Effect of COVID-19-related lockdown on functional urology practice and patient care in Gulf Cooperation Council region.

BACKGROUND: This survey was designed and conducted during the lockdown period to assess its effect on urology practice dealing with patients with voiding dysfunction and their care in the Gulf Cooperation Council (GCC) region.
METHODS: An online survey was sent across to urologists managing patients with voiding dysfunction in countries of the GCC region through various social media platforms. All valid responses were tabulated and analyzed.
RESULTS: A total of 202 responses were received. Higher proportion of urologists in private sector (98.2%) were treating patients in comparison to those in public or governmental hospitals (82.7%); (P = 0.007). Telemedicine was used by 72% of the respondents. Telephone calls were preferred With regard to perception of risk while examining patients, 65% of the respondents felt that their risk was equal to other specialties. Their preferred prevention strategy would be pre-operative screening. Financial impact affected only 10% claimed major catastrophic effect. There was a significant difference between private and public government urology services provided, with a higher proportion of patients seen, operations performed, fees charged for telemedicine, and financial effect in the private sector with P = 0.012, P = 0.037, P = 0.004, and P = 0.001, respectively.
CONCLUSION: Our survey showed that majority of urologists in the GCC region were seeing patients during COVID-19 lockdown. Emergency services were prioritized. A large proportion of urologists had switched over to telephonic communication. Most of the responding urologists were uncertain about when and how to resume surgical procedures upon easing of the COVID-19-related restrictions. Copyright:

INTRODUCTION

In December 2019, coronavirus disease-19 (COVID-19) was first described in Wuhan, China, and the new acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) was identified as the causative agent. Due to its rapid spread, by March 11, 2020, it has been announced by the World Health Organization as a pandemic when there were 118,000 cases in 114 countries and 4291 deaths.[12]

With the rapid spread of SARS-COV-2, many countries and health systems around the world took a variety of measures to contain the disease and minimize its spread. Some countries adopted screening measures along with quarantine, others banned international traveling, while some announced a state of national emergency and a curfew was applied.

Health-care sector was also affected by this pandemic where many changes and regulations were applied to face the pandemic. Some of the actions were taken in urology departments around the world including, but not limited to, the cancellation of outpatient visits, screening of planned visits, the implementation of telehealth practices, or rescheduling appointments for a few months later.[3] On the otherhand, some urologists were only evaluating and managing patient with urgent oncological conditions. Even oncological procedures were held at some places due to a lack of resources.[1]

Many authors believe that the current situation will have an impact on the prognosis of patients with oncological issues. Furthermore, patients with benign conditions such as voiding dysfunction will have a significant negative impact due to the delay in management.

This survey was designed and conducted during the lockdown period to assess the effect of COVID-19 on urology practice dealing with patients with voiding dysfunction and their care in the gulf region.

METHODS

An online survey created through Google Forms was created and circulated among urologists practicing in the Gulf Cooperation Council (GCC) countries on the May 4, 2020, while lockdown was enforced. Local ethics committee ruled that no formal ethics approval was required in this particular case. The invitation to participate was circulated through multiple groups on social media. Each Gulf country was represented by one of the authors who is accessing the local urology society and distributing questionnaire throw their local urology database assuring that they are actively practicing, the questionnaire was not including any retired or under training urologists. There was no difference between governmental and private setup.

The survey consisted of 15 questions [Table 1]. The questionnaire included doctor e-mail and mobile number to avoid duplication. The questionnaire was open for a period of 7 days. It was mandatory to answer all questions. All online filled data were transferred into Excel files codded and analyzed using SPSS software to be reliable. We did not use Google statistics. Association between categorical variables was assessed using Fisher exact test or Chi-squared test. We considered P < 0.05 as statistically significant.

