The COVID-19 pandemic continues unabated. India is currently in the midst of a difficult second wave and the UK and Italy still haven’t gotten out of the throes of the virus. Though the vaccine offers hope, it is too early for us to make any credible sense of what this year has in store for us. In this second part of the series on the impact of the pandemic on urogynecology practice in the worst affected countries, we interviewed Dr. Stephen Radley from Sheffield NHS Trust, UK; Dr. Stefano Salvatore from San Raffaele Hospital, Italy, and Dr. Karishma Thariani from the Center for Urogynecology and Pelvic Health, India, regarding the provision of urogynecology care in their respective countries during the pandemic.
How did the pandemic impact urogynecology practice in your hospital and in your country overall? What were the challenges?
Dr. Radley: From the perspective of our hospital, we were perhaps aware of the seriousness of what was coming and were semi-prepared because we had heard of the situation in Italy. I have good friends in Italy, and it was quite helpful to speak with them about what was going on there. However, there was a bit of denial. We also did not really know what it would mean for the wider health service. But soon it became quite clear that benign gynecology, of which urogynecology is a part, was going to be suspended for a period. And fairly early in the pandemic that did happen because we had a complete lockdown. Elective surgeries were quickly curtailed to zero. There was a time when it was like we were in the eye of a hurricane (the calm before the storm) when the outpatient clinics and elective surgeries stopped, and we were getting ready. We started doing Cesarean sections, on-call duties, administration duties, and telephone-based clinics. Except in the case of emergencies, we switched to telephonic consultation completely. This continued until the first wave started to abate when we got back to a degree of normality in June-August 2020, although it was just a partial resumption of urogynecology services (at best, 50% of our normal capacity). We were restricted to doing day-case procedures (for example, single-site repairs for prolapse). Surgeries that needed inpatient care were postponed as we lost our inpatient ward. And then the second wave hit in September 2020. Again, our surgeries reduced and then stopped altogether in October-November 2020. We have had little or no elective urogynecology surgery since then. We are just talking of introducing urogynecology surgeries, on a restricted level, in April 2021. The only urogynecology surgery I have done this year is a case of impacted pessary.
Based on national and international guidelines, the hospital has graded elective cases in all fields according to their need and severity. Urogynecology surgeries are graded 3 (not urgent) and 4 (elective surgeries in which patients will not be harmed if the surgery is delayed). Hence, in the near future, we might only operate on patients with grade 3 and 4 prolapse and perform day-case surgeries. Our current surgical waiting list is probably 4-6 months. And I suspect it will continue to grow in the next 6-12 months due to our reduced surgical capacity.
However, because of the increased manpower right now, in terms of consultants’ time, we have increased the capacity of our cystoscopy and out-patient urogynecology treatment clinics, depending on the availability of nursing staff. We have a backlog of Botox injections, urethral bulking injections, and cystoscopy cases that we are taking care of. Also, because of the lockdown and women’s reluctance to see GPs and therefore their tendency to downplay or put up with their symptoms, we have received fewer referrals (like other hospitals in UK). Therefore, despite having fewer clinics and at times, no face-to-face outpatient clinics, we have very few new patients waiting. The referrals are picking up now but are not back to the pre-COVID levels.
With respect to incontinence treatment, there certainly has been a shift: sling surgery is suspended, and we have done virtually zero open or laparoscopic major incontinence surgery in the last year. But we have done an increasing number of urethral bulking injections under local anesthetic in the outpatient clinic. Patients are told that they would have to wait for major surgery as it is assigned to the 4th grade. The patient choice is hence shifting to periurethral injections as it is more easily available. If TVT sling surgery were an option right now, we would have done day-case sling procedures. It is a shame as I believe there are patients who would have opted for TVT sling surgery as the outcomes are superior to that of urethral bulking agents.
