










































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2021 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Urology Amidst the War on COVID-19
Bishoy Hanna,1,2 Stuart Jackson,1,3 Harry Narroway,3,4 Amanda Chung2,5,6

1 Nepean Urology Research Group, Nepean Hospital, Kingswood, Australia 2 North Shore Urology Research Group, St Leonards, Australia 3 University of Sydney, 
Camperdown, Australia 4 Central Coast Local Health District, Gosford Hospital, Gosford, Australia 5 Department of Urology, Macquarie University Hospital, Macquarie 
University, Australia 6 Department of Urology, University of Sydney, Concord Repatriation General Hospital, Concord, Australia

Abstract

Objectives We sought to review the impact of the COVID-19 pandemic on the practice of urology internationally, 
with particular focus on the Australian response.

Methods A literature search of PubMed was conducted using search terms “urology,” “coronavirus,” “COVID-19,” 
and “surgery.” This generated 165 articles. The abstracts were reviewed for relevance, and 33 articles were selected, 
reviewed in depth, and information synthesised along with relevant government, surgical college, and urological 
society policy documents.

Results Extensive health care changes have been implemented worldwide to curb infection rates. Elective surgery 
cancellations have been widely mandated to curb infection rates with mixed success. Whilst demand on hospital 
resources was reduced by up to 80%, the estimated cost to clear the surgical backlog in the UK has reached £100 
million. Strict perioperative precautions have also been employed with mandatory personal protective equipment 
for all surgical staff and guidelines fast tracked for safe aerosol-generating procedures. Attempts to reduce exposure 
to patients and health care workers resulted in compromised operative time, blood loss, and length of hospital stay, 
with potential increased risk of short- and long-term complications. Systemic changes to education and training have 
also been made. Clinically, the cancellation of training examinations and a freeze on rotations and elective surgery 
restrictions have blunted surgical experience and teaching. The effect has rippled through junior doctor positions, 
with uncertainty remaining for training positions in 2021.

Conclusions The COVID-19 pandemic is the greatest current challenge facing health care worldwide. Amidst 
elective surgery restrictions, novel preoperative testing procedures and intraoperative precautions, providing safe 
and appropriate urological care is a major challenge. This review was derived entirely from expert opinion articles. 
Further research into the virus is needed to bring the world safely through the pandemic, and post-pandemic recovery 
will likely be the next challenge.

Introduction

The first reported cases of coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome 
coronavirus 2 (SARS-CoV-2), originated in Wuhan City, Hubei Province, China in December 2019[1]. The virus spread 
rapidly around the world and was declared a pandemic by the World Health Organisation (WHO) on March 11, 2020. At 
that time there were 118 000 cases in 114 countries with 4291 lives lost[2]. The exponential nature of the infection meant 
that by February 2021, there were 104.4 million reports cases worldwide with 2.3 million deaths[3]. Figure 1 shows the 
growth in COVID-19 deaths to the time of writing.

Key Words Competing Interests Article Information

Urology, COVID-19, coronavirus, pandemic None declared. Received on September 27, 2020 
Accepted on February 8, 2021

Soc Int Urol J. 2021;2(2):120–128

DOI: https://10.48083/OOBF6912

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The impact of t his pandemic is w idespread. 
Internationally, governments face the challenge of 
imposing lockdowns, social distancing measures, 
personal protective equipment laws, and health care 
resource allocation to curb infection rates. Given the 
unprecedented nature of the pandemic, policies are 
often guided by expert opinion in the absence of high-
level evidence base with potentially enormous economic 
consequences. Measures have had varied success 
worldwide.