Table 1

Questionnaire survey and it answers

Question	Answer
1: Which country you are representing?	KSA
	Kuwait
	Bahrain
	UAE
	Qatar
	Oman
2: What is your current position?	Consultant
	Specialist
3: Nature of your practice?	General urology
	Voiding dysfunction
	Others, specify
4: What percentage of your patient care are dealing with lower urinary tract dysfunction (voiding dysfunction)?	<20%
	50%
	>50%
5: Which represents your clinical practice?	Public hospital
	Private hospital
	Private clinic
6: Are you seeing the patient during the lockdown?	No
	Yes
7: If yes what kind of patients you see?	Emergency
	Infections
	Retention
	BPH
	Incontinence cases
	Neurogenic patients
	All patients
8: What cases are you currently operating?	All emergencies
	Cystoscopy
	TURP
	Sling procedures
	UDS
	Intravesical injections
	Greenlight laser prostatectomy
	Urethral procedures
9: Have you started video, e-mail social media consultations?	No
	Planning to do so
	Phone
	Video calls
	Social media (e-mail, WhatsApp, Telegram)
10: In regard to telemedicine, are you charging fee?	No
	The hospital or clinic are charging fees but 0 balance for me
	Yes the same as in-person consultation
	Yes higher than the usual fee
	Yes, lower than the in-person consultation
11: From the current international available information what is your opinion regarding the risk that you face regarding COVID-19 in comparison to other branches of Urology?	Lower risk
	Equal risk
	Higher risk
12: Upon easing of COVID-19 related restrictions what would be your plan regarding elective surgeries?	Restrict elective surgeries
	Wait 2 weeks before starting
	Not sure when to start
	Waiting international recommendations
13: Regarding surgeries that would be planned after resumption of clinical duties, what would be your preferred approach?	Screen all cases for COVID-19 preoperative
	Use additional PPE in all cases
	Both preoperative screening and PPE
	Not sure awaiting guidelines
14: What was the effect on your financial status over the lockdown period?	No much effect, stable monthly payment
	Minor effect, missing some of bonus
	Major catastrophic effect, no work no payment

TURP: Transurethral resection of the prostate, BPH: Benign prostatic hyperplasia, PPE: Personal protection equipment, COVID-19: Coronavirus disease-19, UDS: Urodynamic test

RESULTS

A total of 202 responses were received by May 11, 2020. More details of respondents’ demographics are in Table 2. The respondents were asked to specify the nature of their practice and percentage of their patient care dealing with lower urinary tract dysfunction (voiding dysfunction). Of all, 71.8% (145/202) were working in government/public hospitals and 28.2% (57/202) were in private sectors either hospitals or their private clinics.

Table 2

Questionnaire answers according to Gulf Cooperation Council country

	Saudi Arabia	Kuwait	Bahrain	Qatar	UAE	Oman	Total
Total responders	60	35	14	42	27	24	202
Consultant	48	10	12	26	17	10	123
Specialist	12	25	2	16	10	14	79
General Urology	38	27	10	30	23	21	149
Other subspecialty	13	5	4	11	4	3	40
Voiding dysfunction	9	3	0	1	0	0	13
Percent voiding dysfunction cases (%)
>50	14	9	2	7	4	5	41
50	24	12	9	20	16	7	88
<20	22	14	3	15	7	17	73
Governmental hospital	48	31	8	30	9	19	145
Private hospital	11	3	5	9	10	5	49
Private clinic	1	1	1	3	2	0	8
Doctor seeing patient during lockdown	47	33	14	36	22	24	176
Not seeing patient during lockdown	13	2	0	6	5	0	26
Type of patients seen
Emergency	34	23	3	21	13	13	107
Infections	0	1	0	2	0	0	3
Neurogenic bladder	1	0	0	1	0	0	2
All patients	24	11	11	16	14	11	87
Retention	1	0	0	2	0	0	3
Urologist doing operations	44	30	14	35	19	23	165
Not doing operations	16	5	0	7	8	1	37
Type of operations done
Emergency	55	32	12	41	24	24	188
Cystoscopy	3	2	0	0	1	0	6
TURP	1	0	2	0	0	0	3
UDS	1	1	0	1	0	0	3
Green laser prostate	0	0	0	0	1	0	1
Urethral procedures	0	0	0	0	1	0	1
Telemedicine
Not using	9	2	1	4	0	3	19
Phone call	25	12	9	32	17	6	101
Social media	14	13	2	3	1	3	36
Planning to use	7	5	2	3	8	12	37
Video calls	5	3	0	0	1	0	9
Fee for telemedicine
Non	46	30	14	37	11	23	161
Hospital system charging	8	3	0	3	11	1	26
Yes lower than regular	4	0	0	0	3	0	7
Yes same as regular	2	1	0	2	2	0	7
Yes more than regular	0	1	0	0	0	0	1
Urologist risk during COVID-19
Low risk	17	4	4	9	4	6	44
Equal risk to other specialties	40	27	10	23	19	13	132
High risk	3	4	0	10	4	5	26
Plan surgeries on ease of restrictions
Restrict elective surgeries	13	8	1	7	3	7	39
Wait 2 weeks	3	2	3	1	3	0	12
Not sure what to do	19	11	2	16	4	5	57
Wait for international recommendation	25	14	8	18	17	12	94
Preventive approach
Screening for COVID-19	13	6	5	20	6	1	51
Additional use PPE	5	3	1	2	3	3	17
Both screening and PPE	11	10	3	6	6	7	43
Wait international guidelines	31	16	5	14	12	13	91
Financial effect of lockdown
No effect	30	17	4	19	12	15	97
Minor effect	23	17	9	17	11	6	83
Major effect	7	1	1	6	4	3	22