Though I have recounted the experience of Sheffield NHS, I believe this has been the experience of most NHS hospitals except a few hospitals which were less affected by COVID and hence have restarted regular urogynecology work to an extent. The number of surgeries performed in the private sector have similarly reduced, though some private hospitals are sharing, on a subcontract basis, some of the load of the NHS and some patients are opting to have operations in the private sector due to the long waiting lists in the NHS. However, consent processes have changed to include the risk of COVID and overall patients are reluctant to get treatment even in the private sector due to the increased risks.
With respect to urogynecology subspecialty training, there is a general feeling that the training period will have to be extended due to the lack of experience gained last year. Our trainees have spent a huge amount of time covering obstetrics and have not done much in terms of urogynecology elective surgeries and outpatient clinics. We do not entirely know how it is going to pan out, but it is a major concern.
We have access to full PPEs for all our work. Initially there were some issues with availability of visors and gowns and there was some talk of recycling (we even began cleaning and reusing visors). However, though the situation did reach a critical stage, we never ran out of PPEs due to the support of local industry and charities. There were some issues though around education regarding PPEs, including how and when to use the right kind of PPE. And there was exposure to COVID patients in the emergency setting during our obstetric work initially. In the peak of the pandemic, we would sometimes learn that the patient we had just seen had turned out to be COVID-positive and we would struggle to find a bed in the COVID ward.
Lastly, our protocols during COVID for management of urogynecology patients is in sync with the IUGA guidelines.
Dr. Salvatore: Italy was the second country, after China, where the COVID pandemic started. Particularly, it had a devastating effect in Milan, where I live. The priority was immediately given to emergency and oncology procedures. And so, we had to resort to telemedicine and emails to look after urogynecology patients. It was certainly not ideal, but we could manage some of the issues that needed immediate care, for example, women who had urinary tract infections or problems with ring pessary or pelvic pain. Impact of COVID differed in Italy from region to region. In the southern part of Italy, which is now going through the third wave, the situation was not as dire as that in Lombardy and Veneto in the north. And so, women in different parts of the country faced different situations with respect to access to urogynecology care. Most of the tertiary referral centers are situated in the northern part of the country, which was the hardest hit. The waiting list in the national health system for surgical procedures is already quite long. And the situation has worsened dramatically. We hope that once we are out of this situation, the regional authorities will take the necessary steps for us to be able to take care of the patients who have been waiting.
Between the first and second wave, we did manage to open up and do surgeries from second half of May until the end of the first half of October. During summer, the pandemic had receded and during that time, we almost operated at pre-COVID levels. Then we had to close everything once again in October. I supervise the Urogynecology Unit in San Raffaele Hospital, the largest hospital in Milan and a smaller hospital, Zucchi, in Monza. The manager in Monza tried to keep some parts of the hospital COVID-free. And therefore, I could perform surgeries there until the first half of November. But then the situation worsened, and we had to stop. We then opened up again in January, especially in Monza where we worked at half our capacity. But that was only for 5 weeks as the third wave hit us with the British variant of the virus.
In our hospital, gynecologists were not involved in care of COVID patients as they had to take care of the labor ward. However, in our unit, 3-4 doctors and 3-4 midwives tested positive for COVID. This was more common during the first wave because we were not prepared as we are now, and even the protective equipment available (for example face protection, gowns) then were not adequate. We also did not have enough doctors dedicated to the labor ward. We had to import PPEs from China initially. Many countries like China, Russia, Cuba, and other European countries helped us during the tragic time.
Our hospital is a teaching one. Our residents and medical students worked hard to help us in taking care of patients. My residents contacted patients who had previous mesh surgery, or a ring pessary inserted, and those with recurrent UTIs to provide them guidance and reassure them. We have a residency program in which the final two years can be completely dedicated to urogynecology. We hope to extend the time of surgical training after they finish their residency program to make up for this lost time. We are also trying to open urogynecology units in the other hospitals in the group to distribute the residents and improve the efficiency of their training. But this is not going to be easy. In our system, we have a cap on reimbursement and hence we cannot suddenly increase the surgical load. Hence, we hope that our regional authorities will provide more funds to raise the reimbursement limit so that we can do justice to both our patients and the residents by increasing the number of operating days.