Health care administration is at the forefront of the 
COVID-19 response. Consequently, the global urological 
community grapples with maintaining patient safety by 
balancing potential delays in diagnosis and treatment 
of urological conditions against risks of COVID-19 
exposure and additional stress on health care resources. 
Table 1 outlines the deferral protocols for urological 
surgeries at the height of pandemic restrictions. So far, 
the response has been relatively successful in Australia 
and New Zealand, with 10 and 4 COVID-19 deaths 
per 1 million people respectively; however, Australians 
are acutely aware that the COVID-19 pandemic is far 
from over as one of the Australian states, Victoria, is 
coming out of a “second wave” of the infection. At the 
time of writing of this article, by way of comparison, 
the statistics abroad are 475 deaths per million in the 
United States of America, and 230 deaths per million in 
Europe[3]. As the COVID-19 pandemic is still active, the 
impact of policy measures on urological disease will not 
be apparent until the post-pandemic recovery period. 
This article describes the changes in urological practice 
in Australia during the COVID-19 pandemic in the 
context of the international response.

Methods 
A literature search of PubMed was conducted using 
search terms “urology,” “coronavirus,” “COVID-19,” 

and “surgery.” This generated 165 articles. The abstracts 
were reviewed for relevance to the topic of this article, 
and 33 articles were selected, reviewed in depth, 
and information synthesised along with relevant 
government, surgical college, and urological society 
policy documents for the writing of this article.

Results and Discussion
Elective Surgery Cancellations 
On March 26, 2020, all elective surgery in Australia, with 
the exception of category A (within 30 days) and urgent 
category B (within 90 days), was suspended in an attempt 
to prepare for a COVID-19 related surge in demand for 
health care resources[4]. This was swiftly followed by 
the Urological Society of Australia and New Zealand 
(USANZ) guidelines for urological prioritisation[5]. The 
Board encouraged shared decision-making with patients 
and consideration for individual hospital/health district/
country/state and territory health care resources. 
Surgical guidelines are summarised in Table 1. These 
guidelines were intended to provide urologists and their 
patients with a framework of priority. They empowered 
the decision to operate where appropriate given the risk 
of multiple contacts, whilst reassuring patients of the 
urological safety to defer. A recent systematic review 
compared 15 guidelines and recommendations for 
urology care during the pandemic[6]. The European 
Association of Urology (EAU) was the only other 
international urological group to publish urological 
guidelines on practice during the pandemic, with 
all other guidelines being single expert opinion[7]. 
A comparison of the USANZ and EAU guidelines is 
summarised in Table 1.

The guidelines reflect not only the existing differences 
between Australian and European urological practices 
but also the varied impact of the pandemic in these 
regions. For example, the Australian guidelines did not 

FIGURE 1. 

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TABLE 1. 
Summary of the USANZ and EAU guidelines for urological prioritisation during the COVID-19 pandemic

Condition 
Operation

Consider proceeding with surgery Consider deferral of surgery

Testicular Cancer

USANZ
• Inguinal orchidectomy as planned
• RPLND for progressive mass post chemotherapy

EAU
• Inguinal orchidectomy in 1-2 days
• RPLND for progressive mass post chemotherapy 

within <6 weeks
• Stage ≥ IIB seminoma or NSGCT treat within  

<24 hours

USANZ
• Slowly growing mature teratoma

EAU
• Stage 1 seminoma for AS

Renal Cancer 
Transplant

USANZ
• RCC >7cm as planned
• RCC complicated by venous thrombus  

as planned
• Upper tract UCC as planned

EAU
• T3 within <6 weeks
• High grade UCC within <6 weeks

USANZ
• Immunotherapy/chemotherapy with delayed 

cytoreductive nephrectomy in metastatic RCC 
setting

EAU
• Renal mass <4cm defer by 6 months
• T1b-T2 RCC within 3 months
• Low risk UCC up to 3 months
• Cadaveric renal transplant up to 3–4 months (case 

by case discussion)
• Living donor up to 6 months 

Prostate Cancer

USANZ
• High risk (select Gleason 8–10) as planned

EAU
• High risk post radiation within 3 months with 

immediate neoadjuvant ADT

USANZ
• Intermediate and some high-risk cancers with initial 

ADT and deferred definitive treatment
• Low risk with active surveillance

EAU
• Low risk postpone for 6–12 month and AS defer  

for 6 months
• Intermediate risk to after pandemic
• High risk treat within 3 months or postpone until 

after pandemic (anxious patient or N1 disease, 
consider ADT and EBRT as alternative)

