Discussion

The SARS-CoV-2 pandemic was a real challenge for all health systems in the world. Due to saturation of hospitals by SARS-CoV-2 patients, and to try to minimise the risk of contagion, many surgeries were postponed or even cancelled with unclear consequences on population health. Aiming to determine the real effect of this outstanding situation in the activity of the urological services, we carried out an objective descriptive analysis of the reduction in the number of surgical procedures during the first year of the pandemic in France. We analysed trends in the entire country and region by region over a 10 years period of time to reinforce the validity of the forecast for year 2020. Even if we cannot formally exclude other reasons for a sudden change in urological activity in 2020, there is very little chance that it could be due to other reason than the SARS-CoV-2 pandemic.

Our results are focusing on the French urological activity and cannot be extended to other countries or specialties. Nonetheless, given the exhaustivity of our analysis, our results may help politicians and hospital directors to reconsider the part of surgical deprogramming in the management of similar crisis in the future in order to limit the impact of such decisions on other diseases. Results show an 11.4% drop in surgical procedures throughout the year 2020, non-oncological surgeries being three times more affected by the pandemic than the oncological ones. These are the consequences of the management recommendations published by the different urological societies, in that surgeries and treatments should be categorised based on the level of priority, and only urgent, life-saving procedures and oncological surgeries that are associated with worse outcomes if delayed should be performed.6 7 To prevent further neglection in a sustained pandemic scenario, alternative methods to replace surgical procedures, outpatient interventions and telemedicine were encouraged for non-urgent conditions.10 In addition, the French Urology Association published new guidelines for the management of functional urology in the pandemic context.11 12

Previous studies reported higher rates of reduction in the number of oncological surgeries in hospitals located in Paris, Île-de-France, with a decrease of 31%, between 12 and 27 March 2020, and 49% during the first lockdown (16 March−30 April 2020).5 13 Considered that Île-de-France was among the most affected regions in France by the SARS-CoV-2 epidemic,14 these results may not be representative at a national level. The discrepancy between our data and these previous studies would suggest that, after the initial response to deal with the rapid spreading of the virus, activity in hospitals was restored to almost prepandemic levels after the first lockdown, or transferred to other hospitals (eg, private clinics), which helped to mitigate the initial impact in patients’ care. Indeed, the current study also shows that the urological care in private clinics was two times less affected than that of the public centres. Despite the implementation of a protocol by the French Federation of Private Hospitalisation to support public hospitals during SARS-CoV-2 era,15 only 20% of patients with SARS-CoV-2 were hospitalised in private establishments. Furthermore, to limit the massive deprogramming of operations, private services also took care of patients with other pathologies that, in normal circumstances, would have been cared for in public institutions.16 However, certain delays are still ongoing, particularly for specific surgical procedures.17

Oncological surgeries should not be postponed, as minimal delays in patients’ care are associated with an elevated risk of disease progression and may lead to fatal outcomes. Hence, we would like to highlight the great impact that the pandemic had on kidney (nephrectomy) and bladder (radical cystectomy) cancer treatments. Our results show that they were the most affected oncological surgeries with a reduction in patients’ care of 9% and 6.1%, respectively. Both surgeries have been impacted because they often require intensive postoperative care10 while ICUs were saturated with patients who developed severe SARS-CoV-2.18 This is not the case for other oncological procedures, such as prostatectomy, for which most patients go home a few hours or days after surgery.

