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Abbreviations:
SARS-CoV-2: severe acute respiratory syndrome coronavirus-2
COVID-19: Coronavirus-19
ER: Emergency room
IQR: Interquartile range
UTI: Urinary tract infection.
Introduction
The SARS-CoV-2 pandemic is one of the most shocking events in recent history. Until December 31, 2020, more than 82 million infections and 1,8 million deaths were reported worldwide.1 In Colombia alone, 1,642,775 cases and 43,213 deaths were registered during 2020.2 The vast majority of regions affected by the pandemic have described a saturation in the capacity of in-hospital care and a generalized increase in the demand for intensive care unit beds.3,4 Thus, increasing the need for mitigation measures such as mandatory social distancing, restriction of free mobility and gatherings, and public places closure.5,6
In this context, healthcare has prioritized its resources for seriously ill respiratory patients.7 In contrast, other healthcare areas, such as urology, have seen a decrease in their usual in-hospital activity. Multiple international guidelines have proposed care pathways and prioritization schemes for patients with urological pathologies during the COVID-19 pandemic.8 Since the declaration of a state of a health emergency, diagnostic outpatient services, outpatient consultation, and elective urological surgery have been canceled or transferred to telemedicine care. However, up to this date, the impact that the pandemic has generated on urological emergency care is unknown.
This study aims to estimate the first- wave COVID-19 pandemics effect on emergency urological care in four tertiary hospitals throughout Colombia.
Material and methods
Design type: A cross-sectional retrospective descriptive multicenter study.
Population and sample: Institutional databases of hospital admissions for urological emergencies in four tertiary centers located in primary regions of Colombia [Bogotá (Cundinamarca), Itagüí (Antioquia), Cali (Valle del Cauca)] during the periods April - May 2019 (period 1) and April - May 2020 (period 2) [initial public health emergency declaration due to the COVID-19 pandemic].
Variables: We analyzed the number of hospital admissions due to urological pathologies, reasons for consultation, surgical index, and average time of hospitalization during the study periods.
Statistical analysis: We calculated the t-student test and two proportions z-test to assess differences in the variables evaluated during the study periods. We described the results in frequencies and central tendency measures. We performed the analysis in Stata 13.0.
Ethics: A risk-free study; according to Colombian regulations (Resolution 8430 of 1993) informed consent was not required. The principles established in the Declaration of Helsinki were respected.
Results
We included 1,570 patients (542 from Bogotá, 778 from Itagüí, and 250 from Cali). In the first period, 883 patients visited the ER with a urological concern, and 687 in the second period. The study group's average age was 49.30 years, with a median of 48 years (IQR: 33-64). Approximately 70% of participants (n: 1094) were men, while 30.32% (n: 476) were women; for period 1, the distribution was 71.35% men and 28.65% women, while for period 2, the distribution was 67.54% men and 32.46% women.
In general, there was a 22.20% decrease in the number of patients who visited the ER for urological disease during the initial phase of the pandemic compared to the same period of the previous year. In Bogotá, the reduction was 26.84%, while in Itagüí and Cali, the decline was 7.43% and 49.40%. Urolithiasis and infectious conditions were the most common urological reasons for consulting to the ER; there was a significant decrease in ER visits caused by acute urinary retention (p: 0.001) (Table 1).
Tabla 1 Reasons for emergent urological consultation in four Colombian hospitals
| Reasons for consultation | Period 1 % (n) | Period 2 % (n) | p-value |
|---|---|---|---|
| Renal colic / Urolithiasis | 41.34 (365) | 50.65 (348) | 0.007 |
| Urologic infections (epididymo-orchitis, Fournier´s Gangrene, scotal abscess, UTI) | 21.63 (191) | 19.36 (133) | 0.6 |
| Others (priapism, penile fracture, phimosis) | 11.44 (101) | 8 (55) | 0.54 |
| Hematuria | 11.09 (98) | 10.04 (69) | 0.8 |
| Acute urinary retention | 10.19 (90) | 6.55 (45) | 0.001 |
| Urological trauma | 3.06 (27) | 3.64 (25) | 0.8 |
| Acute scrotum/ Testicular torsion | 1.24 (11) | 1.75 (12) | 0.75 |
Period 1: April - May 2019, Period 2: April - May 2020 (initial public health emergency declaration due to the COVID 19 pandemic). UTI: Urinary tract infection.
The surgical index (proportion of individuals who required surgical management) for patients who visited the ER for urological diseases had a general increase of 10.74%, ranging from 26.38% (n: 233) in period 1 to 37.12% (n: 255) in period 2 (p: 0.0001). In Bogotá and Itagüí there was an increase of 14.86% (p: 0.04) and 13.43% (p: 0.0001) respectively, while in Cali decreased by 1.08% (p: 0.86).
The medical index (proportion of patients hospitalized for urological pathology for non-surgical management) had a general decrease of 10.73% [period 1: 73.61% (n: 650) versus period 2: 62.88% (n: 432)] (p: 0.001). In Bogotá and Itagüí there was a decrease of 14.85% (p: 0.0029) and 13.44% (p: 0.001) respectively, while in Cali there was an increase of 1.07% (p: 0.8).