Bladder Cancer

USANZ
• Surveillance CE +/- TURBT for high-risk NMIBC only 

(CIS and G3T1)

EAU
• Grade >cT1 treat within 6 weeks
• MIBC treat within 3 months (consider omitting 

neoadjuvant chemo in T2/T3 disease)
• Metastatic within 6 weeks (adjuvant  

chemotherapy if N+)

USANZ
• Neoadjuvant chemotherapy and delayed cystectomy 

for MIBC (after discussion with medical oncology)

EAU
• Low grade surveillance defer by 6 months
• High grade surveillance by 3 months
• Refractory CIS by up to 3 months
• MIBC if palliative consider only radiation and 

chemotherapy 

ADT: androgen deprivation therapy; AS: active surveillance; CE: cystoscopy; CIS: carcinoma in situ; IDC: indwelling catheter; ISC: intermittent  
self-catheterisation; MIBC: muscle invasive bladder cancer; MRI: magnetic resonance imaging; NMIBC: non-muscle invasive bladder cancer;  
NSGCT: non-seminomatous germ cell tumour; PIRADS: Prostate Imaging-Reporting and Data System; RCC: renal cell carcinoma;  
RPLND: retroperitoneal lymph node dissection; TURBT: transurethral resection of bladder tumour.

continued on page 123

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TABLE 1. 
Summary of the USANZ and EAU guidelines for urological prioritisation during the COVID-19 pandemic

Condition 
Operation

Consider proceeding with surgery Consider deferral of surgery

Macroscopic Haematuria

USANZ
• Diagnostic CE if abnormal radiology or cytology

EAU
• Clot retention then within 24 hours

USANZ
• Diagnostic CE if normal investigations  

(delay for 1–2 months)

EAU
• Diagnostic CE up to 6 weeks if not in retention

Prostate Biopsies

USANZ
• PIRADS 4/5 on MRI

EAU
• MRI showing locally advanced or highly 

symptomatic 

USANZ
• PIRADS <4 on MRI
• Protocol based AS evaluation

EAU
• Until after pandemic without MRI or not suspicious  

for locally advanced/highly symptomatic 

TURP
USANZ
• Chronic or acute urinary retention not  

suitable for IDC or ISC

USANZ
• IDC or ISC where possible

EAU
• IDC or ISC and postpone for 6 months 

Endourology

USANZ
• Symptomatic stones as planned
• Obstructed or infected kidney as planned
• Stent in situ as planned

EAU
• Obstructed or infective kidney as planned

USANZ
• Non-obstructing ureteric or renal stones

EAU
• Non-obstructing renal stones for >6 months
• Non-obstructing ureteric stones for 3–4 months 

(manage renal colic with pain relief, avoiding 
NSAIDs where possible)

• Stent in situ for >6 months (after pandemic)

Scrotal

USANZ
• Torsion as planned

EAU
• Torsion as planned

Trauma

USANZ
• Penile as planned
• Urethral as planned

EAU
• Penile as planned

ADT: androgen deprivation therapy; AS: active surveillance; CE: cystoscopy; CIS: carcinoma in situ; IDC: indwelling catheter; ISC: intermittent  
self-catheterisation; MIBC: muscle invasive bladder cancer; MRI: magnetic resonance imaging; NMIBC: non-muscle invasive bladder cancer;  
NSGCT: non-seminomatous germ cell tumour; PIRADS: Prostate Imaging-Reporting and Data System; RCC: renal cell carcinoma;  
RPLND: retroperitoneal lymph node dissection; TURBT: transurethral resection of bladder tumour.