Of all urogenital cancers, bladder and kidney cancer have the most diverse variety of treatments, resulting in a substantial complexity to clinical decision making during the pandemic added to the high sensibility of these patients to SARS-CoV-2.19 20 Hence, transurethral resection of bladder tumour is a diagnostic procedure that should not be delayed. Radical cystectomy should not be delayed and, when possible, neoadjuvant chemotherapy should be considered, as it increases overall survival when waiting time for surgery is extended.21 On the contrary for patients with intermediate risk or poor-risk prognosis of metastatic kidney cancer, surgical therapy can often be deferred in favour of effective systemic therapy, which does not require hospital admissions.20 However, in any oncological disease, the diagnosis and timely treatment should not be compromised.19 22

Functional urology should also not be neglected since, as reported in a recent study, for 22% of patients whose surgery had been postponed at the first lockdown, the operation was not rescheduled 6 months later. This leads to an accumulated delay that increases hospitals’ burden and it may also have a toll in patients’ quality of life and health as well as psychological repercussions.23 We also believe that uncertainty may have played an important role in patients’ decision to be treated. Casalino et al.2 showed that patients may have delayed emergency room visits even for conditions that might have required hospitalisation and/or emergency surgery. It has been reported that patients with minor complaints may have opted for self-treatment. Moreover, patients who needed to go to the emergency room may have chosen to avoid attending hospital for fear of being infected with the novel disease.24 This is particularly the case for elderly patients.25

Female urinary incontinence and BPH are the two major conditions managed in urological practice. Both conditions are particularly common in older people and lead to a significant deterioration in patients’ quality of life.26 27 Our results show that they were the most affected procedures with a reduction in patients’ care of 44.7% and 20.8%, respectively. Nevertheless, they are not considered a serious threat to health. This could explain that, in times of SARS-CoV-2, treatments for both disorders were minimised for the sake of other diseases such as cancer, as advised by the available recommendations for urological practice during the pandemic.6 7

It is noteworthy that consequences of the pandemic on female urinary incontinence surgery were double that of BPH (44.7% vs 20.8%, respectively). This discrepancy in surgery cancellation between male and female does not rely to any medical guideline. One possible explanation is that most of female urinary incontinence surgery is performed in day-case surgical units that were first to close and last to open in most of French hospitals during pandemic. On one hand, closing day-case surgical units may quickly provide operating room healthcare workers with minimal impact on major surgeries, but on the other hand, patients being operated in these units do not represent any additional load on hospital and ICU. As closing day-case surgical units may be achieved without delay, we would suggest to maintain these units as long as possible until healthcare workers are effectively needed in other departments or ICU.

Finally, a discrepancy between the distribution of SARS-CoV-2 across the country and its impact in urological services by region was observed. Most hospitalisations due to SARS-CoV-2 happened in Eastern France (the three most impacted regions being Grand-Est, Haut de France and Ile de France with respectively 89 99 and 126 ICU admissions/100 000 inhabitants). However, we saw a completely different pattern regarding the consequences of the pandemic in the treatment of female urinary incontinence, BPH and even in the performance of oncological surgeries such as nephrectomy and radical cystectomy. A survey from the EAU reported that 80.2% of doctors followed the internal, modified protocols established by their own hospitals or department instead of the guidelines issued by international organisations.4 Hence, we hypothesise that differences in the management of the pandemic among hospitals could explain the disparity between SARS-CoV-2 burden in hospitals and its impact on urologic services by region. Given this observation, we would recommend to better stratify the national guidelines for surgical activity reduction on the true local hospital and ICU loads. Elective surgical activity may be cancelled without any delay. As too much anticipation of pandemic hospital burden may lead to unnecessary delays for other conditions, surgical activity may be adapted on a more rational and daily basis. Multidisciplinary boards have to better take into account the negative impact of delaying surgeries on the prognosis of other diseases even for some benign conditions such as female incontinence or BPH that have very few impact on hospital and ICU loads.

Even if the exhaustivity of our database (including 10 years of surgical activity over the entire country) was a real strength, its main limitation was the descriptive analysis and the absence of any data on stage or prognosis of the diseases at the time of surgery. Hence, consequences of delaying medical care could not be assessed with this dataset. Nonetheless, this comprehensive database allowed us to provide real insights into the disruptions in urological care delivery during the first year after the onset of the SARS-CoV-2 outbreak having a full picture of the situation that may help developing a plan that allows the specialty services to recover from the pandemic in a reasonable time.