be a worrisome tendency to postpone urological consultations even when necessary because of patients’ fear of getting infected. Moreover, this attitude could lead to future consultation requests from the same patients in worse clinical conditions with further overload of the health care system.

A similar scenario has been confirmed by many urologists in different hospitals in northern Italy. It would be of interest to know if the authors also noticed this trend in Singapore and if this is being experienced in other countries, to better understand the underlying reasons and plan adequate management strategies.

The authors have nothing to disclose.