Dr. Thariani: In India, urogynecology is still at a nascent stage. Most specialists have a combined general gynecology and obstetrics practice along with urogynecology, with very few practicing only urogynecology. To understand the impact of the COVID-19 pandemic on the urogynecology practice in our country, we conducted an informal survey using a Google form in February 2021. The survey form was sent to the specialists who practiced urogynecology in different parts of India. We received over 20 responses from urogynecologists practicing across a spectrum of health care setups: private clinics, tertiary level private clinics, and government hospitals. Almost all respondents reported easy availability of PPE in their hospitals.
Irrespective of the setup, 85% of the doctors reported 75% or more reduction in the number of urogynecology patients (both OPD and IPD) during the lockdown phase. Even after the end of lockdown, most of the doctors reported a reduction in footfall ranging between 25 to 50% as compared to the pre-COVID period. Most of the tertiary level government hospitals were converted to COVID hospitals with complete shutdown of OPDs and elective operating rooms until January 2021. Most private hospitals had separate COVID sections due to which patients avoided visiting the hospitals which resulted in reduced numbers.
The number of urogynecology diagnostic tests and procedures reduced by over 75% as most doctors preferred prescribing only essential tests during the worst phase of the pandemic and this has only recovered partially to 50% of pre-COVID levels after the lockdown. 60% of the doctors deferred surgical procedures as they were non-emergent in nature. The pandemic also affected the doctors financially as over 62% reported a 25-50% reduction in their payouts.
Providing optimal care to the patients was one of the biggest challenges during the pandemic. Most private practitioners switched to virtual consultations but only a few government hospitals were able to provide tele-consultations to urogynecology patients. Since government hospitals mostly cater to the lower socioeconomic strata, it was the poor who suffered the brunt of the absence of these services.
How did you face the challenges and ensure that you were able to provide optimal care to your patients?
Dr. Radley: Currently we have been triaging incontinence patients to virtual clinics in which they have an initial telephonic consultation which includes a bladder diary and online electronic questionnaire. They are then referred as required to face-to-face consultation, urodynamics, or physiotherapy. Prolapse patients are counseled to come for face-to-face consultation. This system has been working quite well for us. At the same time last year, we did only telephonic consultations except in the case of emergencies. We postponed almost all patients including those needing pessary unless they had procidentia. We are, however, getting far fewer referrals as the threshold for the same has increased. We will have to wait and watch to see if this will translate into changed attitudes amongst patients towards accessing health care and an increasing number of patients coming later with more severe degrees of prolapse and incontinence.
We use telephonic consultations and not video-based methods. One of the best things about telephonic consultations is that we don’t have to wear a mask or a PPE. It is in some ways less stressful. Telephonic consultations are not brand new to us as it has been a routine part of our practice for follow-up. However, now it has become much more established. In my experience, patients appreciate it, and it is mostly efficient, and one can achieve quite a lot over the telephone. It is gratifying in that respect. We have just submitted an article to the BJOG on patient experiences with telephonic consultation clinics in gynecology. Yes, there are limits, and one can’t run an entire service on it. However, it has changed the way we look at health care provision.
Dr. Salvatore: From the second wave, our group of hospitals started a telemedicine program in which we could have video consultations and share documents. However, this is difficult where urogynecology is concerned as the mean age of the patients is older and older women are not technology-savvy. Telemedicine was useful with conditions like recurrent UTI in which the mean age of the patients is lower. For women with prolapse and ring pessary, telemedicine wasn’t that useful. We created two separate email IDs of our unit for patients. During the telephonic conversation, we encouraged them to get in touch with their relatives so that they could help them in using telemedicine optimally. Telemedicine changed the management of our patients in our hospital dramatically.
