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Year : 2021  |  Volume : 32  |  Issue : 1  |  Page : 23-26

The impact of population lockdown on the referral pattern for urology in a COVID-19 designated tertiary hospital in Malaysia

Department of Surgery, Urology Unit, University Malaya Medical Centre, Kuala Lumpur, Malaysia

Date of Submission26-Jun-2020
Date of Decision18-Aug-2020
Date of Acceptance29-Oct-2020
Date of Web Publication27-Mar-2021

Correspondence Address:
Teng Aik Ong
Department of Surgery, Urology Unit, University Malaya Medical Centre, Kuala Lumpur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_92_20

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Purpose: Once COVID-19 was first reported in Wuhan, China, in December 2019, it has rapidly spread worldwide. The Malaysian Government had taken an early measure by introducing the movement control order (MCO), which is a form of lockdown. This study aims at describing the referral pattern for urology in a COVID-19 designated tertiary hospital throughout the MCO period. Materials and Methods: All urology referrals received from March 18, 2020 to April 28, 2020 (i.e., during the MCO period) were included and assessed prospectively. For comparison, a retrospective study covering the period from February 1, 2020 to March 17, 2020 (i.e. pre-MCO period) was conducted. Parameters measured and compared include sources of referral, type of cases, outcomes, admission status, and COVID-19 status of patients referred. Results: The majority of referrals for urology were received from the emergency department during MCO (42.9%), followed by the medical ward (28.6%) and surgical ward (2.3%). In terms of the type of cases referred, during the MCO, the highest number of hematuria cases (22.5%) was received and a high number of Benign Prostate Hypertrophy (BPH) and urethral stricture cases (18.8%). Conservative measures remain the most commonly adopted outcomes/management for both pre and during MCO. The number of admissions required for urology referral showed a slight difference between pre and during MCO. Conclusion: The workload of urology referral in a COVID-19 designated tertiary hospital did not change despite MCO. This supports that the urology team still has an important role to play as a subspecialty unit in managing urology emergencies, even when elective surgeries and procedures are being reduced or rescheduled.

Keywords: COVID-19, referral pattern, urology

How to cite this article:
Amat N, Philip EF, Chai CA, Yeoh WS, Lim J, Fadzli AN, Kuppusamy S, Ong TA. The impact of population lockdown on the referral pattern for urology in a COVID-19 designated tertiary hospital in Malaysia. Urol Sci 2021;32:23-6

How to cite this URL:
Amat N, Philip EF, Chai CA, Yeoh WS, Lim J, Fadzli AN, Kuppusamy S, Ong TA. The impact of population lockdown on the referral pattern for urology in a COVID-19 designated tertiary hospital in Malaysia. Urol Sci [serial online] 2021 [cited 2021 Jun 19];32:23-6. Available from: https://www.e-urol-sci.com/text.asp?2021/32/1/23/312436

  Introduction Top

COVID-19 was first reported in December 2019 in the Wuhan region, China.[1] The World Health Organization declared COVID-19 a public health emergency of international concern on January 30, 2020 because of the rapid escalation of cases.[2] Currently, the positive COVID-19 cases reported worldwide are >4.5 million cases with a mortality of 322, 821 cases.[3] It has affected 209 countries to date.[4]

In Malaysia, 6978 cases have been reported with 114 mortality cases by May 20, 2020.[5] With the increase of COVID-19 cases in early March 2020, the Malaysian Government introduced the movement control order (MCO), which is a form of national lockdown, commencing on March 18, 2020 that was subsequently extended to April 28, 2020.

The University Malaya Medical Centre (UMMC) was listed as a COVID-19 designated tertiary hospital alongside 34 other hospitals in Malaysia. In “normal” time, UMMC had 1337 beds. The urology unit saw 385 outpatients per week and performed 1337 elective and emergency surgeries per year.

As part of UMMC clinical services, the urology unit has been working together with other departments to provide the necessary facilities and services during the pandemic. The Malaysian Health Care authorities recommended postponing elective surgical cases and rescheduling outpatient clinics in preparation for urgent and critically ill individuals. Besides, the COVID-19 outbreak has also affected outpatient and inpatient urological services.

The current study aims at comparing the emergency referral pattern for urological services at UMMC before (pre-MCO) and during the MCO periods.

  Methods Top

Statement of ethics

This study was reviewed and approved by the Medical Research Ethics Committee of University Malaya Medical Centre (reference number: 202043-8433). This article does not contain any studies with human participants or animals performed by any of the authors. Informed consent was not required in the study.

Study design and participants

All urology referrals received between March 18, 2020 and April 28, 2020 (6 weeks of MCO period) were included and assessed prospectively. These data were compared to retrospective referral data received between February 1, 2020 and March 17, 2020 (6 weeks pre-MCO) which was retrieved from the hospital electronic medical record system (EMR).