, Cont’d

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recommend deferring endourological procedures for 
patients with ureteric stents in situ as the EAU guidelines 
suggested. As Europe is the second most affected 
continent, with 230 COVID-19 deaths per million people 
compared with Australia’s 10 per million, the differences 
in guidelines reflect the differing degree of health care 
resource demand. From Tuesday, 28 April 2020, elective 
surgery restrictions were eased in Australia. However, 
with a substantial second wave of COVID-19 cases 
in Victoria towards the end of June, elective surgery 
restrictions were reintroduced on Thursday, 16 July 
2020. With large fluctuations in case numbers, further 
reviews into scope of elective operating are likely before 
the recovery from the pandemic can begin.

Additionally, the future challenge of post-COVID 
waitlist reduction and health impacts from ongoing 
untreated disease is not fully realised. One study 
modelled the proportion of elective surgery that would 
be cancelled or postponed during the 12 weeks of peak 
disruption[8]. They found that a global total of 2.95 
million urological surgeries will be postponed during 
this period. In the United Kingdom for example, based 
on an average cost of £4000 per operation, it would 
cost over £2 billion to clear the backlog. Additional 
considerations such as costs of complicated disease 
progression, deaths due to untreated disease, and a 
differently structured health care system are other 
post-COVID surgical challenges yet to be completely 
quantified.

Operative COVID Precautions
Once the decision is made that it is safe and appropriate 
to operate, operative measures are implemented to 
further optimise safety and mitigate infection risk.

Preoperative Workup
The Royal Australasian College of Surgeons (RACS) 
has published a rapid rev iew of literature and 
recom mend at ions for preoperat ive COV I D -19 
assessment[9]. If high-risk features (viral symptoms and 
high-risk contacts) are identified on history, patients are 
recommended to have reverse transcription-polymerase 
chain reaction (RT-PCR) test to diagnose SARS-CoV-2, 
and in patients over the age of 70 years, a CT scan of the 
chest is also recommended. The RT-PCR test is 80% to 
100% sensitive compared with the 60% to 70% sensitivity 
of nasopharyngeal and oropharyngeal testing[10]. RACS 
recommends that surgery required within 24 hours in 
high-risk patients should proceed, with surgical staff 
wearing full personal protective equipment and taking 
appropriate intraoperative precautions, especially 
for potential aerosol-generating procedures (AGPs). 
The patient is then to be isolated postoperatively and 
tested for SARS-CoV-2 infection when possible. RACS 
does not endorse testing asymptomatic patients with 
no high-risk features before surgery. This is mirrored 

by the American Centers for Disease Control[11]. 
However, given that 5% to 80% of COVID-19 patients 
are asymptomatic carriers, one systematic review 
article recommends testing all preoperative patients if 
the testing capacity is available[12]. Recommendations 
for preoperative testing will be dictated by local health 
care providers and testing resources, turnaround time, 
and acuity of procedure must be balanced with the 
theoretical risk of an asymptomatic carrier exposing 
theatre staff to the virus.

Safe Minimally Invasive Surgery
Several studies analysing viral shedding have not 
detected SARS-CoV-2 in urine[13–15]. However, one 
Chinese study detected SARS-CoV-2 RNA in the urine 
of 4 COVID-19 patients requiring hospitalisation out 
of a total of 58 patients in the cohort[16]. Viral particles 
have also been demonstrated in COVID-19 patient blood 
samples[17]. Consequently, non-urgent cystoscopies 
should be deferred and extra caution taken to minimise 
trauma during procedures. One American review on 
operative adjustments during the pandemic suggests 
the use of disposable ureteroscopes to further reduce 
the risk of contamination[12]. Given the highest risk 
of aerosolization is during intubation and extubation, 
the Anaesthesia Patient Safety Foundation has further 
recommended that when possible, ureteric stents should 
be inserted under sedation[18]. During the pandemic, 
and particularly within areas of high case numbers and 
stretched health care resources, added consideration of 
nephrostomy tubes in the acute setting is also advised. 
However, this remains contentious. The American 
Society of Anaesthesiologists states that laryngeal mask 
airway may actually increase the risk of aerosolization of 
SARS-CoV-2 in the setting of high airway pressures and 
leakage around the mask[19]. Furthermore, although 
monitored anaesthesia care avoids intubation and 
extubation, it could potentially require the anaesthesia 
provider to be closer to the patient’s airway and be a 
potentially greater risk if there is any issue requiring 
manual bagging or unplanned intubation. The society 
acknowledges that, because there is a lack of validated 
studies, this is expert opinion rather than practice 
guidelines.