Dr. Thariani: To provide optimal care to the patients, 90% of our respondents switched to virtual platforms to provide consultations. Most of these platforms were easily accessible through mobile phones. However, satisfaction rates after virtual consultation were low among both doctors and patients. Amongst the patients, the reasons for reduced satisfaction were connectivity issues and less time spent with the doctor. With doctors, the most common reason for reduced satisfaction was inability to examine and evaluate the patients thoroughly. Due to this, most of the clinicians (67%) were most comfortable in offering only lifestyle modifications, fluid and diet changes, and other conservative treatments to their patients rather than specific drugs. Over 90% of doctors followed the IUGA guidelines on management of urogynecology patients during the pandemic.
What are the key learnings from the last year that you hope to apply in your practice in the future?
Dr. Radley: Key learnings from last year are the resilience that people have shown, the support that colleagues have provided for each other through the psychological and physical stress of the situation, and the understanding that one needs to be flexible, open-minded and be prepared to change one’s plans at short notice. We have managed to keep the service afloat with good support from the team including the management team. The management and clinical teams have learned some valuable lessons on how to work together efficiently. Lastly, having online meetings (through Zoom, Google, and Microsoft teams) with colleagues, medical students, trainees, etc., has become a standard part of the working day. Previously, we might have considered traveling across the UK to discuss teaching and training. But now the increasing use of electronic media in providing clinical services, education, team meetings, and management meetings, has shifted the paradigm. It was already happening but now it has become mainstream.
Dr. Salvatore: Key learning, apart from the use of telemedicine, is that medicine in the community (outside the larger hospitals) has not been managed well. General practitioners did not have access to adequate facilities, instructions, or standardized protocols until the second or third wave. Since they were too busy, we could not ask them to help care for urogynecology patients in the community. Primary health care must be improved. The number of general physicians needs to be increased and their training needs to be improved.
Dr. Thariani: One of the most important lessons that the pandemic taught us is the need to integrate technology with health care systems. In a low resource country like India, where most of the population cannot afford private health care, availability of virtual platforms in the government sector is a must. Use of mobile phones to provide tele-consultations is a cheap, effective, and easily accessible solution. Most of the respondents in our survey (66%) wanted to continue using the virtual platform even after the pandemic.
The COVID-19 pandemic also re-emphasized the importance of life-style modifications, fluid and diet changes, and conservative treatments in the management of urogynecologic issues. With the easy availability and fast action of medications and easily available surgical options, these first line measures were often ignored both by the doctors and the patients before the pandemic. It was a revelation for most doctors and patients who noted that significant positive outcomes could be seen if these measures are optimally used.
Lastly, the use of virtual platforms for conducting CME and meetings is another learning from the last year that we would like to continue in the future as well. Virtual conferences are cost effective and easily accessible to doctors all over the world, saving the time and money involved in travel. Even in the future, CME events and meetings should be hybrid in nature, allowing delegates who cannot travel to attend these meetings virtually and stay updated.
What is the one positive thing that you can share about 2020 with respect to urogynecology practice?
Dr. Radley: These difficult times have shown the human spirit, the resilience of the health service and of the people within the service to keep going. It has brought out the best in people. We are coming out of this stronger together. Lastly, the increased use of technology and multimedia to communicate with colleagues has been positive. Patients are also appreciating the effort that has gone into providing quality patient care.
Dr. Salvatore: One of the positive things is that we now understand the value of life and of being happy. Apart from that, telemedicine will continue even after this pandemic ends. We are also using more technology-based educational tools for our students like streaming, web platforms, and remote training. There is an archive of good material created which they can continue to use in the future. Lastly, we could keep in touch with our colleagues and continue CME activities through webinars. Industry has been incredibly supportive of the same. However, now there is an overload of webinars and too much of anything is not too good.
Dr. Thariani: If we must highlight one positive thing about 2020, then it most definitely is the use of technology in health care systems. It is time that we start using the advancements in the field of technology and artificial intelligence to uplift our health care system and reach out to the underprivileged sections of our society that do not have adequate access to health care.