TURP: Transurethral resection of the prostate, PPE: Personal protection equipment, COVID-19: Coronavirus disease-2019, UDS: Urodynamic test

Data analysis showed that a significantly higher proportion of urologists in private sector (56/57, 98.2%) were seeing patients as compared to those in public governmental hospitals (120/145; 82.7%); (P = 0.007).

When respondents were asked if they were still seeing patients, 87.1% were still examining and seeing patients in clinics (176/202). Of those 176 urologists receiving patients in their clinics, 87 (49.4%) were seeing patients with emergency urological conditions, while 87 urologists (49.4%) were accepting all emergency and nonemergency conditions in their clinics [Figure 1]. Of the same 176 responders seeing patients in the clinic, 86% (152/176) were performing surgical procedures. However, of the whole group, the majority (81.6%, 165/202) were still operating patients, 95.7% of which (158/165) indicated that surgical procedures were performed mainly for emergency conditions [Figure 2].

Figure 1

Type of patient seen in clinics by urologists seeing patients

Figure 2

Type of operations performed by urologists

The questionnaire also explored telemedicine acceptance and preferences. We found that 72% (146/202) of the respondents were using telemedicine. Telephone calling was the preferred method for follow-up by 69% (101/146) and 24.6% (36/146) used social media (Twitter, WhatsApp), while 9% (19/202) did not introduce telemedicine in their practice, and 18% (37/202) were planning to use it.

Of those who were currently involved in telemedicine, 76% (111/146) were not asking for any professional fees from patients; 14% (21/146) their hospital system was charging fees, while 4.7% (7/164) were charging fees less than one person's consultation, 2% (6/146) charged the same fee, and a small minority 0.6% (1/146) were charging higher than usual fees.

With regard to the perception of risk urologists were face while examining patients, given the scenario of the global COVID-19 pandemic, only 12% (26/202) felt that they have been at a higher risk of contracting COVID-19 compared to other specialties when it comes to examining patients, but 65% (132/202) felt that their risk was equal to other specialties.

The last part of the survey focused on strategies upon resumption of regular clinical duties after the lockdown period. When asked about plans regarding elective surgeries upon easing of the COVID-19-related restrictions, 46.5% (94/202) stated that they would wait for international recommendations before resuming elective procedures, while 19% (39/202) would restrict elective surgeries. For preferred prevention strategy with regard to preoperative screening, less than half of the responding urologists (45%, 91/202) were uncertain about what should be done and were awaiting guidelines; 25% (51/202) indicated that they wished to undergo screening for COVID-19 preoperatively; 8% (17/202) would prefer to use additional personal protection equipment (PPE). For surgeries, 21.2% (43/202) indicated that they would perform pre-operative screening for COVID-19 as well as the use of PPE for all surgeries.

When questioning the effect of lockdown period on financial status, 48% (97/202) did not have a noticeable effect as they were receiving stable monthly payments, while 41%(83/2020) had a minor effect. Only 10% (22/202) claimed a major catastrophic effect (no work no payment).

One-way ANOVA test to compare means of urologist responses between governmental and private sectors showed significant difference with a higher proportion of urologists in the private sector seeing patients, undertaking operations, charged fees for telemedicine, and negative financial impact with P = 0.012, P = 0.037, P = 0.004, and P = 0.001, respectively [Table 3].

