Content uploaded by Samuel S. Folkard
Author content
All content in this area was uploaded by Samuel S. Folkard on May 31, 2021
Content may be subject to copyright.
https://doi.org/10.1177/2051415820970396
Journal of Clinical Urology
2021, Vol. 14(1) 47 –54
© British Association of
Urological Surgeons 2020
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/2051415820970396
journals.sagepub.com/home/uro
Introduction
The Kent, Surrey and Sussex (KSS) region is a densely
populated area of the UK and is home to 8% of the UK
population.1 It includes 12 major training hospitals for
urology (Figure 1).
UK government data tracking the coronavirus disease
2019 (COVID-19) pandemic reported the South East as
the third most affected region, with the highest number of
confirmed cases after London and the North West. The
Effect of coronavirus disease
2019 on urological surgery services
and training up to the peak of the
pandemic in South East England
Samuel Stephen Folkard1, Paul Sturch2,
Tharani Mahesan3 and Stephen Garnett4
Abstract
Introduction: The coronavirus disease 2019 (COVID-19) pandemic is having significant effects on health services
globally, including on urological surgery for which the British Association of Urological Surgeons (BAUS) has provided
national guidance. Kent, Surrey and Sussex (KSS) is one of the regions most affected by COVID-19 in the UK to date.
Methods: An anonymous online survey of all KSS urology trainees was conducted. The primary outcome was to assess
the effects on urology services, both malignant and benign, across the region in the acceleration phase and at the peak of
the pandemic compared to standard care. The second was to quantify the effects on urology training, especially regarding
operative exposure.
Results: There were significant decreases in urological services provided at the peak of the pandemic across KSS
compared to standard care (p<0.0001). Only 22% of urology units were able to continue operating for low-risk cancer
and to continue cystoscopy for two-week wait non-visible haematuria referrals in line with BAUS escalation guidelines.
A third (33%) did not complete any prostate biopsies at the peak. The majority of urology units continued clinics
by telephone. Urology trainees reported completing substantially fewer operating procedures and workplace-based
assessments. A third (33%) had moved to consultant-only operating by the peak.
Conclusions: The COVID-19 pandemic has caused significant changes to urological surgery services and training in KSS,
with heterogeneity across the region. We suggest further work to quantify the effects nationally.
Level of evidence: 4.
Keywords
COVID-19, urological oncology, urological surgery, surgical training, postgraduate education, medical technology
Date received: 25 May 2020; accepted: 7 October 2020
1Department of Urology, Kent and Canterbury Hospital, UK
2Department of Urology, St Peter’s Hospital, UK
3Department of Urology, Royal Surrey Hospital, UK
4KSS Training Programme Director and Consultant Urologist,
Eastbourne District General Hospital, UK
Corresponding author:
Samuel Stephen Folkard, Department of Urology, Kent and Canterbury
Hospital, Ethelbert Rd, Canterbury, CT1 3NG, UK.
Email: samuel.folkard@googlemail.com
970396URO Journal of Clinical UrologyFolkard et al.
Cross-sectional Study
48 Journal of Clinical Urology 14(1)
number of confirmed cases by 23 April 2020 had reached
14,053 (Figure 2).2 The effects on urology services and
training have been felt internationally, with published
effects and recommendations from various countries,
including Germany,3 Italy,4,5 Brazil,6 Turkey7 and Iran.8
This prospective study aims to quantify the effects of
COVID-19 on the provision of urological services and the
impact on specialist urology training in the KSS region up
to the peak of the pandemic in April 2020.
Methods
Data from the Office for National Statistics on daily death
rates from COVID-19 in hospital by region were extracted
and analysed to describe the peak of deaths from
COVID-19 in the KSS region.9 An anonymous Google
Form survey was sent to all urology specialist registrars
(SpRs) in the KSS region on a biweekly basis from 23
March to 6 April 2020. The survey included questions on
changes to the provision of cancer diagnostics and treat-
ment in line with British Association of Urological
Surgeons (BAUS) guidance; conversion of face-to-face
outpatient appointments to telephone or virtual clinics;
the provision of emergency, urgent and routine operating;
as well as staff redeployment and educational and training
opportunities. Responses were analysed using Keynote
and Google Sheets. The statistical test was an F-test, two-
tailed, with a significance level set at p=0.05.