AGPs can generate bioaerosols that contain viral 
materials, which should be considered a potential source 
of disease transmission[20]. RACS recommends using 
lower energy ablation devices, where possible, to produce 
fewer or no surgical plumes thus mitigating risk. All 
bioaerosols should be trapped and treated as biohazards. 
For laparoscopic procedures, the pneumoperitoneum 
should be maintained at a lower pressure to reduce the 
risk of gas leak. On desufflation, gas should be vented 
via an appropriate filter and capture device. Despite 
a lack of firm evidence to prove SARS-CoV-2 particle 

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transmission through aerosolization, international 
guidelines also suggest similar precautionary measures. 
A review of the international guidelines into AGPs 
during the pandemic suggested steps to reduce the risk 
of aerosolization during release of pneumoperitoneum 
and diathermy until more information is available[12]. 
Most guidelines suggest frequent suctioning of smoke in 
the pneumoperitoneum, avoidance of air leaks around 
ports and during instrument transfers, and care in 
removing ports, especially when pneumoperitoneum is 
still established. Other techniques to consider include 
using balloon ports or trocars that can be secured to 
avoid pneumoperitoneum leaking at the port sites.

Ultimately, the choice of procedure should not 
compromise the patient outcomes. Therefore, laparos-
copy and robotics must be used when indicated. The 
surgeon should carefully weigh the pros and cons of 
each approach. In addition to reducing the exposure 
of the patient and health care workers, operating time, 
blood loss, length of hospital stay, and risk of short- and 
long-term complications should be considered.

Use of Telehealth
Telemedicine allows the provision of health care 
remotely using electronic communication tools[21]. 
Telehealth is aimed at helping protect health care 
professionals, their staff, and patients from unnecessary 
risk of infection by minimising contacts. Large 
international prospective studies comparing telehealth 
with traditional face-to-face consultations have shown 
clinical equivalency, safety, and acceptable patient 
satisfaction in both prostate cancer and endourology 
settings[22,23]. Although these benefits have been well 
established, barriers include the reluctance of patients—
particularly the elderly—to use the technology, cost-
effectiveness, and security of communication links 
regarding personal (including health) data[24]. As a 
result, Australia has been slow to embrace telehealth 
with uptake mainly restricted to remote communities 
for certain medical specialties such as nephrology. 
Telehealth has been largely underused by urologists in 
Australia. However, to facilitate continued safe health 
care, the Australian government has fast tracked the 
use of telehealth by providing clinicians with subsidised 
telehealth equipment from 13 March[24]. Similar 
provisions have been made in the United Kingdom[25]. 
This allows clinicians to claim for consultations made 
via telehealth, which was previously not a widely 
available option. Ethical considerations need to be made 
for delivering cancer diagnoses remotely, and judicious 
individualised patient care is paramount. The absence 
of cancer specialist nurses and increased isolation may 
worsen the impact of a cancer diagnosis delivered via 
telehealth. However, as the medical industry adapts 
to the pandemic, telehealth may persist and become 

routine practice because it is convenient, it allows 
increased access to regional patients, and it has proven 
efficacy. With increasing use, streamlined platforms will 
no doubt become available. Furthermore, particularly 
within Australia, virtual departmental meetings, 
multidisciplinary team meetings, and morbidity and 
mortality meetings offer similar benefits and are 
becoming increasingly popular.