Table 3

One-way ANOVA test to compare means of urologist responses between governmental and private sectors

	ANOVA
	Sum of squares	df	Mean square	F	Significant
Seeing patient during lockdown	0.984	2	0.492	4.519	0.012
Operations during lockdown	0.985	2	0.493	3.352	0.037
Use telemedicine	1.009	2	0.505	0.469	0.626
Fee for telemedicine	6.079	2	3.040	5.706	0.004
Financial effect	23.326	2	11.663	34.218	0.001

DISCUSSION

Our study showed that despite the lockdown and social distancing protocols applied on a national basis, the majority were still practicing, including those working in the private sector. Interestingly, the private sector had a higher proportion of urologists who were seeing patients during the lockdown period compared to the public sector. This could be explained, in our opinion, that most large public hospitals were largely shifted to the management and care of COVID-19 patients in terms of different resources including personnel and equipment.

Regarding the effect on the financial status, a larger proportion of participants (48%) have not been affected by COVID-related restrictions, while a minority (10.9%) suffered a significant financial impact due to the lockdown. This can be explained by the fact that overwhelming urologists were practicing in public hospitals or large private hospitals, in addition to the significant financial support by the governments to the health-care sector, especially at this difficult time.

Performing surgical procedures in such a pandemic has the potential to put the patients and urologists at risk of cross-infection and therefore actions should be undertaken carefully. As a response to this pandemic, many hospitals around the world have canceled elective procedures and only emergencies as well as high-risk cases were performed. A similar situation was observed in our study where most participants indicated that only emergency procedures were undertaken. A group of urologists from Italy gave similar recommendations. In addition, they strongly recommended continuing to operate on high-risk oncological cases. Puliatti et al. also published similar recommendations for emergency and high-risk oncological cases.[34]

During the lockdown period taking into account the effort exercised to keep social distancing, around half the participant urologists were conducting consultations through phone calls, and the majority (79.7%) of the teleconsults were free of charge. The main goal for a urologist is to deliver optimal urological care to patients and in the current pandemic, protecting patients from getting COVID-19 as well as health-care workers is a paramount consideration. That where telemedicine gained extreme popularity from both doctors and patients. Many authors investigated and tried to categorize patients for whom the telemedicine approach would be sufficient. A study was conducted evaluating the patients’ perspective regarding telemedicine and the majority of patients preferred telemedical consultations during the pandemic, while a minority (2.5%) preferred personal contact. They also divided patients into those eligible and not eligible for telemedicine based on COVID-19 risk assessment where eligibility was higher for oncological patients as they have more risk factors. They concluded that patients with more risk factors and urological malignancies are significantly more often eligible for telemedicine. Larson et al. showed that telemedical intervention in cancer patients is comparable with face-to-face interaction regarding the quality of life. However, no data exist about the oncological outcome in patients who received consultations in telemedicine form.[56]

With the uncertainty that accompanied the lockdown period, most urologists prefer to wait for guidelines that would regulate the return of clinical and surgical duties for elective cases as to the pre-COVID era.

During this pandemic, the European Association of Urology published guidelines aiming to help and support urologists to categorize and select appropriate patients as they recommended to treat only high priority and emergency cases surgically, where many preventive strategies have been recommended including preoperative testing of asymptomatic patients whenever possible within 48 h prior to surgery as those asymptomatic patients who tested positive after they have undergone surgery had a poor outcome.[7]

A minority of the participant urologists felt that they were at a higher risk of acquiring COVID-19 compared to other specialties. However, upon reviewing the literature, one study in China found SARS-CoV-2 RNA in the urine of four COVID-19 patients out of a total of 58 patients studies.[8] in addition, another study reported that blood from COVID-19-positive patients has been transfused in seven patients, and none of the recipients developed symptoms. The latter study concluded that transfusion transmission of SARS-CoV-2 to recipients did not occur.[9] However, disposable equipment has been encouraged to be used to minimize the risk of contamination.

Limitations of your study include the number of included urologists. We expected the response would have been larger if we have had included all practicing urologists not just specialists and higher. However, we decided not to include them since they are not decision-makers and would follow whatever their consultants would decide. Another limitation is to study the status of COVID-infected urologist with these practices but was not done at the time of survey as restrictions applied at that time for the diagnostic test. Selection Bias can be a limitation as cannot be excluded, but we tried our maximum effort to distribute to all accessible centers in GCC.

CONCLUSION

Our survey showed that majority of urologists in the GCC region were seeing patients during COVID-19 lockdown. Emergency services were prioritized. A large proportion of urologists had switched over to telephonic advice or other forms of telemedicine to assist patients. Most of the responding urologists were uncertain about when and how to resume surgical procedures upon easing of the COVID-19-related restrictions. Regulatory bodies should take note of this and issue appropriate guidelines.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.