Results
Analysis of published government data shows a rapid
increase in the COVID-19 daily death rate in the South
East during the period between 23 March and 4 April 2020
(acceleration phase), and reaching a daily high in the week
of 6 April 2020 (peak phase; Figure 3).
Thirteen urology SpRs responded to the survey for the
week beginning 23 March 2020, which covered 9 of the 12
(75%) training hospitals. At this point, daily deaths in the
South East from COVID-19 were at approximately two
thirds of their peak. A second survey covering the peak
phase (week beginning 6 April 2020) was completed by
nine urology SpRs, also covering 9 of the 12 training hos-
pitals. The three hospitals not able to respond to the survey,
due to illness for example, were not the same at both time
points and were all district general hospitals. All specialist
services across the KSS region were represented at each
time point in these nine training hospitals and were detailed
by the SpRs: six offering pelvic oncology services, two
offering female and reconstructive services, five offering a
specialist endourology stone service with six centres offer-
ing extracorporeal shock wave lithotripsy and two special-
ist tertiary andrology services. All nine hospitals offered
paediatric services.
Figure 1. Specialist registrar (SpR) training places by hospital in the Kent, Surrey and Sussex (KSS) region.
Figure 2. Coronavirus disease 2019 (COVID-19) UK cases by
region.
Folkard et al. 49
Effect on urology services
The responses during the acceleration phase showed a sig-
nificant effect on urology services well in advance of the
COVID-19 peak (Figure 3). While all sites still provided
usual emergency urology throughout, there was a statisti-
cally significant difference between urology activity pro-
vided prior to COVID-19 (mean 96%) and during the
acceleration (46%) and peak (39%) phases (F=27.78,
p<0.0001). This was calculated by the F-test using the
percentages of sites providing each of the activities shown
in Figure 3.
Oncology
High-risk cancer surgery was defined as per the BAUS
specialist guidance or by the local protocols of the survey
responder based on this guidance. High-risk cancer sur-
gery continued as normal in 85% of centres during the
acceleration phase, and this was maintained through the
peak of COVID-19. Cancer surgery that was not high risk
was completed in 39% of units during the acceleration
phase, decreasing to 22% at the peak. Of the six units
offering pelvic oncology in the region, six reported com-
pleting laparoscopic or robotic operating in the accelera-
tion phase, and four continued at the peak. Just under half
of units continued Bacillus Calmette–Guérin and mitomy-
cin bladder instillations. One unit reported offering neo-
adjuvant chemotherapy during the surveyed period.
All units continued to provide flexible cystoscopy for
two-week wait (2WW) visible haematuria referrals and
31% cystoscopies for 2WW non-visible haematuria or sur-
veillance for bladder cancer during the acceleration phase.
At the peak, the ability to continue cystoscopies to investi-
gate visible haematuria decreased to 78%, with non-visible
haematuria investigations and cystoscopic surveillance
relatively unchanged from the acceleration phase at 22%.
Two units switched to telephone triage clinics of 2WW
haematuria referrals.
Our results show that 44% of units were able to con-
tinue prostate biopsies, including at the peak, as per their
usual strategy, whether this be transrectal ultrasound-
guided biopsies (TRUS) or transperineal biopsies or both
(Figure 4). A third (33%) of units stopped all prostate biop-
sies completely. The remainder made changes to their
biopsy strategies including ceasing biopsies under general
Figure 3. Percentage of units offering different urological services in the acceleration and peak phases as number of deaths per day
increase over time.
50 Journal of Clinical Urology 14(1)
anaesthetic and initially switching to transperineal biop-
sies only in the acceleration phase.
Endourology
The provision of endourology was significantly reduced
during the study period, with 62% and 23% of respondents
identifying their units as being able to complete non-emer-
gency and routine operating during the acceleration phase,
respectively. At the peak none of the surveyed units in the
KSS region were offering non-emergency endourology
operating. Two units out of six offering extracorporeal
shock wave lithotripsy were able to continue through the
peak of COVID-19.