There was a decrease of 0.74 days in hospital stay for patients who required urological emergency care in the initial period of the COVID-19 pandemic in Colombia, compared to the previous year. Accordingly, in period 1, the average time of hospitalization was 3.33 days/patient, while in period 2, it was 2.59 days/patient. In Bogotá and Itagüí, there was a decrease of 1.16 days and 0.66 days in average hospital stay, respectively, while in Cali, there was an increase of 0.52 days (Table 2).
Table 2 Average hospital stays for patients admitted for emergent urological diseases
| City | Period 1. | Period 2. | Change | p-value |
|---|---|---|---|---|
| Bogotá | 3.88 days | 2.72 days | -1.16 days | 0.007 |
| Itagüí | 2.86 days | 2.20 days | - 0.66 days | 0.009 |
| Cali | 3.44 days | 3.96 days | + 0.52 days | 0.12 |
| Total | 3.33 days | 2.59 days | - 0.74 days | 0.39 |
Period 1: April - May 2019, Period 2: April - May 2020 (initial public health emergency declaration due to the COVID 19 pandemic).
Discussion
The SARS-CoV-2 pandemic has not only had an impact on the care of symptomatic respiratory patients. The prioritization of hospital care for seriously ill respiratory patients, high hospital occupancy, and cross-contamination risk forced a transformation in the care for “non-respiratory” patients.9
Pinar et al.,10 described an overall decrease in urological surgical activities (55%), urological emergencies (44%), and urooncological surgeries (31%) in France. They also described a reduction in scheduled outpatient urological surgery of 84%, and kidney transplantation of 92% during the SARS-CoV-2 pandemic. Up to two-thirds of major urological surgery could be safely postponed in Italy until the crisis generated by the SARS-CoV-2 pandemic had resolved.11There was an overall decrease of 55% in urological emergency consultation.12 In Germany, 77.9% of urologists stated that they had more significant restrictions in their surgical practice, and 9.4% had a total cessation of their surgical activity due to the SARS-CoV-2 pandemic.13 In Portugal, Madanelo et al.,14 described an overall decrease of 46.4% in urological ER consultation between March and april/2019 compared to March-april/2020.
A survey conducted among 846 Latin American urologists showed that 60.9% currently perform only emergency surgical procedures. In contrast, 49.4% state that their outpatient clinic service is closed, and 48.2% carry out their consultations with telemedicine.15 Worldwide, a delay more significant than eight weeks secondary to the SARS-CoV-2 pandemic has been described for 28% of urological consultations, 30% of urological outpatient diagnostic studies, and 31% of elective surgeries.16 In Colombia, a 56.45% decrease in kidney transplants performed during the initial phase of the public health emergency declaration due to the SARS-CoV-2 pandemic has been reported.17
The results obtained here are similar to other international experiences. They show that the SARS-CoV-2 pandemic and the public health strategies implemented to mitigate the pandemic's effect translate into a decrease in the volume of patients who visit the emergency room for urological diseases. Besides, a reduction in hospital stay length and an increase in the urological surgical index might be explained by a delayed consultation. All these events are undoubtedly related to the rationing of the physical and human resources required in critical moments of the pandemic. It is essential to highlight the increase in consultation for urolithiasis seen during the initial phase of the pandemic (a fact that might explain the rise in surgical procedures), and the significant decrease in the consultation for acute urinary retention. This rise could also connect, in some way, to the measures established by local governments during the initial phase of the pandemic (limited mobility due to quarantining at home, restriction on the sale of alcoholic beverages, the prohibition of social events and meetings, etc.).
Our study's dynamics are similar to those described by Motterle et al.,18 in Italy. Urological emergency care's common denominator was decreased consultations and an increased proportion of surgical procedures performed (28.6% in 2019 versus 33.6% in 2020 during the COVID-19 pandemic).
Despite the limitations derived from the type of study, sample size, the temporal effect of the pandemic, and its variability in the different regions of the country, this study can characterize some initial exploratory results and constitutes the first experience described in Latin America on the effect of the pandemic on emergency urological care. Noting that a pandemic´s peak had not been reached at the time of data analysis and consolidation (Figure 1), and that additional peaks are expected in our country, the impact on the Colombian urological services is expected to be exponentially greater.
The behavior of new cases due to COVID 19 in Colombia. Taken and translated from https://www.ins.gov.co/Noticias/Paginas/coronavirus-casos.aspx. 2
Figura 1 Daily reported cases
Conclusions
The SARS-CoV-2 pandemic has had a significant impact on emergency and elective urological care around the world. During the initial phase of this emergency, there was a decrease of 22% in hospital admissions due to urological emergencies in Colombia. The surgical index for critical urological diseases increased by 10.74%, and the average hospital stays decreased 0.74 days. There was a significant increase in the emergency consultation for urolithiasis and decreased consultation for acute urinary retention. According to the pandemic's dynamics, we expect an increase in the impact on elective and emergent urological care in our country.
