Reply to Guglielmo Mantica, Nazareno Suardi, and Carlo Terrone’s Letter to the Editor 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

The insightful letter from Mantica et al in response to our article [1] reports a trend for a decrease in emergency department (ED) urological consultations in Italy during the COVID-19 lockdown and highlights two major issues for urologists. First, postponement of urological consultations carries a risk of potential rebound attendances in worsened condition and larger numbers. Our hospital implemented measures in anticipation of this, reviewing and triaging [2], [3] all scheduled appointments and adopting telemedicine strategies including phone consultations and prescriptions (with courier delivery), a huge endeavour given the sheer volume of ambulatory patients. Second, the pandemic-related decrease in ED consultations is a reminder of the delicate balance in managing urological conditions in the community and tertiary settings.

Singapore and it's Ministry of Health implemented nation-wide “circuit breaker” restrictions [4] on April 7, 2 mo after raising the national Disease Outbreak Response System Condition (DORSCON) level from yellow to orange [5], and 1 mo after lockdown in Italy. We reviewed urology admissions via the ED, excluding non-admitted patients (as our ED has consistent admission criteria), divided into three groups according to important national timelines: group A (heightened surveillance period) from January 3 to February 6 (35 d), group B (1 st month of DORSCON orange level) from February 7 to March 6 (29 d), and group C (2nd month of DORSCON orange level) from March 7 to April 6 (31 d). At the time of writing, data after the “circuit breaker” restrictions are unavailable.

Group A included 109 patients (3.11 patients/d), group B 83 (2.86 patients/d), and group C 66 (2.22 patients/day). Urolithiasis cases accounted for 24 patients in group A (22.02%), with a decrease to 12 in group B (14.46%) and 12 (18.18%) in group C. Genitourinary infections remained the most common diagnosis, increasing in percentage despite increasing COVID-19 concerns: 39 in group A (35.78%), 46 in group B (55.42%), and 35 in group C (53.03%).

The second issue, brought to the surface by this pandemic, of possible chronic abuse of hospital resources by low-complexity cases is a sensitive one. A review of our data set revealed that the decrease in urolithiasis consultations reported by Mantica et al is similar to our reduction in urolithiasis admissions. We postulate that during the COVID-19 pandemic, Singapore patients were preferentially seeking conservative care in the community or deferring consultations. This is in contrast to the higher percentage of haematuria cases noted by Mantica et al, similar to the higher percentage of genitourinary infections we observed, as these conditions can seldom be deferred. Importantly, we must further analyse if this percentage rise in infections and haematuria is a consequence of delayed health-seeking behaviour or of failed treatment in the community. Our data set is unable to definitively determine if ED abuse was the case, but with rigorous admission criteria we can prevent unnecessary admissions and preserve inpatient resources.

COVID-19 will have a long-lasting impact on health care and urological practice will be no exception. These observations remind urologists of the importance of our nations’ health care policies to establish an integrated system of primary, emergency, and tertiary care so that patients can access essential care in the community, even during crises. If urologists act quickly in anticipating post-COVID-19 issues and in using this pandemic to review reforms for our health care systems, we can emerge stronger than before.



 Conflicts of interest: The authors have nothing to disclose.