Outpatient clinics
The percentage of units seeing patients face to face in
clinic decreased through the acceleration phase and peak
of COVID-19. Across the region, 39% of units were see-
ing 2WW referrals in person during the acceleration
phase. This decreased to two (22%) units seeing 2WW
and urgent referrals in a ‘hot’ clinic at the peak, with one
unit continuing to see only suspected testicular cancer
referrals face to face. Only one unit continued routine and
paediatric clinics face to face in the acceleration phase,
but none continued to the peak. The number of units com-
pleting clinics by telephone increased throughout the
COVID-19 pandemic. At the peak, all surveyed units
were completing some or all 2WW clinics by telephone.
Telephone consultations were conducted for routine out-
patient appointments in 78% and for paediatric clinics by
44% of units.
Staffing changes
During the acceleration phase, 85% units reported approx-
imately 25% of the urological medical workforce sick or
self-isolating. At the peak, 22% of units reported sickness
rates of approximately 50%, with a further 44% of units
reporting rates of staff sickness of around 25%.
Effects on urology training
The SpRs responding to the survey represented a range of
training stages between ST3 and ST6 (Figure 5). Almost
80% of respondents described no change to their usual out-
of-hours work, remaining on a non-resident second on-call
work schedule. A third (33%) of SpRs covered additional
ward work, as their junior colleagues were redeployed to
Figure 4. Changes in the prostate biopsy strategies of units across KSS in the acceleration and peak phases as number of deaths
per day increase over time.
Folkard et al. 51
other areas to support the direct COVID-19 response. Two
units changed their SpRs to resident on-call full shift pat-
terns. Only in one unit in the region were urology regis-
trars redeployed to support a non-surgical rota (intensive
care).
During the acceleration of the COVID-19 pandemic,
SpRs continued to operate with their own lists with remote
consultant supervision (23%) and with direct consultant
supervision (39%). Up to 62% of SpRs described only
continuing to operate for CEPOD emergencies during the
pandemic. By the peak, 33% of SpRs were not spending
any time in the operating theatre at all, as their Trusts had
moved to consultant-only operating.
Of those SpRs still operating at the peak, 75% com-
pleted less than one third of the indicative operating num-
bers they would usually complete in a week, with the
remaining 25% completing approximately one third. Two
thirds (67%) completed no workplace-based assessments
during the peak, and 33% completed fewer than they
would usually expect to in any given week.
Prior to COVID-19, trainees undertook one full day of
regional teaching per month, alongside at least biweekly
local educational meetings. Other available teaching
included journal review meetings and morbidity and mor-
tality meetings. Additional informal teaching took place
during consultant-led activity, including theatre lists, clin-
ics and multidisciplinary team (MDT) meetings.
Responding to our survey, no trainee described usual
educational activities continuing to run through to the peak
of COVID-19. One unit continued to provide local urology
teaching. Attendance at MDT meetings continued either in
person or virtually for almost 90% of trainees. However,
78% did use novel educational technologies in the COVID-
19 period (Figure 5). Webinars were the most popular, and
these were provided by the Royal Society of Medicine and
also the BAUS Office of Education. Others accessed
online resources that they would not otherwise have used,
as well as telephone teaching.
Discussion
The response rate for our survey from urology units (75%)
was similar to other published SpR surveys in the UK.10
These surveys quantify the significant effect of the
COVID-19 pandemic on urological surgery services in
South East England – the third worst-affected area in the
UK by number of cases. The disruption covered both the
acceleration and peak phases described, lasting for at least
four weeks.
In response to the outbreak, BAUS published guidance
on the management of urological services on 19 March
2020. This was well before the substantial surge in cases in
the region (Figure 3). The bladder cancer contingency plan
included strategies based on a three-step model for current,
Figure 5. Effects on urology training: stage of SpR respondents and the percentage using different technologies for teaching at the
peak of the pandemic.
52 Journal of Clinical Urology 14(1)
reduced and severely reduced service provision (Figure 6).
Up to 30 March 2020, during the acceleration phase, 69%
units in KSS had reached ‘reduced service provision’, and
78% reached it at the peak. One unit (11%) reached
‘severely reduced provision’ at the peak.11 With regards to
biopsies for suspected prostate cancer, the BAUS COVID-
19 policy recommended that men with a prostate-specific
antigen (PSA) <20 (and therefore not warranting a bone
scan or prostate-specific membrane antigen scan) and a
PSA density >0.15 µg/L/cc should be offered a prostate
biopsy (potentially limited core numbers), providing this
was available in the outpatient department. With no mag-
netic resonance imaging likely to be available, it was sug-
gested that a systematic ‘Guy’s/Ginsberg protocol’ perineal
biopsy should be performed, with further recommenda-
tions that a TRUS biopsy should be avoided if possible.12
Our survey demonstrates that 33% were not able to offer
prostate biopsies at all at the peak of the pandemic in the
KSS region. Therefore, even within our limited geographi-
cal area, there was heterogeneity in the provision of urol-
ogy services, including cancer diagnostics through to the
peak of COVID-19.