Education and Training 
The COVID-19 pandemic has had a significant impact 
on national and international urological education 
and training. The USANZ annual scientific meeting 
and all individual state meetings have been cancelled 
in Australia along with the American Urological 
Association annual meeting. Other international 
meetings such as the European Association of Urology 
Congress and the Société Internationale d’Urologie 
Congress have moved to virtual platforms. With 
research resources shifted to COVID-19, specifically 
vaccination development, the slowing of urological 
development is inevitable. Clinically, the cancellation of 
training examinations, freeze on rotations, and elective 
surgery restrictions have blunted surgical experience 
and teaching. The effect has rippled through all training 
doctor positions from clinical medical student to 
advanced trainee, and uncertainty remains with respect 
to training positions for future years. Similar disruptions 
have been observed in the UK and Singapore, with all 
undergraduate clinical rounds being cancelled and all 
teaching activities (for residents and undergraduates) 
switched to the online platforms[26]. This will not only 
impact trainee clinical development but also increase 
junior doctor stress and burnout. With social distancing 
laws and community lockdowns increasing individual 
isolation, the added employment uncertainty raises 
significant concern for the mental health of junior 
doctors.

Australian Rural Experience
Australia is an expansive country, with 29% of the 
population living in rural or remote regions[27]. 
These areas are often hundreds of kilometres from 
metropolitan centres and are therefore reliant on 
under-resourced health care services. After the country 
weathered the largest bushfire disaster regional Australia 
has ever experienced, COVID-19 posed an additional 
challenge to communities that were just starting to 
recover.

Regional and remote urological care in Australia 
is largely self-sufficient with transfer to larger centres 
generally reserved for critical deterioration or where 
multiple subspecialty services are required. Many of 
these communities rely on f ly-in/f ly-out urologists, 
who also provide emergency surgical support whilst 

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on site. As a result of elective surgical cancellations, 
urologists were f lying in more sparingly. Emergency 
urological procedures were therefore being attended 
to by resident general surgeons or required atypical 
metropolitan transfer. This has led to increased time to 
definitive treatment such as scrotal exploration in the 
event of suspected torsion, and to greater reliance on 
interventional radiology for acute renal decompression 
in the event of obstructive uropathy.

Furthermore, all Australians have exhibited more 
restrained health care practices. For example, data 
from the Cancer Council have shown that there were  
14 4 982 fewer mammograms and 4 4 3  935 fewer 
cervical screening tests between January and June 2020, 
and 144 379 fewer bowel screening tests returned from 
January to July, compared with previous years[28]. 
Similarly, patients are presenting later with haematuria, 
and t hose on active sur veillance for urologica l 
cancers are more likely to delay routine surveillance 
appointments to avoid contacts. This challenge is 
exaggerated in regional and remote communities, 
particularly amongst Indigenous Australians, where 
follow-up procedures and compliance are already fragile.

However, as a result of geographical isolation, these 
areas were largely unaffected by COVID-19, with 
infection rates very low and early travel restrictions 
preventing spread of the virus from metropolitan areas. 

Most rural urological services have since returned to 
routine practice, with the pandemic highlighting the 
longstanding health care inequalities in these regions 
and challenging policy makers to provide solutions.

Conclusions 
The COVID-19 pandemic is the greatest current 
cha llenge facing hea lth care worldwide. Amidst 
elective surgery restrictions, novel preoperative testing 
procedures, and intraoperative precautions, providing 
safe and appropriate urological care is a major challenge. 
Australia is fortunate to have successfully contained 
the pandemic and therefore to have had minimal 
disruptions. This can be attributed to fostering strong 
clinician-patient partnerships with the use of telehealth 
and swiftly implementing policies and procedures to 
minimise the risk of surgery on pandemic progression 
to provide optimal urological care. Invariably, urological 
academic and clinical development is challenging 
during the pandemic and insight into mental health 
challenges for frontline workers needs to be considered 
and managed. This review was entirely derived from 
expert opinion articles, and further research into the 
virus including promising vaccination programs will be 
key to bringing the world safely through the pandemic 
with post-pandemic recovery likely being the next 
challenge.

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128 SIUJ  •  Volume 2, Number 2  •  March 2021 SIUJ.ORG

REVIEW

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