Elective Urological Procedures in Times of Reduced Operating Room Capacity

Since the COVID-19 pandemic, a lack of skilled medical professionals, especially nursing staff, has continued to result in cancelled operations (OP), closures of operating theaters, and increasingly longer waiting periods for elective urological procedures. Since a delay in treatment is associated with a poorer prognosis for many urological tumor entities (1, 2, 3), the lack of resources is forcing departments to prioritize uro-oncological procedures.

The multitude of postponed or cancelled procedures for benign non-oncological indications (for example, benign prostatic enlargement) has not received much attention to date.

Methods

We analyzed volumes of procedures as well as the reasons for cancelled operations in the urological departments in Styria, Austria (University Hospital Graz, LKH Hochsteiermark—State Hospital, Upper Styria) for the years 2018–2022. The utilization of urological operating tables was determined by using the OCTOPUS OP reporting platform. Data from the Styrian hospital society were extracted by medical specialty and individual medical services and evaluated by using Analysis for Excel.

We determined elective operations on the urogenital tract in patients aged 18 years or older with a benign or oncological urological main diagnosis.

As examples the individual medical services were evaluated for:

• Radical prostatectomy
• Radical cystectomy
• (Partial) nephrectomy
• Transurethreal resection of the prostate (TUR-P)
• Hydrocelectomy.

Institutionally, the waves of the pandemic were defined as follows:

• 1^st wave: March to May 2020
• 2^nd wave: October 2020 to February 2021
• 3^rd wave: November 2021 to January 2022.

These time periods and the pandemic years were compared with the mean [median?] of the preceding years 2018/2019.

Results

In 2022, a total of 18 days of urological OP capacity were reduced at Graz University Hospital as a result of COVID-19 (versus 79 days in 2020). Furthermore, owing to staff shortages, In 2022, a total of 18 days of urological OP capacity were reduced at Graz University Hospital as a result of COVID-19 (versus 79 days in 2020). Furthermore, owing to staff shortages, unplanned reductions in capacity occurred on 21 OP days in 2022 (versus 7 days in 2021). At LKH Upper Styria State Hospital, a total of 24 fewer OP days were recorded in 2021 and 79 fewer OP days in 2022 than in 2018/2019.

In sum, the volume of elective procedures for benign versus oncological main diagnoses was reduced by −20% versus −7%, 11% versus −6%, and −21% versus −2% in the years 2020, 2021, and 2022 (Figure). During the first, second, and third waves of the pandemic, reductions in operations of the urogenital tract with a benign versus oncological main diagnosis of −71% versus −17% (2020), −62% versus −17% (2021), and −38% versus −11% (2022) were recorded. Volumes of undertaken radical prostatectomies (2020: +7%, 2021: +17%, 2022: +55%), nephrectomies (2020: −8%, 2021: +5%, 2022: +23%), and radical cystectomies (2020: +40%, 2021: +4%, 2022: +28%) remained constant or even increased. For TUR-P a fall of −14% was recorded in 2020, −10% in 2021, and an increase of +5% in 2022. Hydrocelectomies fell by −32% (2020), −27% (2021), and −57% (2022).

Figure

Number of elective procedures for non-oncological main diagnoses (red) versus oncological main diagnoses (green) in 2018–2022

Discussion

In 2020 and 2021 the COVID-19 pandemic led to constraints in the healthcare system, whereas the predominant cause in 2022 was the lack of skilled medical staff. Strict prioritization prevented a drop in volumes of oncological surgeries, but simultaneously the numbers of procedures for non-oncological indications (such as hydrocelectomies) fell.

Many benign urological conditions and their symptoms are associated with functional impairments. For example, delayed treatment for benign prostatic enlargement can cause recurrent urinary retention, urinary tract infections, and long-term injury to the lower as well as upper urinary tract (4). Furthermore, even benign urological disorders are associated with substantial psychological stress and burden for the patients—for example, as is the case for patients with therapy refractory (conservative or medical) urinary incontinence. The consequences of delayed surgical treatment of, for example, patients with benign prostate enlargement, hydrocele, or urinary incontinence can be enormous in this setting (5).

In the coming years we will witness the effects not only of delayed cancer diagnoses and treatment but also the complications and losses to quality of life as a result of procedures for benign indications that were not carried out. Unfortunately no studies are available to date that have investigated the consequences of delayed surgical therapy in functional impairments/disorders.

Our data are restricted to urological care in the region of Styria and are therefore not generalizable. Since the COVID-19 pandemic and the lack of skilled medical staff are not a regional phenomenon, however, we expect similar results in other (German speaking) regions. Similar studies using data from other healthcare regions or, ideally, data from national registries would be required to be able to compare results and subsequently develop strategies for sustaining patient care to an ideal extent.

Conclusions

We used the example of the healthcare region Styria to show how the situation for elective urological procedures has continued to deteriorate even after the COVID-19 pandemic, as a result of the current staff shortages. Especially surgical care for patients with non-oncological indications is subject to continuing losses.

To manage the current situation, one objective is to enforce strategies that sustain good patient care—for example, outsourcing procedures, bundling capacities, restructuring tasks. A further objective is transparent communication with patients. Health related quality of life and the degree of suffering related to the respective disorder are important parameters for follow-up and decision making in the context of having to postpone procedures on a regular basis.

Further studies are needed to capture the effects of postponed elective procedures.

Lukas Scheipner, Doroteja Jankovic, Samra Jasarevic, Julia Altziebler, Iva Simunovic, Johannes Mischinger, Almut Frank, Thomas Alber, Sascha Ahyai, Marianne Leitsmann

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 15 September 2023, revised version accepted on 31 January 2024.

Translated from the original German by Birte Twisselmann, PhD.

Cite this as:
Scheipner L, Jankovic D, Jasarevic S, Altziebler J, Simunovic I, Mischinger J, Frank A, Alber T, Ahyai S, Leitsmann M: Elective urological procedures in times of reduced operating room capacity.
Dtsch Arztebl Int 2024; 121: 300–1. DOI: 10.3238/arztebl.m2024.0025

References

1. Fahmy N, Aprikian A, Al-Otaibi M, et al.: Impact of treatment delay in patients with bladder cancer managed with partial cystectomy in Quebec: a population-based study. Can Urol Assoc J 2009; 3: 131–5

2. Gao W, Song L bin, Yang J, et al.: Risk factors and negative consequences of patient’s delay for penile carcinoma. World J Surg Oncol 2016; 14: 124

3. Tachibana I, Ferguson EL, Mahenthiran A, et al.: Delaying cancer cases in urology during COVID-19: review of the literature. J Urol 2020; 204: 926–33

4. Frendl DM, Chou WH, Chen YW, Chang DC , Kim MM: Early vs delayed transurethral surgery in acute urinary retention: does timing make a difference? J Urol 2023; 210: 492–9

5. Von Gontard A, Baeyens D, Van Hoecke E, Warzak WJ, Bachmann C: Psychological and psychiatric issues in urinary and fecal incontinence. J Urol 2011; 185: 1432–6