Our survey highlights contributory difficulties in main-
taining these services, including theatre space, staff sick-
ness and the need to protect vulnerable patients and staff.
At the time of writing, 106 health and social care workers
have died of COVID-19 infection in the UK. The number
of health-care worker deaths was second highest by region
for the South East, and nationally five deaths of the 18 to
date amongst doctors were in surgical specialties.13 One
strategy to try to reduce risk to all health-care workers in
the operating theatre is consultant-only operating in order
to reduce surgical time as far as possible. This has to be the
priority, and service provision must also take priority in the
NHS’s response to this global pandemic.
A further consequence of the COVID-19 pandemic is
the impact on surgical training. The Joint Committee on
Surgical Training emphasised the need for measures for
‘minimising spread of infection, personal and patient safety,
maintenance of normal processes where possible and the
need for pragmatism’,14 while all higher surgical exams
have currently been cancelled. This survey helps to quan-
tify these effects, and emphasises that trainee experiences
during this pandemic have also been different, depending
on local Trust requirements. This is consistent with the
Italian experience, whose trainees described that Urology
SpRs were ‘experiencing a severe reduction (>40%) or
complete suppression (>80%) of training exposure ranged
between 41% and 81% for “clinical” activities while
between 44% and 62% for “surgical” activities’ during
their COVID-19 peak.15 Our survey suggests, however, that
the use of technology for alternative educational activities
has been widespread amongst trainees, and with training
organisations in the UK set to increase webinars, this
should be well maintained as social distancing restrictions
make traditional methods of teaching difficult.
The rapid and widespread adoption of telephone and
videoconferencing technology for clinics offers a socially
distant line of communication to help triage and treat uro-
logical problems where possible. Commentary has already
been made of the potentially ‘devastating’ long-term
impact of cancelling clinics addressing benign urological
conditions to ease pressure on the health service in the
interim in the UK.16 With virtual clinics already estab-
lished in some areas of urology,17 the current crisis may
lead to greater adoption of remote technology to amelio-
rate the huge burden of work that would otherwise be post-
poned until after the pandemic.
England’s Chief Medical Officer Professor Chris
Whitty’s recent warning that the NHS will be dealing with
Figure 6. COVID-19 British Association of Urological Surgery Oncology section bladder diagnostics guidance.
Folkard et al. 53
COVID-19 for the foreseeable future18 suggests that like
all surgical specialties, urology must prepare for a long-
term plan to protect our patients. The ‘Getting It Right
First Time’ report for urology detailed the use of urology
area networks19 ‘to provide comprehensive coverage of
urological services, beyond existing network arrange-
ments, to optimise quality and efficiency’. The further
development of these networks may offer a way to main-
tain consistency of urological care at this challenging time.
Conclusion
In conclusion, the COVID-19 pandemic has caused signifi-
cant changes to urology services and training in the KSS
region – one of the worst affected to date in the UK by
COVID-19. There appears to be heterogeneity to the changes
in services across the region, with units reaching different
levels of planned escalation in line with BAUS guidelines at
different times. Surgical training cannot be a priority in the
current environment, and in our region, SpRs have com-
pleted fewer indicative procedures, non-emergency operat-
ing and workplace-based assessments as expected during the
pandemic. Remote and videoconferencing technologies
embraced during this period to provide education for trainees
as well as safer outpatient consultations for patients are likely
to reshape the way that urological training and patient care
are provided long after this crisis resolves. We suggest fur-
ther work to quantify the effects on surgical services and
training nationally to ascertain whether our experience in
KSS is representative nationally.
Conflicting interests
The authors declared no potential conflicts of interest with respect
to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research,
authorship and/or publication of this article.
Ethical approval
Not required.
Informed consent
Not required.
Guarantor
S.F.