Suspected COVID-19 patients were screened at triage and placed at a specific area in which urology referral involving this group of patients, the urologist was required to wear full personal protective equipment (PPE) when attending those patients.

For urology patients who required admission or urgent operation, our center's standard operating procedures (SOP) consisted of screening questionnaires and nasopharyngeal swabs for COVID-19 screening. For elective operation, urology patients would be admitted 2 days prior in which similar procedures were conducted. COVID-19 reverse transcription-polymerase chain reaction test was used for a nasopharyngeal swab.

Data collection

All referral and consultation data retrieved from EMR for each case were recorded in a case report form. The total number of urology referrals calculated for both study periods with specific parameters was assessed:

  1. Source of referral: Emergency department, medical department, surgical department, orthopedic department, and others (hematology, oncology, and intensive care unit)
  2. Case-mix of cases referred: Hematuria, benign prostate enlargement/urethral stricture, urology infection, uro-oncology, obstructive uropathy, and others (renal cyst, tench off assessment, and angiomyolipoma)
  3. Referral outcome: Surgery (stenting, open surgery such as bladder repair, wound debridement, incision, and drainage), Bedside procedures (bladder catheterization, irrigation, and bladder washout, suprapubic catheterization [SPC]), and conservative measures (antibiotic, daily review, outpatient clinic appointment)
  4. Admission status (i.e. the patient was admitted or discharged after review)
  5. COVID-19 status of the patients referred: Positive for COVID-19, patient under investigation (PUI), and non-COVID.

Statistical analysis

Categorical variables were expressed as frequencies and percentages, then compared by Pearson's Chi-square test between pre- and during MCO groups. All statistical analyses were performed using the SPSS for Windows version 25.0 (SPSS Inc., Chicago, Illinois, USA). Two-tailed P < 0.05 was termed as statistically significant.

  Results Top

There were 154 and 133 referrals for urology during the pre-MCO and MCO periods, respectively. The majority of referrals for urology were received from the emergency department during MCO (42.9%), followed by the medical ward (28.6%) and surgical ward (2.3%). During the pre-MCO period, a nearly similar number of referrals was received from the emergency department (37%) and medical ward (37%), followed by the surgical ward (15.6%). There was a significant reduction in the number of cases referred from the surgical ward during this period (P = 0.001) [Table 1].
Table 1: Urology referral pattern before and during the COVID-19 pandemic

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As for the type of cases referred, hematuria was the most common case encountered during both pre-MCO (25.3%) and MCO (22.5%). There was a statistically significant difference between pre-MCO and MCO, across all case-mix studied with the most significant is the increase in BPH/urethral stricture cases (4.5% vs. 18.8% P < 0.01).

It was noted that there was a significant reduction in the number of cases requiring surgical intervention between the pre-MCO and during MCO (16.9% vs. 6.0%, P < 0.05 increase in bedside procedures (3.9% vs. 26.3%, P < 0.05).

Most of the cases were managed conservatively during the pre-MCO (79.2%) and MCO (73.4%) periods. The number of patients requiring admissions under urology showed only a slight decrease in the MCO period (20.3%) compared to the pre-MCO period (27.9%) and this was not statistically significant (P = 0.07) [Table 1].

One positive COVID-19 case was encountered which required a bedside procedure and another seven patients categorized as PUI, whose swab test results were later turned out to be negative. None of the clinicians in the urology team was infected by COVID-19 during the consultation in the MCO.

  Discussion Top

Urology referral or consultations during the COVID-19 pandemic were unavoidable despite the marked reduction in all elective urological services. There was a paucity of data concerning the difference in referral patterns in urology comparing the pandemic period and the prepandemic period. There is a study that provides evidence on urology referral patterns which reflects the urology workload during a nonpandemic period.[6] The current paper seeks to explore the urology referral patterns during a pandemic period.

The total number of referrals during the MCO period was similar to the pre-MCO period indicating that the effect of the COVID pandemic on the urology subdivision workload was negligible. [Figure 1] shows no significant difference in the urology referral number despite an alarming rise in Malaysia daily new COVID-19 cases. Despite the MCO enforcement, the number of urological emergencies presenting to the emergency department were not affected by the pandemic. Therefore, an adequate workforce for urology on-call needed to be maintained during the pandemic period in order to cope with the various urological emergency referrals in a tertiary hospital.
Figure 1: Distribution of Malaysia daily new COVID-19 cases in Malaysia and urology referrals in University Malaya Medical Centre during movement control order

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The majority of the inpatient referrals in the current study were from the medical ward. This was similar to a previous study done on the spectrum of urological emergencies in a tertiary teaching hospital (SMS Medical College and Hospital) in India in 2015 where the medical wards contributed to most of the urology referrals, followed by the common polytrauma unit, nephrology, and surgery.[7]

Fewer inpatient referrals were seen from surgical wards during the MCO period, while there were more referrals from the other departments like oncology, hematology, and intensive care unit. Surgical referrals were likely reduced as there were less elective and emergency surgical cases on the wards due to hospital-enforced access block. The increase in referrals from hematology and oncology may be due to the fact that these were the specialties that maintained their clinical workload despite the MCO as they were dealing with cancer patients. Maintenance of services among the hematology and oncology units were following the directive of hospital administration.

As for the type of urology cases reviewed, hematuria, urological infections, and obstructive uropathy were the top three categories during both pre-MCO and the MCO period. However, there were significantly more BPH/urethral stricture cases during the MCO period. A postponement of prostate surgeries, e.g., transurethral resection of the prostate and surgeries for urethral stricture may have led to the rise of these cases. Besides, the postponement of clinic appointments resulting in exhaustion of BPH medications may have led to more patients presenting with acute urinary retention.

In the present study, it was noted that the number of patients undergoing surgery during the MCO period was less among the new referrals received. Most patients needed bedside procedures like SPC insertion, Continuous bladder drainage (CBD) insertion, and bladder washout which were offered continuously despite the pandemic. The main source of referral for these bedside procedures was for the inpatient cohort. The significant reduction in patients undergoing urological surgery was due to the fact that patients were referred out to other non-COVID designated urological centers if required semi-emergency surgery. The patients were also allowed to seek treatment at any private hospitals upon request due to the risk of COVID-19 infection in UMMC.

This study is the first of its kind to assess the pattern of referral during a crisis period. It portrays the effect of a pandemic on urological services in a tertiary center designated to manage patients affected by the disease. However, the current study has some limitations. First, the pre-MCO data were collected retrospectively. This led to some missing data as well as recall bias. The duration of this study was relatively short (6 weeks pre MCO and 6 weeks of MCO). The 6 weeks of study was chosen as the hospital services resume the usual clinical services after 6 weeks of MCO with strict SOP. A longer study duration would have given a better picture of the effect of the pandemic on the urology workload in the hospital during the two periods. However, the period of a lockdown was also affected by other factors such as the cumulative new COVID-19 cases of the country.

It is worth noting that none of the health-care workers was infected by COVID-19 in the hospital in the course of reviewing the patients. This reflected the early planning, proper instructions, and availability of PPE in the hospital. This compared favorably to the reported incidence nationwide which recorded 275 affected healthcare workers as of April 17, 2020.[8]

  Conclusion Top

The workload of urology referral in a COVID-19 designated tertiary hospital did not change despite the MCO. This shows that the urology unit is an important subspecialty with almost equal workload despite the reduction of services during a pandemic period. We hope that this study can serve as baseline data and provide further insights into planning and developing strategies for management and manpower allocation in other urological units affected by this pandemic.


We thank our urology unit team members, outpatient clinic staff, and department of surgery team for their support for this study.

Financial support and sponsorship


Conflicts of interest

Prof. Teng Aik Ong, an editorial board member at Urological Science, had no role in the peer review process of or decision to publish this article. The other authors declared that they have no conflicts of interest.

  References Top

Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.  Back to cited text no. 1
World Health Organization. Coronavirus Disease (COVID-2019) Situation Reports February 2020. Available from: https://www.who.int/emergencies/diseases/novel-corona-virus-2019/situation-reports.  Back to cited text no. 2
Ministry of Health Malaysia. Latest COVID-19 Updates in Malaysia. Available from: http://www.moh.gov.my/index.php/pages/view/2019-ncov-wuhan. [Last accessed on 2020 April 14].  Back to cited text no. 3
Chan MC, Yeo S, Lee Y. Stepping forward: Urologists' efforts during the COVID-19 74 outbreak in Singapore. Eur Urol 2020;78:e38-9.  Back to cited text no. 4
Naspro R, Da Pozzo LF. Urology in the time of corona. Nat Rev Urol 2020;17:251-3.  Back to cited text no. 5
Terlecki R, Miller N, Terlecki R, Miller N, Inman B, et al. Trends in urological referral patterns: A study of community and university urologists in the United States. Urol Pract 2018;5:480-8.  Back to cited text no. 6
Talreja S, Banerjee I, Teli R, Agarwal N, Vyas N, Priyadarshi S, et al. A spectrum of urological emergency reported at a tertiary care teaching hospital: An experience. J Clin Diagn Res 2015;9:PC12-5.  Back to cited text no. 7
Daim N, Arumugam T. 275 healthcare workers down with COVID-19, New Straits Times, April 17 2020.  Back to cited text no. 8


  [Figure 1]

  [Table 1]


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