Contributorship
S.F., T.M., P.S. and S.G. conceived the study. S.F., T.M. and P.S.
collected the data. S.F., T.M. and P.S. competed the data analy-
sis. S.F. wrote the first draft of the manuscript. All authors
reviewed and edited the manuscript and approved the final ver-
sion of the manuscript.
Acknowledgements
KSS Urology Group (Kent, Surrey and Sussex Urology Group,
London and South East Postgraduate Medical and Dental
Education, Stewart House, 32 Russell Square, London, WC1B
5DN) for contributing in collecting the data.
ORCID iD
Samuel Stephen Folkard https://orcid.org/0000-0003-2351
-9107
Supplemental material
Supplemental material for this article is available online.
References
1. BAUS. Kent, Surrey & Sussex (KSS). 2020. https://www.
baus.org.uk/professionals/regions/south_east_coast.aspx
(accessed 25 May 2020).
2. Armstrong M. Coronavirus cases in the UK, https://www.
statista.com/chart/21079/coronavirus-cases-uk-map/
(accessed 24 April 2020).
3. Kriegmair MC, Kowalewski KF, Lange B, et al. [Urology
in the corona-virus pandemic – a guideline 4/20]. Urologe A
2020; 59: 442–449.
4. Simonato A, Giannarini G, Abrate A, et al. Clinical path-
ways for urology patients during the COVID-19 pandemic.
Minerva Urol Nefrol 2020; 72: 376–383.
5. Ficarra V, Novara G, Abrate A, et al. Urology practice during the
COVID-19 pandemic. Minerva Urol Nefrol 2020; 72: 369–375.
6. Carneiro A, Wroclawski ML, Nahar B, et al. Impact of the
COVID-19 pandemic on the urologist’s clinical practice
in Brazil: a management guideline proposal for low- and
middle-income countries during the crisis period. Int Braz J
Urol 2020; 46: 501–510.
7. Ho HC, Hughes T, Bozlu M, et al. What do urologists
need to know: diagnosis, treatment, and follow-up during
COVID-19 pandemic. Turkish J Urol 2020; 46: 169–177.
8. Nowroozi A and Amini E. Urology practice in the time of
COVID-19. Urol J 2020; 17: 326.
9. Office for National Statistics. Coronavirus (COVID-19),
https://www.ons.gov.uk/peoplepopulationandcommunity/
healthandsocialcare/conditionsanddiseases (2020, accessed
25 May 2020).
10. Ajwani SH and Biant LC. The prevalence and effects of on-
call stepdown on orthopaedic registrar training: the North
West trainees’ perspective. Ann R Coll Surg Engl 2020; 102:
277–283.
11. BAUS. COVID-19 bladder cancer contingency plan. 2020.
https://www.baus.org.uk/mybaus/covid19_members_infor-
mation.aspx (accessed 25 May 2020).
12. BAUS. COVID-19 strategy for the interim management of
prostate cancer prepared by the BAUS Section of Oncology.
2020. https://www.baus.org.uk/mybaus/covid19_members_
information.aspx (accessed 25 May 2020).
13. Cook C, Kursumovic E and Lennane S. Exclusive: deaths
of NHS staff from covid-19 analysed, https://www.
hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19
-analysed/7027471.article (2020, accessed 22 April 2020).
54 Journal of Clinical Urology 14(1)
14. JCST. COVID-19 and trainee progression in 2020. 2020.
https://www.jcst.org/jcst-news/2020/10/01/update/ (accessed
25 May 2020).
15. Amparore D, Claps F, Cacciamani GE, et al. Impact of the
COVID-19 pandemic on urology residency training in Italy.
Minerva Urol Nefrol 2020; 72: 505–509.
16. Ahmed K, Hayat S and Dasgupta P. Global challenges to
urology practice during the COVID-19 pandemic. BJU Int
2020; 125: E5–E6.
17. Smith T, Blach O, Baker S, et al. Virtual stone clinic –
the future of stone management? J Clin Urol 2018; 11:
361–367.
18. Sparrow A. UK coronavirus live: some ‘disruptive’ lock-
down measures set to remain in force for rest of year, says
Whitty. The Guardian, 22 April 2020.
19. Harrison S. Urology GIRFT Programme National Specialty
Report. 2019. https://www.gettingitrightfirsttime.co.uk/girft-
reports/ (accessed 25 May 2020).